Be sure: what follows are not complaints; these are just the facts.
Here’s a recent exchange from an enlightened physician leader, one who has yet to give up:
“My colleagues are discouraged and frustrated every day, leaving the office defeated and fatigued. There are other ways to practice.”
High healthcare costs get most of the attention, but there’s a more important crisis coming your way. First a review, then to the looming crisis.
Excessively disruptive, ineffective and downright inhumane care of the elderly is also a major driver of rising costs. This is tragic.
Fee-for-service rewards doing more ‘work units,’ whether or not such units are grounded in science or aligned with a patient’s goals for care. Listen to this one: A couple of years ago, after my trip to Germany, I learned to do AF ablation without an expensive ultrasound catheter. That saved the healthcare system a lot of money. Alas, using an ultrasound catheter is well compensated–there is a code for that. Doing the procedure more cost-effectively, therefore, saved the system money; but hurt the bottom line for the hospital and me. This too is nuts. It should be the opposite.
If I was piling on, I could add the costs of defensive medicine. Ask any ER doctor about that. How in the world can any human do ER medicine? These folks have my admiration.
You get the point. President Clinton, in his plenary speech at the Heart Rhythm Society Sessions this year, said it well: “we can’t keep going on like we are.” No one disagrees. Things must change.
The issue is how it’s being done.
The default, and I can see why, is that payment for services must be cut. Doctors and hospitals must get less. The caregivers are the problem. And oh my, if it was only that. On top of lower compensation has come onerous regulations. These oppressively burdensome intrusions take caregivers away from delivering care.
Doctors went into medicine to use their hard-won skills to help people. We desperately want to deliver care. Our self-esteem turns on how well we do it. And this is the problem:
Skillful, compassionate and well-aligned care takes time. It goes slowly. It requires face-time, not computer time. We have to listen to the fellow human in our midst, examine her, go over both relative and absolute risks and benefits of treatment options, and then be clear about expectations. You don’t really think an EMR is capable of removing fear and ignorance from medical decisions, do you? And the 6-page office note…this helps align care with a patient’s goals?
There were two important essays this week on the state of doctoring in the United States. Dr John Schumann writes poignantly (on NPR blog) about how doctors are looking for a way off the hamster wheel. I liked it because it contained a shred of optimism.
When I was a medical student, I held the naive and idealistic belief that if I just did good work, the business side of things would somehow take care of itself.
How wrong I was.
Dr. Danielle Ofri captures the problem perfectly:
For the average practicing physician, the major goal of any given day is simply to stay afloat. The typical 15-minute office visit is rarely enough time to fully address the clinical needs of patients with multiple chronic illnesses, and the onerous documentation demands of electronic medical records ensure that doctors spend most of that visit interacting with the computer rather than with the patient.
US healthcare is mired in an epidemic of over-treatment. One way out is with better decision quality.
It is fantasy to think our current model of delivery will foster decision quality. You can’t see more patients, sign more forms, click more boxes, do more corporate safety modules and also expect high quality shared decision-making.
For me, I have decided to run slower on the hamster wheel. I will see fewer patients, not more. Decision quality is just too important. I need for my patients to make informed decisions. They must know what an ICD can and cannot do; they must not be surprised when AF recurs after a single ablation procedure, and they must understand that taking an anticoagulant means trading an increase in bleeding risk for prevention of stroke–and that decision is up to them. I have it easy; specialists focus on one organ system.
You can’t have shared-decision making and patient-centric care when the hamster wheel turns that fast. It’s not possible.
But few doctors have the luxury of going slower. Most will simply keep trying to run faster on the wheel. But you know what happens when athletes run too much and rest too little. You don’t think caregivers are immune to inflammation and joylessness, do you?
A cycling reference fits. Etched into a wooden bench at the top of a nearby mountain bike trail is a recommendation: “Hey racers: stop racing around so fast, you are missing all the good stuff.”
Why is this stuff so important?
It’s not when you are well.