Medicine is a business. There is no reason why the practice of medicine should conflict with sound, and legal, current business practices.
Physicians are fiduciaries. That's an established legal fact. There is no ambiguity about that. If the nation needs a model to follow to reform the current corruption of the practice of medicine one only needs to follow corporate fiduciary law. Read the following definition and description of a fiduciary and the duty of care of a fiduciary from the Cornell Law School website:
https://www.law.cornell.edu/wex/fiduciary_duty
You really have to read it.
What you see described in this article, the physician's interactions and relationships with their patients are little more than a fiduciary's conscientious duty of care toward his client, principal or beneficiary. It's also mandated by law. It's not a touchy, feely option. For example, it is a breach of fiduciary duty for a fiduciary to profit from his position as a fiduciary. A physician who fails to listen to his patients and dismisses them quickly so that the next patient can be seen in the next fifteen minutes, so that a minimum number of patients can be seen in a day, is failing his fiduciary duty to his principals. To prioritize a hospital administration's, or an insurance provider's, including Medicare, mandates over that of a patient's best interests is a breach of fiduciary duty.
Most doctors today are criminals. Real estate agents have more integrity.
1
That the personal care of a family physician cuts medical costs is not surprising. But cutting costs is not an incentive in large hospital systems or the business of healthcare in general. The degree to which the demise of the doctor patient relationship is not only a casualty of modern medicine, but a design of the financial incentives built seamlessly into the medical-industrial complex, needs to be taken into account.
I hate the hospitalist system. He sees me as 77, heart failure, diabetes 2, right out of old lady central casting, no need to ask any questions. "Knows" this mix at this age. My primary physician sees me as person who worked to lose 50 pounds to deal w diabetes, retired diplomat, Red Cross in Viet Nam, Agent Orange and more who is 77 with heart failure and diabetes 2, managed w/o insulin.
3
I just retired from 38 years of hospital nursing. Every one of my patients or their families just wanted to tell their story and have someone listen to them. Each patient was a stranger at first, but I asked them about their pets, what they did for a living, how they met their spouse. I treasure their stories still.
One example of many why I have a hard time trusting medical doctors in this country: After I moved from Switzerland to the US I got terrible pain in my left shoulder joint every time I moved my left arm. At a sports physician's office the first thing the nurse did was to x-ray my shoulder. Only after that procedure I had a short conversation with the doctor; he told me I had a frozen shoulder and I would need to get some physical therapy. I know that my Swiss doctor would have come to the same diagnosis by touching my shoulder and moving my arm around. I wouldn't have been exposed to the unnecessary and expensive radiation. I often have the impression that medical doctors here are kind of afraid of the patients bodies.
1
It is sad that academic medicine and our managed care-focused bloated government bureaucracy have to use taxpayer dollars to "prove" in a randomized trial that a personal doctor-patient relationship saves money.
The author notes that hospitalists had been "proven" to save money. The lesson from all of this is that academics (in medical schools, schools of public health, business schools, and departments of public policy)-- who are never in the trenches and regard those in the trenches as inferior -- have promoted a whole series of real structural changes to the practice of medicine that have hurt patients and caused half of physicians to feel burned out. And the mainstream media have helped this process by reporting these theories as valid because they came from "professors' at the very best universities. All practitioners would do well to focus on real clinical outcomes in real patients and make that the focus of patient care. Computers are a vital part of that process but not for their current purpose -- (up)coding for profit. All of the randomized trials in the world, and even a single payer system, will not improve patient care as long as insurance company executives and their lobbyists control the way medicine has to be practiced.
1
This is a wonderful article. It is something that I truly believe in.
I had the same doctor since the age of 23, and when I turned 70, he retired. It is very hard to express how unique he was. He was about 75 or 76 I am guessing. He KNEW me. He understood my quirky ailments and he was a superb diagnostician who loved a medical puzzle and usually figured it out. But, what was most important was that he made the time to listen, ask questions, and check that I had seen the dentist, the gynecologist, etc. He also was hands-on, examining through touch and questioning. Most doctors today ask questions and then order tests, rather than do the hands-on examining that was common in my youth. He really left time to find out what was going on in my life because I think he knew that those things might be affecting my health.
