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FROM THE FIELD‘Fifteen Minutes Of Fame’: Reflections On The Uses Of Health Research, The Media, Pundits, And The Spin
In January 2001 we reported on some aspects of our tracking research on the length of visits to physicians in the New England Journal of Medicine.1 The article consisted of an empirical report on visit time between 1989 and 1998 using two sources of national data. The central finding was counterintuitive: The average time physicians spend with patients increased during a period in which managed care penetration grew. The article sought to explain why physicians believe they have less time for each patient while they were in fact spending more time than before. Nowhere in the article did we make attributions to the quality of care or the advantages or disadvantages of health maintenance organizations (HMOs); nor did we offer any kind of evaluative judgment. An accompanying editorial by deputy editor Edward Campion further suggested how changes in medical practice might influence physicians’ perceptions. He too offered no judgments of how the results might reflect on HMOs or quality of care. Since the findings contradicted common assertions that managed care required a reduction in visit time, we anticipated some media interest. We were surprised at the intensity of interest and the extent of coverage on national television, newspapers, and magazines. Our fifteen minutes of fame is now well over, and we offer some reflections on the experience.
As typically happens, the media sought its pundits for the intriguing sound bite that adds interest and tension to reports based on scientific research. Most typically, they chose physicians and patients who attested to or refuted the accuracy of the report on the basis of their experiences. But the media also sought the opinions of national experts and representatives of medical, hospital, HMO, and insurance trade organizations. They all had their own spin, sometimes having little to do with the content of the paper itself. Perhaps the most authoritative voice came from Jerome Kassirer, a medical professor at Tufts University and former editor of the New England Journal of Medicine. In his tenure as editor, Kassirer was a strong spokesperson against managed care and its damaging effects on physicians.3 In his comments to the press he rightfully noted that our study depended on reports made by physicians or their staff in completing the survey form for each visit, that such reports could not be independently verified, and that some of the busiest doctors may not have participated in the survey (a point we had made). So far so good. But he also speculated on the result. "We know older people take more time, and there are more older patients...What we may be seeing is an artifact of the aging population." We had considered this point in the paper and concluded on the basis of the data that age of patients could not explain the result. Kassirer also offered another intriguing hypothesis to WebMD: "Managed care organizations are looking for doctors who will spend time with patients regardless of the restrictions, and so assistants or secretaries may be keeping track of time differently than they did in the past."4 In our paper we reported that the upward trend in visit time was true for both prepaid and other visits, so the explanation of selectivity of managed care plans, however interesting, was not really to the point. The meaning of the latter part of the statement remains ambiguous, but a physician appearing on a local television segment covering the story was more blatant. He told the television audience that managed care paid more for longer visits and thus doctors now run fast clocks. It is his business if he wants to call his colleagues "crooks," but for his hypothesis to fit, he would have to account for the fact that these visit time reports are to a confidential survey and not to payers. He would also have to explain why the same pattern persisted for both prepaid and nonprepaid visits. Moreover, he would have to argue that such "clock adjustments" took place in small increments each year, not a plausible likelihood. David Himmelstein, a Harvard medical school professor and critic of managed care, was another pundit called on by the press. He weighed in with the observation in the Wall Street Journal that "there’s no way in this data set to look at the severity of illness of a given patient. There’s still a fair amount of data out there that tells us that managed-care patients receive less care."5 The implication was that we were contending otherwise or had sought to assess the quality of care under managed care. We were not, and had not. Our paper began with a quote from Kenneth Ludmerer, a physician and historian, as an example of the prevalent informed consensus about this issue. As he noted: Perhaps the most extraordinary development in medical practice during the age of managed care was that time, in the name of efficiency, was being squeezed out of the doctor-patient relationship. Managed care organizations, with their insistence on maximizing "throughput," were forcing physicians to churn through patients in