The downside of racing around so fast…

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.

When Americans travel to Belgium or India on their own dime to get cheaper medical care, you know things are bad. The same AF ablation costs ten times more here than in Europe. This is crazy.

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.

JMM

8 comments

  1. “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? ”

    I saw exactly what you are talking about during my recent visit to the ER after a bike crash. Now I did not have a scratch on my head and nor the helmet. Most of the damage was to my right leg.

    But I had a head CT, cervical CT, a couple of x-rays of the lower spine & hip.

    And the closes thing to a “physical” exam was after the CT’s & x-rays the ER doctor ask if I could walk.

    My comment was I think so, but I had been in the bed all the time. So I got up and took a couple of steps as I was still tied to the monitor.

    Only then did they, a tech, started treating the leg wounds.

    The only exam that they did that made any sense was sternum/chest x-ray as I hit the handle bar and had bad contusion on my chest and I have had a
    CABG.

    Fortunately I have had better responses from my PCP. He always pokes and prods as needed. Although “too much” of his time he is focused on the EMR.

    And that would not be too bad, but his practice is owned by the hospital and the hospital ER could not access my records.

    And my cardiologist is also “hands on”.

    1. Out of curiosity, if you hadn’t had your bell rung, why did you submit to a head CT? Was this coerced?

  2. I had this older GP in Manhattan whom I loved. Went to get tested and he refused to do a couple of the more uncomfortable tests for me because I wasn’t showing any symptoms of any kind. He didn’t want to waste my time or his on “everything” when he could see I didn’t need it. Insurance aside, we need to get back to this type of medicine.

  3. Sometimes when I read your articles I think…” Is this guy for real”? In a world mired in corruption there still exists the true “Physician”. The person dedicated to medicine as it should be practiced. And ever more perfected. If I was a young man just starting my career life, you would be my role model for pursuing a career in medicine. Keep writing and learning John. And NEVER sell out.

    1. Amen! It’s tragic that the most honest and ethical physicians are being the most heavily burdened and least compensated for it – and I can imagine how it influences the behavior of young doctors. Dr. M, are there any action steps you can recommend for members of the public to help you reverse these trends?

  4. First, I would commend you for taking a stand and doing right by your patients by providing adequate discussion od complex medical decisions (informed consent). The physician perspective is unique but no less frustrating than any caregiver. Regulations (rules) are written for the criminals. While the vast majority of physicians are humanitarian at the core, it only takes one greedy physician to upset the regulators and overturn a well operating apple cart. “Productivity” is the new standard in healthcare delivery. Quality is important and measured but with the decreasing reimbursement, expanding auditing of charges (costs increase in an attempt to justify/defend the billings), and employed physician models (encourages more work units) the only way to make enough monet to provide care is to do more with less. While the cost of EMR technology drives costs upward it also slows the process. Are the benefits enough to justify the cost? Does it add to the quality of care? There is a lot to be said for patients that have atrult portable medical record; but, currently, the EMR does not transfer from institutions. I can’t speak of foreign medical care but I do know that the average Kentucky consumer cannot grasp the risks associated with invasive procedures. The expectation is to be treated without complication and be home by the evening after the MI. Is our American standard of care so different than other countries or is it our need for Tort reform that further drives expense? Reform is coming but will it be in the right areas?

  5. Boy do I have stories – and boy, can relate from a patient perspective.

    I’d love to share some, but I’m avoiding the personal aspect per Dr. M’s requests to posters.

    One example I can say is how astounded a physcian was when I told him how much the hospital charged for my outpatient procedure that he did.

    I hope I’m wrong, but it seems to me that too often a test is ordered that requires an expensive piece of equipment that needs to be paid for, instead of just doing a simple question and answer, prod and poke, and a bit of common sense.

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