Reform of healthcare in the United States is infinitely complex. Millions of words have been written. The noise drowns out the signal. It’s rare therefore that one paragraph could sum up the problem so concisely.
It came from Edward Davies, an editor at the British Medical Journal. He was quoting journalist Owen Dwyer who was writing on the challenge of doing less.
“How many of us would voluntarily take steps that slash our income, and that of our employees, while simultaneously alienating our customers? That is what US physicians are being asked to do. Only a physician of rare moral courage could push back alone against these relentless pressures, which is why physicians are now being asked to try collectively.”
As many of you know, I am a vocal advocate for both the Choosing Wisely campaign from the American Board of Internal Medicine Foundation and the Less is More movement from Dr. Rita Redberg at JAMA-Internal Medicine. These ideas, which urge doctors to practice less disruptively, fly in the face of human nature. No headwind is tougher to pedal against than human nature.
Consider the roofer anecdote: How many times has a roofer looked at your roof (which you cannot see) and told you: “No sir, your roof is fine; you don’t need any of my highly profitable services.”
I often kid around with patients and proclaim that I am the only doctor in this city trying to make less money. Hyperbole? Yes, surely.
But the point is that when I practice less disruptively; when I teach patients to help themselves; when I give time a chance to cure, and when I do fewer procedures, there are certainties:
- I practice the best medicine possible;
- I come home mentally and emotionally fatigued;
- I hurt my productivity;
- I endanger my referral base;
- I might just expose myself to liability risk.
These are the problems that ObamaCare does nothing to address. These are the hard problems.
Read that quoted paragraph again. Then put yourself in the shoes of a young doctor who does not have a stable referral base, adequate savings or paid off student loans. Consider what the good young doctor does have: a compliance officer breathing down her neck to prescribe guideline-mandated ‘quality’ care, twenty other patients to see before she picks up her kids at day care and maybe even the false idea that more care is better care. Does the good young doctor know that said guidelines are born from medical societies with financial ties to industry? Does she realize that today’s quality care might be tomorrow’s medical reversal?
It’s a mess.
The complexity of it all always leads me back to the same basic and obvious things.
To patients: I say take care of yourself. Make good choices and stack them together. Such is not a guarantee, but it improves your chances of avoiding this imperfect business.
To doctors: I say go slowly and think. Aim for less disruption. The human body can do a lot if we let it.
To medical educators: You have one shot with these young people. Teach them well. (Not everyone gets the benefit of Hoosier wisdom, but you can get close.)
And to policy makers: Please pay more attention to the contact points of healthcare–that is, where human doctors meet human patients. Human nature is a stiff headwind to go against. Ask real doctors to help you, even cardiologists.
JMM
See also this Storify Twitter thread published by my colleague Jay Schloss (@ejsmd).
Paul says
October 6, 2013 at 4:50 pmAll excellent points. Let’s not forget how we got here. The AMA has fought every attempt at government involvement in healthcare since the 1930’s and perhaps they were right – having a third part interfere with a doctor patient relationship is cause for caution. When the SSA act of 1964 increased healthcare access for millions of disabled and uninsured the floodgates opened. Technology expanded at a pace that many could not anticipate, physicians became specialized (how many types of cardiologists can you name?) and fee for service encouraged medical procedures. Despite these advances and the opportunities for physicians to become very rich, the health of Americans is no better than many third world countries. Reform is still needed as many are still without care but once again our leaders cannot foresee a solution that does not interfere with patient -physician relationships.
Ken Grauer, MD says
October 7, 2013 at 7:24 amTough problem you describe John that physicians are faced with. You bring this home powerfully with the 5 bullets of what happens when you (as a clinician) practice “less disruptively”. Clearly there is LOTS that needs to be fixed with our Health Care System – including the incredibly difficult need to get at the root of ever-increasing costs … (which is caught in the self-fulfilling prophecy of swimming “upstream” that you describe).
Along the way you mention ObamaCare. The good part about ObamaCare – is that it at least is trying to get a greater percentage of Americans covered with health insurance. ObamaCare ain’t perfect (far from it) – but at least it is a well-meaning start. I wish those legislators who are so firmly against it could be there with a patient of modest income and no health insurance who faces the prospect of potential bankruptcy any time he/she or one in their family is faced with a not-even-major medical illness that requires not-even-a-large-amount of health care. Unfortunately, the way things are going – ObamaCare will never even get a chance to attempt to make things better. In the best of worlds – that would take years of collaboration and cooperation among not only politicians, but the entire medical community and their administrators. Instead, Obamacare is being “killed” politically before it is born by those who don’t have to worry about their own health insurance or health care expenditures …
Thanks for listening. Just expressing frustration with another aspect of our Health Care System … We are the BEST in the world when truly acute illness strikes and the finances of treatment are not a factor. We are far from “the best” under all-too-many other circumstances.
Jerry says
October 7, 2013 at 9:24 amGood commentary.
A question regarding an aspect of human nature not considered here:
How many people are negatively affected by the moral hazard inherent in insurance?
Obamacare puts the cart before the horse (yes, I realize that in politics, one must get what one can when one can). Thus, our country’s collective well-being may worsen, not improve as the president hopes.
