22 April 2010

ACEP Measures the Emperor's Nose

A long time ago, in a faraway and mythical country which we'll call China, everyone wanted to know how long the Emperor's nose was. Of course to look at the Emperor's visage was punishable by death. But so many people were curious, that a group of sages got together to look for a method of finding the answer, and this is what they came up with.

Questionnaires were printed and sent out in bundles to cooperating village chiefs, who distributed them to the peasants. Literacy was at a sufficient level that most were able to complete the single question, which was, of course: "How long do you think the Emperor's nose is?"

When the forms were collected, mathematicians added up all the values, and divided by the number of forms. Thus it was known that the length of the Emperor's nose was 6.734602 cm. The complete set of data was of course preserved, and many years later, with advances in statistical understanding more advanced mathematicians pointed out that fringe values - obviously the product of deranged minds - were distorting the honest opinions of the rest, and by eliminating them and using the very latest numerical modeling techniques, the mathematicians corrected this value to 4.980403 cm. To this day, no-one has produced a better estimate.

I got a survey request today from ACEP.  It asks, over 26 questions, what I, a practicing Emergency Physician, expect will be the outcome of the recently passed health care reform bill.  At first I was eager to complete the survey and have my voice heard.  Then I noticed that the questions, while not exactly biased, seemed more likely to reflect the level of cynicism among physicians rather than an educated projection of the effects of HCR.  Consider this question, which is representative:
Do you think emergency department visits will increase or decrease over the next 6 months as a result of the newly enacted health care reform efforts?
Visits will decrease
Visits will increase
Visits will first increase, then decrease
Visits will first decrease, then increase
Visits will stay the same
Don’t know
Considering that 99% of the meaningful reforms don't take effect until 2014, any physician who answers anything other than "Visits will stay the same" has identified him or herself as someone who is ignorant of the actual provisions of the HCR law.  The survey also asks the standard "temper tantrum" question, whether this law will induce you to quit practicing Emergency Medicine.  Physicians routinely threaten this, which is pretty much the equivalent of "I'll take my ball and go home," sort of brinksmanship.  Note to the media: it's patently a hollow threat, unless you've made so much money that you can retire at a young age, and those guys are usually fat & happy and not exactly being driven out of medicine.  The survey also askes the standard apocalyptic questions -- will all the specialists retire, will there be no more people going into medicine, will all the hospitals close, will there be mass hysteria, cats and dogs living together, human sacrifice and the like.

So while the wording of the questions seems neutral and not overtly biased, the choice of the questions seems explicitly designed to elicit a certain response -- that Emergency Physicians think the whole thing is going to go to hell as a result of Health Care Reform.  Because physicians are a cynical bunch to begin with, frustrated with the administrative demands of our careers, politically right-leaning and because there was such toxic rancor over the HCR law, it's predictable that a significant number of ER doctors are going to just click the "worst case" on all the questions as an expression of their opposition/disappointment.  What is that going to tell us?  Not bloody much.

Once I realized where they were going with this survey, I didn't bother to complete and submit it, and I suspect that response bias will also skew the results pretty far in the anti-reform direction.  Those who are opposed tend to be intense in their opposition and will be pretty eager to say so publicly. Those who supported the reforms are weaker in their support, and especially with such a biased survey are less likely to participate.  Worse, the survey tends to split the "support" response options, whereas the "opposition" choices are unitary:
Do you think the health care reforms will address the critical issues affecting your care of emergency patients, such as boarding and overcrowding?
More will be needed -- but the reforms are a step in the right direction
The reforms don’t do nearly enough
The reforms will ultimately solve boarding and overcrowding
The reforms will worsen conditions for emergency patients
This will effectively magnify the apparent gap between the supporter and opponents of HCR.

So clearly is this survey designed to generate a predetermined result that I'll go ahead and pre-write the press release that ACEP will publicize in a couple of weeks when this study is released at the Leadership Conference:
Emergency Physicians Fear the HCR Law will Reduce Access to Care
Results of a survey of practicing Emergency Physicians (EPs) reveal widespread concerns regarding the impact of the HCR Law.  Fully xx% of EPs expect that overcrowding and boarding will increase as a result of this law, and yy% are concerned that this will reduce access to on-call specialists.  zz% of EPs don't know crap about the law expect ED volumes to increase this year as a result of the reforms. Furthermore, concerns about the physician workforce are raised by the HCR Law as aa% of EPs are considering early retirement due to this reform, and bb% of EPs think this law will discourage students from entering medicine. 
Just plug in the actual numbers from the survey; I expect that they will range 40-60%.  But when you see the result in your mailbox or in the news, don't believe them -- they don't tell you anything except that the Emperor's nose is 4.9804 cm long.


  1. I think an answer of "increase in the next 6 months would be reasonble" as 1) visits (at least in my region) are increasing anyway and 2) we've seen people showing up for their "free healthcare" and didn't realize things don't start until 2014. So while it may not be purely due to the HCR it is in part due to the patients thinking they can be seen.

    Still, overall, good point and I also didn't fill out my form either from my subspeciality group.

  2. I appreciate your level headed approach to this issue. This survey reminds me of something I might have whipped up in a Basic Statistics class during undergrad.

    Also, I couldn't help but read "cats and dogs living together" with Bill Murray's voice in my head. (ref: Ghostbusters)

  3. Nuclear -- I half agree. If volumes are going up, then the increase isn't as a result of the HCR law. But more patient may show up expecting free care, now that we're a socialist republic! ;)

    Drew -- I'm profoundly happy someone got the reference!

  4. At time when technology when has made surveying members and compiling data easier than ever before, it's ironic that political organizations seem less likely to gather reasonably objective data from their members before taking positions/developing plans of action than they are to use surveys to support a pre-determined outcome.

    Just curious, shadowfax, was this survey electronic or paper?

    (And add me to the folks who smiled and heard Bill Murray's voice as I read "cats and dogs living together".)

  5. Reminds me of a cartoon I saved for FB "politics" showing a hysterical Palin Tea Party supporter yelling "Commie!!" at the Canadian health system Guy quietly sipping his Tim Horton's coffee saying "As long as my Timmies is hot...."

    So much fear for a system that most of the civilized world embraces.
    AND.. why do people think it is "free" healthcare?? It is never free....just socialized - like a LOT of other things in America. Medical access for everyone should be a priority.

    Question: If socialized medicine is so darn unaffordable ...why is it that Canada is doing so much better financially than the USA??? and we have had socialized healthcare since 1962. By most Republican's opinions - Canada should be broke by now.....


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