I hope that the research that Meltzer is doing will lead back to emphasizing in medical training that "caring" relationships between patients and their doctors, who truly know his/her patients leads to trust and ultimately better health as the article showed.
1
Excellant article I enjoyed as a retired physician who had a fabulous experience with a great cardiologist at albert einstein montifiore hosp at Bronx,Dr.MENAGUS.People of his caliber&compassion gives us all hope in good medicine.As a great teacher even more so by training good future cardiologists.
There is no doubt hands on medicine saves both money and lives. There has never been any doubt. No segment of our healthcare system benefits from saving money. We are capitalist by nature. The more money saved, the less profit accrued. "Cheaper" and "less" is not in the healthcare lexicon.
Again, just plain commonsense wins. Just as children need touch, care, sustained constant and consistent care, so too do older people. The reason this is necessary is because all human beings require this type of care. People are not made to be passed around and through ever changing and new hands, which the human being finds impossible with which to bond.
Human beings of all ages, with all types of diseases, injuries fare better and longer when they bond with their health service providers, including doctors, nurses, social workers, physical therapists, dentists and home attendants. This is especially true for the one discipline which underpins a concept of bonding. . . psychiatry. A 15 minute session or exam is dollar wise but pound foolish. Remember, most folks walk this earth in the long run and do not pass through in need of pit stops.
Bottom line, dump the health insurance carriers and resort to a Medicare for all. Pay for what human beings require, namely, consistent health service providers. You will be amazed how much money is actually saved and how society will be improved. BTW, stop second guessing doctors over care necessary and pay health providers what they actually deserve.
1
It's all starting to change...
70-80% of healthcare costs is spending on chronic illnesses for which allopathic medicine has NO appropriate protocols, and this is what is driving costs out of control. Those costs are 75% reducible because the vast majority of those conditions can be prevented or reversed with lifestyle changes. The American College of Lifestyle Medicine (ACLM) is at the center of this change. Kaiser Permanente, still the largest healthcare system in the country, has already been recommending this diet for years, and Blue Shield of CA is just starting a program with ACLM.
Eventually, the PCP will be a truly personal physician again and probably would be on retainer to the patient as a lifestyle coach, and a medical subject matter expert, to manage any further health care needs. The rest then really becomes a matter of catastrophic health insurance. In the process we can cut our healthcare costs in half and PCPs will be restored to a meaningful function as Lifestyle doctors, which is far better than their current roles as legalized dope peddlers. I am writing this as the son of a doctor (albeit a psychiatrist), who passionately refused to become a legal drug pusher, and in his case he evolved his practice towards Jungian psychotherapy, amidst the rising tides of Valium and other psychophramaca.
Voltaire said - The art of medicine is to amuse the patient while nature cures the disease. I think the MD/patient relationship is very important in that process. I've stopped going to conventional medicine as I'm not finding what I need there. For a long time, Western medicine has only treated the physical body and not taken into consideration the psychological, emotional, and spiritual factors that are a part of "dis-ease". I think this movement to improving the MD/patient relationship is a step in the right direction.
I am a Internal Medicine Hospital Doctor/Hospitalist in a large teaching hospital in Los Angeles. Before that I did primary care for 17 years until I nearly had a nervous breakdown from the impossibilty of trying to see patients in 15 minutes. I love being a Hospitalist and it is especially great when I see my old patients from the clinic years prior to 2006. We still have a really strong bond which I love. It is unfortunate that the system is the way it is--completely dysfunctional.
One suggestion for your pictures of the "old timey" doctors would be to include a woman doctor. In this day and age to be so sexist is really surprising!!
4
I find it interesting to compare what Dr. Meltzer and his colleagues are doing for a Medicaid population to what concierge services are doing for the 1%.
Wouldn't it be wonderful if this was available to all?
2
To be pragmatic, I think we can take the argument out of the realm of warm and fluffy and look at this issue from a pure monetary standpoint and still make a case for supporting physicians.
Our system is anchored in physician decision-making. Even if the money doesn't touch our fingers, we authorize how it is spent and the money we unknowingly direct with the touch of a keystroke is orders of magnitude greater than what we are paid. When you pinch pennies on the doc, the work-arounds we find for the sake of our individual survival cost multiples of what is spent on us. We are burdened with a government designed reimbursement system that has cynically programmed pitfalls with the conscious goal of shorting us. We are mandated to use dysfunctional information systems constructed for the primary convenience of the IT masters and to enrich the lobbyist-protected monopoly that controls them.
