The greatest speakers are known for their pauses. The selective moments in which they break, wait, breath, and stop. Which is often difficult for novice speakers to understand. For many, the ability to speak quickly and say as much as possible in as little time as possible is the definition of superb speaking skill. But speaking has a cadence to it, a particular pace – and mastering speaking entails mastering that pace.
Healthcare is the same way – it has a specific pace. To slow and time is wasted, but too fast, and mistakes are made. Optimal healthcare works best when it moves at a pace that balances progress against mistakes. A notion we have completely dismissed in our never-ending quest for speed.
We believe the faster something moves, the more efficient it becomes. But efficiency is not just speed, it is effectiveness relative to speed, or the ability to achieve a certain number of goals within a specific unit of time. And if increasing speed decreases effectiveness, or what can be achieved, then the speed does not increase efficiency, it decreases it.
Which is what we find happening across healthcare.
The onset of COVID-19 marked the opening salvo for the vaccine race. And off they went, in a mad dash to implement the latest vaccine development technology, and to be the first to manufacture a vaccine. But in their haste, many pharmaceutical companies made mistakes, we saw numbers posted about vaccine efficacy that were proven false upon closer evaluation. We saw medications touted as cures only to be proven dangerous with subsequent clinical studies.
And we saw academic publications divulge data from incomplete clinical studies into the mainstream media world of breaking news. Clinical studies would post results even before the study was complete to draw publicity to the study – but quickly found themselves recanting certain study results or revising the analysis from the data.
As a result, public trust and confidence in clinical studies and medical data has dropped to nearly unprecedented low levels. People simply do not trust what they read. They see study after study publishing all sorts of promising numbers that promise immense benefits to patients. But the more studies they see, and the faster the results come, the less they trust it.
As a result, while a COVID-19 vaccine may have been developed in rapid time, its efficiency may actually be less than if the vaccine was developed more slowly because now fewer people trust it, and fewer people than anticipated may take the vaccine in the initial months that it is available.
This is the paradox of speed in healthcare – when something moves too fast, it actually loses efficiency.
Vaccine development is just one example. A more germane example, closer to home for many, may be the presence of retail clinics popping up within corporate pharmaceutical chains and department stores across the country. Promising convenient care at a moment’s notice, these clinics have formed across the country seemingly overnight. Often branded as immediate care clinics or retail care clinics, they promise an efficient overall care experience, minimizing the overall time for patient care by prioritizing the speed of medicine.
But should patient care and clinical medicine really move that fast?
The effects of expedited clinical care are manifestly apparent. Many of these retail clinics have higher prescription rates for antibiotics, often lead to higher cost of care for patients, and have a higher rate of misdiagnosis than traditional clinics. And we have no one to blame but ourselves. We should have seen these effects coming.
When car manufacturers would increase the speed of the assembly line, more employees would get injured and more mistakes would occur. The reason was obvious, when you force people to work at a face faster than they are accustomed to, they will compromise somewhere – and inevitably, quality is compromised for speed, and efficiency goes down.
The same premise is now appearing again when medicine turns up the pace too quickly. When a patient presents with a common symptom of an upper respiratory disease – like a cough – the provider will more likely than not simply give a prescription and move on, knowing that it may be viral or bacterial, but also knowing that the time needed to parse through the details will affect the expediency of care.
That is why prescription rates are higher in retail clinics. When in doubt, simply default to an antibiotic.
A seemingly sensible decision for the provider who faces immense time constraints. But a decision that has led to anywhere from 23,000 deaths per year – according to the CDC – to 115,000 deaths per year – according to Cambridge University.
Patient costs also increase, as many retail clinics do not consider insurance coverage or more cost-effective solutions to patient care when seeing patients. These additional considerations may take time and may be unnecessary in the moment. Something retail clinics acknowledge by listing their care services at a lower price point.
But over time they result in higher costs of care for patients because much of the care is not covered by insurances, leading to costs being passed onto patients, many of whom cannot afford these additional costs. As a result, many retail clinics have become de facto debt collectors, hiring third parties to pursue outstanding patient bills from patients who simply cannot pay them. So while the allure of presumed low cost care rapidly attracts patients to retail clinics – believing the cost of care will be lower – the true coverage cost and medical debt incurred to patients prove to be higher in the long run.
Many studies evaluating retail clinics have found comparable quality of care relative to more traditional forms of primary care. And the notion that retail clinics provide worse quality of care seems to be unfounded. But the studies themselves are not the gauge for clinical quality. Rather, we should look at the coding methods for retail clinics to glean the quality of care. For the most common medical conditions, studies have repeatedly shown that the quality of care is nearly equivalent.
But a proper evaluation of medical care cannot be distilled down into the most common conditions only. Medicine is an amalgamate of numerous medical conditions, some common and some uncommon. And a closer look at the coding documentation for Medicare patients finds that many retail clinics have a lower coding diversity than traditional primary care services, which may mean that they diagnose a smaller set of clinical diseases – but also could mean that those patients with less common clinical conditions are likely to be misdiagnosed for something more common.
Those types of errors would not appear in a traditional evaluation comparing the quality of care – and would only appear in the rates of follow up visits to other healthcare facilities after visiting a retail clinic. Which is likely why many retail clinics recommend following up with a primary care physician as a precautionary measure.
These seemingly innocuous errors and default tendencies can become serious inefficiencies in the overall healthcare system. Whether resulting in long term drug resistance, higher costs due to less coverage, or redundant visits, increasing the pace of a clinic visit decreases the overall efficiency.
This is a counterintuitive notion that many seem to ignore, resulting in more and more innovations designed to increase the speed of medicine. The latest, and possibly most questionable trend, is the direct engagement of pharmaceutical manufacturers and distributors with patients. Many start-up companies have reached billion-dollar valuations by finding ways to market directly to patients. Turning physicians into glorified operators, rubber-stamping prescriptions for medications patients already expect to receive.
Many physicians who work for such companies complain that they are pressured to prescribe medications based upon the patient’s request, and simply fill out standardized template forms which serve as perfunctory documentation for presumed clinical oversight.
Aggressively pushing for such speed will likely reduce the effectiveness of medications and result in higher rates of medication misuse and complications – reducing the efficiency of medications as a form of treatment. Something we should heed sooner than later.
Hopefully we will learn that true innovation in patient care comes not from the speed, but from the efficiency – which is a balance of effectiveness and speed and errors – and start to prioritize being effective more than just being speedy while glossing over the errors.
Association between COVID-19 outcomes and mask mandates, adherence, and attitudes
Using an event study design, authors estimate the treatment effect of the introduction of mask mandates (shown on the vertical red line) on Z-scored population-normalized COVID-19 daily new confirmed cases, daily new hospitalization admissions proportion, and deaths across all 50 states and D.C. over the time period between February 1 and September 27, 2020.
Source: Dhaval Adjodah, Karthik Dinakar, Matteo Chinazzi, Samuel P. Fraiberger, Alex Pentland, Samantha Bates, Kyle Staller, Alex Vespignani, Deepak L. Bhatt. Association between COVID-19 Outcomes and Mask Mandates, Adherence, and Attitudes.