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Physician Work
I was in conversation recently with a woman who was thinking back over the choices she had made earlier in life and wondering if she had made good decisions. As we talked about it, I suggested she was really trying to decide if her life had meaning and purpose now that her basic needs for food, clothing, shelter, and family had been satisfied. But don’t we all have to do this at some point? Rosenthal and Verghese have written an editorial addressing this.[1] They began their editorial by reflecting on the nature of physician work as it was when I was in medical school and contrast it with how the medical young find it now. Their key point is that creation and maintenance of the “iPatient” has become the primary focus of their work and the relationship between this construct and the human being is sometimes quite loose. Interestingly, the amount of time actually spent with a patient on the ward has not changed much in the past sixty years; the change is in the “scut work” that consumed house staff energy then and now. “But technology cannot restore our professional satisfaction. Our profession will have to rebuild a sense of teamwork, community, and the ties that bind us together as human beings. We believe that will require spending more time with each other and with our patients, restoring some rituals that are meaningful to both us and the people we care for and eliminate those that are not. Solutions will not be easy, since the problems are entangled in the high cost of health care, reimbursement for our work, and obstacles to health care reform. But we can start by recalling the original purpose of physicians’ work: to witness others’ suffering and provide comfort and care.” I agree with their diagnosis of the issue and the obstacles as I have written about these issues several times. I have brought this editorial forward as the focus of this article, though, because of the curious juxtaposition of two other articles that shed some light on a possible way forward. The first is from that well-known medical journal National Geographic.[2] Mr. Vance examines several examples where faith and belief have been associated with startling improvements in medical conditions and looks at the neurobiology of the mind-body connection. Hospitals are just one common venue for the theater of belief…belief-based healing requires not only a good story, but also the effort of an active listener—one with the ability to make what is imagined feel real. Another common phrase for this is the priestly function of medicine, which is part of the art. Sometimes just having someone listen is all that is needed for the patient to feel better—but that is not captured in the “iPatient.” We are training our medical young to believe their job is to check the boxes in the computer, but what patient really want is an empathetic and knowing ear. But, you say, checking the boxes is what is being paid for at the moment. Kaplan and associates from Harvard Business School have addressed this in an editorial entitled “Adding Value by Talking More.”[3] They begin with an example familiar to me from my own practice—getting patients with progressive chronic kidney disease to go ahead and get a vascular access fistula placed before the need for dialysis. Kaplan and associates assume it is the press of time that limits the nephrologist’ ability to persuade the patient and that for another $200 in time, thousands of dollars in aftercare could be saved. Time is clearly one, but not the only, issue in getting patients activated. “A related role of talking is motivating patients with chronic conditions to adhere to their treatment plans. Several studies have shown that spending more time addressing patients’ concerns and discussing their management of their own chronic conditions leads to substantially higher levels of treatment adherence and fewer costly complications…Physicians can also productively use talking time to set patients’ expectations. Several studies have shown that patients with high expectations for the outcomes of their care have greater improvement thatn those with low expectations…Talking is also required for engaging patients in their care choices, and when patients are actively engaged in decision making, they have better outcomes and less expensive care.” While the authors are economists, they really don’t spend any time suggesting solutions as to how this work can be captured and reimbursed—only that from the payer perspective, it would likely save money. As I think about how I spend my days, I find that almost all of my face time is consumed addressing the issues outlined above—I don’t “do” much. Early in my practice I had a patient who consulted me for advanced chronic kidney disease. I did have a fistula constructed, but he got sick before it was mature enough to use, so I ended up admitting him to the hospital to place dialysis catheters in his femoral vein. (This was before the days of the Permacath.) As I was loading the syringes with lidocaine and heparinized saline to start the procedure he looked up at me and said: “I didn’t know you did anything like this.” When I asked him what he thought I did, he replied: “All you ever did for me before was talk.” It is not just insurance companies that want us to “do something.” And we ourselves are programmed to “do.” It is difficult to realize that what our patients often need for us to do is to be present and attentive for a little while. 30 November 2016 [1] Rosenthal DJ, Verghese A. Meaning and the Nature of Physicians’ Work. N Engl J Med 2016;375(19):1813-1815. doi. 10.1056/NEJMp1609055. [2] Vance E. Mind Over Matter. National Geographic 2016;230(6):30-55. [3] Kaplan RS, Haas DA, Warsh J. Adding Value by Talking More. N Engl J Med 2016;375(20):1918-1920. doi. 10.1056/MEJMp16007079. |
Further Reading
Activating Patients - The Achilles Heel of Healthcare Reform? Studies show 25% of the population is not involved in their healthcare, but reform efforts assume wider application of evidence-based medicine is the key to better value. Perhaps it is the Achilles' Heel? Changing Physician Behavior Gail Wilensky, an expert on Medicare policy as observed that "changing physician behavior is harder than we thought." Patient-Centered Care A consideration of the interactions of patient preferences, evidence-based medicine and peer review. Physician Engagement Is physician engagement a strategy to promote physician leadership, or a code word meaning how do we get the doctors to do what we want? The Practicing Physician and Medicare What Business Are We In? All healthcare organizations have both a clinical and a business function. The proper balance is crucial for success. |