Utterly, pathetically stupid and cruel system.
3
Thank you for putting value in the doctor-patient relationship. That is the reason I went into medicine and then after realizing that is not the incentive of our hospital systems I left the system and started a direct primary care practice. This has been an incredible experience for not only me but our patients. I now make house calls, fill prescriptions in our office and come in after hours to stitch up kids. It is not only sustainable but affordable. I actually save money for most of my patients despite the fact it costs them $65 a month to join my practice. In an error of high deductible health plans, direct primary care allows patients to have the freedom to be proactive about their care vs. always rationing their care. There is no doubt in my mind that trusting relationships improve overall health outcomes. Hopefully direct primary care practices will continue to flourish and be the norm.
1
My father was a general surgeon who worked 40 hours a week to put himself through medical school and graduated 3rd in his class from Temple. He never forgot what hunger and deprivation were and so, in concert with my RN mother, saw everyone and everybody. He was the only 'specialist' in a small Midwestern town; the only MD who would see anyone; at any time; no matter their ability to pay. Roosevelt's CCC camps saved his life and that of his family of origin.
A miracle worker? Yes, indeed. At a small Midwestern county seat hospital in the 50's and 60's - built with Hill-Burton, 1948, monies to put hospitals in under served parts of America (inner cities and rural areas) he saved a man's life who had third degrees burns over 99% of his body; only the bottom of his feet were spared when his tractor exploded in the field.
He methodically grafted the man's entire body from the bottom of his feet; inch by inch, patch by patch. The farmer was Catholic, had a dozen or so kids and a strong will to live - and a true physician by his side. I think this is one of the periods in my childhood that i simply did not see my father. In retrospect, I have a hunch he slept in his patient's room.
My father would say, "If anyone tells you medicine is a science, they simply don't know what they're talking about. It is an art - the art of knowing your patient." He would be overjoyed by this academic validation of his methodology - of caring for all.
2
I found this piece interesting....and sad.
By way of background, I grew up 'blue collar', spent 14 yrs in the USN, in the 70'-80'S.
I was the only person in my family who ever "went onto medicine".; but I discouraged my kids from pursuing it, though I think my oldest son would have made a good doctor...he's a forest firefighter/ wild lands EMT; he likes helping people.
I'm 69 yrs old-retired now-thought I'd work 'forever", but I' dropped out' a few years ago. I got out of practice because I could not stand the changes I'd seen the last 10-15 years.....The biggest problem with medicine today is the third party system/racket. In my opinion Single Payer would improve things, and after the "shake down cruise" was over, would save a lot of money-The third party maw sucks up 40%, off the top, while providing nothing of use.
I miss seeing/talking to patients, but don't miss the practice of medicne, at all.
Like I said, sad....
5
Good Luck! It's only going to get worse! Instead of The Hippocratic Oath, it's now Show Me The Insurance Card and Money! ( Despite all those ads about Caring! )
Maintaining good health and staying well, have never been more important!!!
2
When I was growing up, my family used a German-Jewish doctor who was a refugee from Nazi-Germany.
I remember him fondly.
He was a friend of our family.
You could always tell what he was having for lunch, because his wife was next door in the kitchen cooking it.
He lived just a few blocks from our house. He made house calls whenever they were needed, sometimes including minor surgery.
He came to the funerals of his patients.
Don't tell me that all of modern medicine is progress.
11
Acute pharma or surgical intervention can blow past $100K…
2 aspirin – ten cents…
So – how to help primary care folks establish and maintain more value than a bottle of naproxen while costing less per year than a week of Hep C drug…
First - dispense with abstraction and altruism…Prevention – like other free advice – doesn’t pay the bills…
Now - what are the here/near pre-interventional technologies that’d be worth the time and trouble…Glad you asked – suggested list, to start:
1. Whole-genome-sequencing…Folks who say this info isn’t worth having in your back pocket probably don’t have a smartphone in their coat pocket
2. Full-body scan by 3-Tesla MRI…Tried to get one a couple of years back – have had more luck getting pricing and specs from used-car people…
3. Circulating Tumor DNA/RNA testing…Like WGS, will make more progress and become more useful more quickly than incumbent labs will admit
Each should trend less than $1K, when in higher volume-use…Only 2 and 3 to be done regularly…
Backing each of these up is fantastic supercomputing and AI that could pretty much run a person's own game console, for their own diagnostic need…
And lose the stethoscope - for a pocket-sized ultrasound that also hears really well...