“People respond to incentives, although not necessarily in ways that are predictable or manifest. Therefore, one of the most powerful laws in the universe is the law of unintended consequences.” -SuperFreakonomics
With that in mind, see:
“Obamacare: Making a bad situation worse”
http://relevantmatters.wordpress.com/2012/05/21/obamacare-will-make-a-bad-situation-worse/
Ken Grauer, MD says
October 7, 2013 at 11:02 amJerry – I fully agree there are LOTS of potential problems with ObamaCare. But it IS a start and DOES aim at improving one fundamental KEY issue for those without health insurance in this country who are subject to potential bankruptcy as I stated above from potentially a not-major illness to any member of the uninsured’s family.
I respectfully have LOTS of problems with info at the link you provide. To imply that the situation will be made “worse” by facilitating getting insurance because people will “now drive less carefully” (since they have insurance) is prime example of looking for “facts” that in some contrived way support whatever your viewpoint is. Those of us who have been in the medical system have long ago recognized that the hospital is the LAST place you want to be IF you don’t need to be there (risk of getting all sorts of problems just from being in the hospital ….) – but the FACT is that sometimes ALL of us (be us old, sick and frail – or young and healthy) – ALL of us develop a need for medical care – and while not free from risk, such medical care can be helpful (and at times even lifesaving).
Obama has repeatedly emphasized that ObamaCare is far from perfect. He KNOWS there will be many “glitches” that need to be worked out. This will NOT be a fast process – and it will NOT be a realistic process unless and until a spirit of collaboration and cooperation develops among politicians, medical providers and medical administrators with much patience on the part of patients during the extended “fixing” process. I am not holding my breath (not anticipating seeing this come to fruition during my lifetime). The ONLY thing I am certain about – is that as great as the American Health Care System can be when one gets real sick and has the means/access to quality providers/hospital – our overall Health Care System is “broken” and is NOT sustainable at the current pace unless dramatic change is implemented. The reason I favor ObamaCare is because at least it is a primitive initial step in a complex “broken system”. IF all that is cited are problems with ObamaCare primarily because it was proposed by Obama – then there will be nothing. The RICH (hospitals, administrators, Big Pharma, and doctors who aren’t “disruptive” in their practice approach) will become richer – which is the reason they continue to criticize ObamaCare and fail to propose potential alternative (because they keep getting richer). And the “Have Nots” will still not have – won’t be insured (can’t afford it) – and our glorious Health Care System will eventually go broke and collapse. I have insurance and I doubt that I’ll be affected by the collapse as I would be if I was new in practice. But the handwriting is on the wall – and I feel terrible for my grandchild who will be growing up in this sad state of affairs … THANK YOU all for listening.
Jerry says
October 7, 2013 at 12:02 pmThank you for taking the time to graciously reply.
The primary aim of my linked-to commentary — a point that may have gotten lost in the verbiage! — is to bring attention to the many factors converging to put our collective well-being at risk. One of those factors is the addition of millions of more people who will soon begin relying on the “broken system” of Medicaid (President Obama’s words).
One of the things I wish had happened is that all those who favor universal access to healthcare had years ago begun working to put the horse before the cart — creating incentives for a huge increase in the number of primary physicians to handle the huge increase of healthcare users. To address that, there are moves afoot that began recently, but they apparently are failing.
Good discussion.
Ken Grauer, MD says
October 7, 2013 at 1:54 pm@ Jerry – I agree entirely with you! As a family physician educator who for 30 years was full-time faculty educating residents and doctors-to-be in family medicine (until I retired in 2010) – you are speaking to the “choir”. That said – my “hope” was still that ObamaCare might at least be a start – and that little-by-little the system could be adjusted with eventual progress to something functional. Alas, this will probably never happen because of the reasons we have both stated above. Good discussion though.
Jim Collins, CPC, CCC says
October 7, 2013 at 5:06 pmHI Dr. Mandrola, I am a coding consultant and billing company operator that works exclusively with cardiologists and EPs. I do not have medical training but I am fairly well versed on the clinical issues pertaining to pacemakers and defibrillators. In the immediate future Medicare will stop covering pacemakers for patients with Long QT Syndrome or Chronotropic Incompetence. I believe that this will be generally bad for patients and implanting physicians. I am executing an advocacy effort to close this gap in coverage. (see the “Advocacy” page at http://www.CardiologyCoder.com).
I would love to hear your thoughts about the impact of the policy change and about my advocacy effort.
PGYx says
October 7, 2013 at 6:55 pmThank you for so beautifully summing up many of the greatest challenges facing physicians who try to practice better medicine.
Dr John says
October 7, 2013 at 7:42 pmThanks for the nice discussion.
I appreciate the candor. It’s really good.
Please type and hit that submit button.
Dan Matlock says
October 7, 2013 at 11:11 pmI love the comment about human doctors and human patients. I sometimes wonder if the policy makers understand how emotional and personal a medical interaction is. All of these policies become very very personal to everyone involved. Even when I agree with them.
Andy Bailey says
October 8, 2013 at 8:58 amThere are rays of sunshine that break through the darm and gloomy clouds on occasion.
1. Reading on the arcane topic of the management of pancreatic mucinous cystadenomas, I came across the recommendation to completely ignore these premalignant lesions in candidates for whom intervention of any kind would make little sense. For some reason, this appeal to common sense struck me as unexpected and refreshing.
2. If you build it they will come. If you’ve been out to Floyd Park lately, there are scores of new cyclists taking advantage of the car-free environment to get in some risk-free cycling. It’s very encouraging.