This is an occasional blog post on the current medical scene. It is presented as a reality check on what is being proposed as solutions to our escalating health costs.
There is an absolute frenzy to cut health care costs. The solutions promoted call for decreasing services or making them less expensive. Unfortunately none of this lowers the cost. The mainstays of providing care in terms of the professional labor required, the main expense, does not change. To be quite clear about this none of these reforms are advocating less hospitals, less doctors, less nurses, less therapists or less workforce to maintain them. However there is one casualty in this process, the bedrock of any healing system: The doctor-patient relationship. A number of untested vehicles of care have been introduced. Unfortunately they have had unintended negative consequences on the interaction between a doctor and their patient. Let’s go through these one by one.
Doctors in increasing numbers are handing over hospital care to Hospitalists. At the most needy time in a person’s life the professional most knowledgeable or most interactive with your health is not involved. This hospital based specialty was touted as cost saving with better outcomes. Recent review of this work has shown it does neither. Try to picture a spouse or a daughter or son or some other close relative calling a doctor’s office to get some information on their loved one. That caller has to be referred to some hospital based provider who is less familiar with family dynamics. In its starkest form it has to be a dehumanizing and disappointing interaction. If hospitalists had been set up with effective communication and they practiced as private entities there may be some hope of making a positive transition. However hospitalists have been set up as a corporate enterprise married to a bottom line rather than true allegiance to the patient.
Another recent development is placing electronic medical records in doctor’s offices. It should be a tool to improve a physician’s skills to accomplish their primary mission, namely personal attention to the patient. However it has become an exercise in filling in boxes. Patient observations have described doctors with their heads buried in a computer screen during a visit. Much of this time is spent clicking off a run of questions homogeneously established but not suited for nuance. Missing is the sense of individual care.
Another program being promoted is the “Patient Centered Medical Home.” This is a system carried out by a team of professionals with a primary care physician at its head. Although it has some attractions on paper it is still unproven. There are many moving parts(nurses, therapists, nutritionists, hospice care, case management, etc.). They operate simultaneously and vie for a piece of the action. It has substituted personal interaction with the doctor to one of more impersonal delegation. It is true enough that many doctors failed to do this in the past. However it is now being replaced by a whole cadre of interventions. This has the potential of creating more miscommunication due to the increased number of providers involved. Since more people are participating and derive income from the endeavor, expense needs to rise since none of this replaces any workers in the core delivery system.
For doctors themselves we now have approaches that either make their income dependent on ordering certain targeted tests or by sending patients for particular procedures or imaging. The hope here is by preventing disease it will be less costly to the system as a whole. No one is questioning that these interventions should not be done. However it will save no money. First because revenue is lost to the hospital with fewer admissions with no change in their overhead. Second more people will reach old age with timely care. This means, however, they enter the most expensive category of healthcare in human life. Progress should march on in these areas but the public must clearly know it will cost more not less.
Because of these changes there has been a lost focus on one of the major rewards of the medical profession. With so much emphasis on cost control and other bottom line issues the prestigious calling of a doctor and that it is a profession that still pays well has gotten lost . The practice of medicine is becoming a day to day job. Doctors in training are becoming more “lifestyle” and income oriented. This derives from large student debt and a morbid fear of failing in general practice. We have succeeded in making the health profession seem unhealthy. The mere mention of a career in primary care produces instant anxiety. This is reinforced by mentors who advise students against entering primary care. As these students move through their schooling and into residency training they more frequently choose to become employees. They become wards of the bottom line of whatever large group practice or hospital employs them.
The public on the other hand is fairly precise in what they want of the medical profession. It is a hands down vote for easy, affordable access to a knowledgeable provider who takes personal responsibility for their health needs. Human beings crave a confidential empathetic connection when they are troubled with disease, wellness, or psychological problems. By barking up the wrong trees, as we are doing, we are taking a detour from this reality.
In conclusion we cannot prevent our way out of expensive care. We must undertake some more basic repairs. It is also unconscionable to use punitive measures or extra dollars to create a compassionate system of healing. Modernization is necessary but it should not be at the loss of medicine’s most treasured asset, the social contract between a doctor and the patient.
Donald M. Green MD