assembly line fashion at ever-accelerating rates of speed...By the late 1990s, the pressure on doctors to see more patients in less time showed no signs of abating, and many doctors were staggering under the load.6 Thus, it was hardly surprising that the Reporter, a publication of the Association of American Medical Colleges (AAMC), sought his response. He remained skeptical of our results, stating: When you’re examining a trend with solely administrative data, the way Dr. Mechanic did, the study lends itself to numerous unanswered questions that could completely change the results...For example, who are the patients and how sick are they? What were the doctors doing with their time? As you start controlling for these factors, you get closer to individual patient experiences, and thus more accurate answers. I suspect future studies will not confirm Dr. Mechanic.s findings.7 He then noted, "My guess is that the length of time spent on office visits has decreased, but not as much as some people may think." The trade organizations, of course, had their own spin. Not surprisingly, the tenor of remarks corresponded to the interests of the organization. Karen Ignagni, president of the American Association of Health Plans, offered the press the observation that "this study is an important contribution to the dialogue about managed care because so much of the discussion in Washington is anecdotally driven... This study indicates that the experience is often very different from the rhetoric." Dale Florio, spokesperson for the New Jersey Association of Health Plans, went further in saying that the study should "comfort patients and doctors in the fact that the system can work." James Fanale, senior vice-president for provider partnerships at Blue Cross Blue Shield of Massachusetts, told the press that "I think it points out that physicians are doing what they need to do for patients." A less enthusiastic response came from spokespersons for physicians. Virginia Latham, president of the Massachusetts Medical Society, told the Boston Herald that "our surveys on physician satisfaction with practice indicate that they feel rushed—much more so in the last two or three years."
As one might expect, media coverage varied in quality, but, on the whole, the media did a credible job in covering the research. The arrangement the New England Journal of Medicine has with the press, in which prepublication copies are made available on an embargoed basis, allows reporters to digest the data and ask questions to clarify issues. While it was clear that some reporters wrote stories without reading the paper, we were impressed by the number who read the paper and asked thoughtful questions. Health Scout, a health news service, provided thoughtful coverage, and the Associated Press’s coverage was accurate as well. WebMD provided considerable detail in its coverage, and Robert Bazell, chief medical correspondent for NBC News, did an informative segment on its national television news program. Patricia Neighmond’s piece on National Public Radio’s All Things Considered was fair and interesting, but perhaps the most interesting coverage was the story by Barbara Gabriel for the AAMC. Some reporters who wrote stories for local newspapers got the facts wrong. Stories adapted from these reports further disseminated these errors. Most disconcerting was a major health news service that produced a widely disseminated story based on some of these incorrect newspaper reports. Some of the publications that covered the story used fact checkers; others asked us to review their stories for factual errors. In the case of one medical publication, we twice reviewed its coverage for accuracy and provided factual corrections. The final copy included this medical editor’s note: It should be emphasized that managed care has resulted in an increase in the administrative aspects of patient care, and the time required to do these administrative tasks may contribute to less time actually spent with the patient but more time spent on the patient’s records. We informed the publication that this statement was inconsistent with the AMA data reported in the paper; the writer responded that "I know what you are saying is that the data does not uphold his comment, but I am going to leave it in there as an editor’s note, because it is in his experience."
Since the New England Journal of Medicine paper was published, 1999 data from the National Ambulatory Medical Care Survey (NAMCS) have been released. These data continue to confirm an increase in the amount of time physicians spend with patients during office visits; mean length of visit increased by one minute since 1998, to 19.3 minutes in 1999. Consistent with the data published in our paper, an upward trend in visit length continues for prepaid and nonprepaid visits, for primary and specialty care, for established and new patients, and for both less and more serious medical conditions. Nonprepaid visit time increased more than prepaid visit time, resulting in an average time in 1999 of 19.7 minutes as compared with 18.5 minutes, respectively. The original story that physicians are spending more time with patients remains essentially unchanged.
