The Doctor-Patient Relationship
I realize it is confirmation bias, but the Shattuck Lecture, delivered by John Noseworthy, M. D., makes several cogent observations about the centrality of the doctor-patient relationship to provision of good medical care and the threats to its preservation. He states his argument thusly.
“Amid the complexities and changes in health care today, medicine’s most fundamental element remains the relationship between patient and physician. This relationship at the heart of health care has been a constant across cultures and centuries, and I believe it must remain central to medical practice even as medicine evolves. In order to ensure that it does so, we can advocate for two important principles that support this relationship. First, it is critical to enable physicians to spend adequate time with patient who need extra time, such as those with diagnostic uncertainty, those whose treatment plans are failing, and those at the end of life. Second, we need to identify and support the work of a coordinating physician for patients who are seeing multiple specialists, to ensure that everyone is talking with one another and, if there are disagreements, to clarify the diagnosis and treatment plan and help the patient make decisions about next steps. Working together, physician leaders and practicing doctors can take action to bring these elements to their practice.”
Dr. Noseworthy is not an academic theorist—he speaks after having served for 10 years as the chief executive officer at the Mayo Clinic. He is fully aware of epidemic burnout among health care “providers,” and its cousin, compassion fatigue, and the current stress on “efficiency” and costs of care. But, as he points out, spending more time on the front end is likely to save a great deal of money on the back end, particularly with complex patient problems. He also commented that even at the Mayo Clinic with its long-established culture of teamwork, we “must provide constant support, resources, and institutional prioritization for taking time to work in teams—time that is always in short supply in today’s climate focusing on productivity and volume. Relevant resources such as consultants, seminars, and toolkits to guide practice redesign, also require institutional support.”
He recommends several “action items” that should be a priority in all health care organizations. The first is aligning physician engagement, administrative support, and the culture of the practice to effect change. Second, prioritize identification of opportunities for innovation. Third, involve all the members of a team and get them to rethink the purpose of their work and the skills they bring to the practice. Fourth, identify the barriers to success. Fifth, create the role of coordinating physician. Sixth, build a relationship with administration for long-term support. “Redesign efforts are always more difficult and time-consuming than expected.”
It seems appropriate to pair this lecture with an op-ed published in the New York Times by Lisa Rosenthal, M. D., two days later. In this article, she relates her experiences trying to deal with the aftermath of a bicycle accident in which her husband sustained severe injuries. Her basic conclusion: “Much of what we accept as legal in medical billing would be regarded as fraud in any other sector.” She noted some of the charges were inexplicably high, but her primary concern was the charges for “things that simply didn’t happen, or only kind-of, sort-of happened, or were mislabeled as things they were not, or were so nebulously defined that I could not figure out what we might be paying for.” (Bear in mind she is a practicing physician—if she can’t figure it out, what is a layman to expect?)
“Why do insurers pay? Partly because insurers have no way to know whether you got a particular item or service. But also because it is not worth their time to investigate the millions of medical interactions they write checks for each day. Despite the advertised concern for your well-being, as one benefits manager enlightened me: they’re “too big to care about you.”
Today we have a system that is committed to “productivity” including what amounts to sloppy, if not fraudulent, billing practices and where no one has any commitment to defining “real” costs and accounting for them. Trying to drive the care process to attain maximum reimbursement has seriously disrupted morale in the primary workforce—practicing physicians—and created wide-spread cynicism, hence the needs for lectures like the one Dr. Noseworthy delivered.
I had an extended discussion of these issues with friends recently, and, as I pointed out, money has always been an issue. But in the “old days” when I treated people for free so did others. Nobody made any money out of the transaction—we all did it because we thought it was the professionally correct thing to do. Somewhere along the way—for me during the “managed care” days—the equation changed. When I treated someone for free, some businessman or executive made money on the transaction. The only person who lost money was me. Somehow it warps one’s view of charity care. But I think the practice was better, and more satisfying, when the principle was “take care of the patient and we can sort the money out tomorrow.”
The other issue, of course, is that if we, physicians and managers alike, are trapped in a fraudulent system, we are all having our values corrupted, (just as our currently coarse, divisive, and selfish political discourse threatens our underlying ideals of government.) Perhaps a “burning platform” reason to support payment reform is to stop the corrosive influence our current payment system is having on those who work in healthcare, and consequently on all of us who will eventually consume those services. Our efforts to protect turf/income streams at current levels is unlikely to succeed, and the cost may be more than we are prepared to pay. Think about it.
15 December 2019
 Noseworthy J. The Future of Care—Preserving the Patient-Physician Relationship. N Engl J Med 2019(Dec 5);381(23:2365-2369. doi: 10.1056/NEJMsr1912662.
 Rosenthal L. Where the Frauds Are All Legal: Welcome to the Weird World of Medical Billing. The New York Times, 7 December 2019. Accessed same day at https://www.nytimes.com/2019/12/07/opinion/sunday/medical-billing-fraud.html.
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