There were, of course, a variety of communications to us and to the New England Journal.8 As with the medical editor quoted earlier, most were physicians who believed that their personal experience trumped the results gleaned from hundreds of thousands of visits and intensive analysis of them. It has long been recognized that physicians give more credence to their personal clinical experience than to more abstract research results.9 We hope that the current interest in evidence-based medicine is moving us toward a better balance. As we noted in the paper, many physicians feel frustrated by a variety of aspects of contemporary practice. Ironically, some of the complaints we heard were in fact criticisms of fee-for-service practice. As one doctor wrote: "In order for me to be paid for my professional services, I have to complete a billing checklist. When Mrs. Jones complains of left earlobe pain, and I fail to check the right foot, I have to downcode my bill. I no longer have professional discretion on how I spend my time with the patients, if I want to be paid for it." One of us (David Mechanic) wrote back with tongue in cheek, noting that this was perhaps a great case for capitation. For us, researchers who typically neither seek out the press nor are usual subjects for their attention, a major lesson was the enormous amount of time expended in the aftermath of publication of this paper. Although funding agencies and universities welcome such attention, the cost-effectiveness of this expenditure remains unclear. Our paper highlighted the large disconnect that often exists in perceptions about an issue and the true situation. These abound in descriptions of our medical care system and, in particular, about managed care.10 Indeed, the lead author’s belief that the expansion of managed health care had eroded the time physicians could spend with patients was the genesis of the original paper. For us, the counterintuitive findings pointed to the need to challenge common understandings (including our own) of reality with scientific evidence. Ironically, in the translation of our research to the general public and the accompanying spin, the need for evidence seemed at times once again lost; the gap between rhetoric and reality was as wide as ever. It should not be surprising that a study such as ours should be used as a foil by those with varying agendas. One would have hoped that respected commentators might have been more accurate about their characterizations. Some of the commentary by pundits was simply uninformed, but the public has no way of knowing that. Individuals who should have known better characterized the NAMCS, a major national survey, as "solely administrative data"; restated interpretations that were examined in the analysis and found wanting; and contested conclusions that were far from the substance of the paper itself. This incident is only one passing event in an information-saturated environment. Although the press overall did a credible job, reporters generally have a story frame and filter information to fit the angle they seek to present. Even more challenging is the fact that all of us resist information that seems inconsistent with our interests and preferences. Physicians’ responses, in particular, often built on unique clinical experience and an action orientation, are strongly resistant to change. Numerous efforts have been made to change physicians’ behavior through practice guidelines, feedback, and other methods, but results have been inconsistent.11 A study by Jonathan Lomas and his colleagues of efforts to use guidelines to reduce cesarean sections illustrates the complexities.12 Most of the obstetricians and hospital personnel surveyed were aware of the guidelines and indicated that they agreed with them. One-third reported changing their practices in keeping with the recommendations, but objective data showed little change from the previous trend. Instead, rates of cesarean section were 15–49 percent higher than obstetricians reported. As the authors conclude, the "practices of physicians are influenced by many things besides research evidence, even when such evidence is packaged in a set of clear and concrete recommendations."13 In principle,we all accept that good policy is based on our best understanding of the factors that influence successful treatment and outcomes. Public opinion is one of the many factors that affect adoption of best practices, and many interests seek to shape these public views. Notwithstanding the fact that media will always be manipulated, researchers, pundits, and journalists could do more to convey the true complexity and diversity of our health care arrangements.
David Mechanic is the René Dubos University Professor of Behavioral Sciences and director of the Institute for Health, Health Care Policy, and Aging Research at Rutgers University in New Brunswick, New Jersey. Donna McAlpine is an assistant professor in the Division of Health Services Research and Policy, School of Public Health, University of Minnesota, in Minneapolis. This research was supported by a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research (to David Mechanic) and by the Healthcare for Communities study funded by the RWJF. The views expressed in this paper are the authors’ and imply no endorsement by the foundation.
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The Performance Of The...
A 1999 Update