After year 1, just comparing with prior year data could be enough – my primary doc could take me through in 5 minutes, after getting the hang of things…
Anything more - still flows to specialists for intervention…
Just prevented a few heart attacks...
Some carriers of BIG INSURANCE are far worse than others since they no longer offer comprehensive plans and mask that fact with creative marketing regurgitations like:" the flu season is upon us and its a pleasure to serve you." Emblem health fraudsters are in bed with NYS and The City of NY so no matter how shady and nefarious their practices are, they can count on the public sector to enable them, at the detriment and expense of their patients.
This is really sad. Interestingly enough as my own career is slowing, I find I have more time to do this again as I really don't care so much about my productivity. I am working just because I want to
And in the USA, for-profit hospitals barely existed before 1970.
Kind of a big problem, omission, that this article makes no mention of that fact, and just treats for-profit hospitals as the norm.
Even so-called non profit hospitals are grabbing for the dollars. They are little better than the profit hospitals.
1
Aristotle Gluteus Maximus:
To a certain extent that's an unrelated problem.
Medical insurers, for profit ones, also didn't exist until the mid-1970s. For-profit medical insurance being illegal.
Now, more broadly you're describing non-profits being run to count dollars not care in 2018, which is a problem that stems from treating the delivery of medical care as a for profit business broadly, whether or not some particular hospital is non-profit.
The NYTimes has yet again omitted significant facts about medical insurance and hospitals in the USA.
"...what if hands-on medicine actually saves money — and lives?"
If so, lives will continue to be lost, and the cost of health care will continue to skyrocket out of reach of many people.
Google understands the importance of doctor-patient relationship and has infiltrated primary care practices in the SF Bay Area by providing Google Glass for primary care physicians. The idea is the doctors who use this device spend more time listening to their patients and less time typing into the computer. The win for Google is continued use of a failed device in the general population; the win for doctors is supposedly more direct patient contact; the win for patients - I am not so sure.
I do not like the idea of another human being on the receiving end of the Google Glass who is typing my doctor's dictation in real time (almost as if the transcriptionist is in the room) and if the camera is on, all is visible to another individual. It feels like a invasion of privacy.
When my physician uses Google Glass, I do not feel that I have more of her attention. In fact I feel like her attention is divided. I would much rather have her type into a computer, than stare off in to the air and talk to someone else during the exam. I now request that my doctor not use the Google Glass (and my request is often met with resistance from staff who are quick to point out that 'everyone else is fine with it" - I don't buy it).
The device has not magically turned my primary care doctor into a better listener. She was poor at that skill and still is. Going forward. when I am able to seek a new primary care physician, I will select someone who doesn't use this ridiculous device.
1
Doctors are burnt out by administration telling them 15 minutes a patient, by government regulations on computer charting, MIPS and other criteria, dealing with insurance regulations who deny payment. Medicare funding for new residencies has been frozen since 1996. So we have a steady supply of new medical school graduates who are $300,000 in the hole and no residency to train in. Pay being cut left and right. Sounds like a great field to encourage your children to go into.
1
Tingly has, in one sense, researched and written a powerful warning shot over the bow of the green eye shade guardians at the gates of our inimitably foul health care system.
But, in another sense, he has, at the outset, conceded to the barbarians at those gates the commanding heights that define the very way that we look at the world, and, in that, what we hold to be good.
I am not oblivious to the fact that we live in a capitalist system, which means everything’s inherent value is converted into an all-mighty dollar sign and then dumped, unceremoniously, into THE marketplace.
But, even though snared in that web, if it has any enduring sensibility, some things that are the measure of our short lives must be excepted from its grasp.
How we die, and how we extend our love to those in their final chapters, is the only bellwether of a civilization’s true worth, along with how we treat those people and species weaker than ourselves and in distress.
In that, Tingly has, to me, shortchanged the human experience by, in an effort to be heard in the crassest of times, accepted that truth only exists if it can be measured with a dollar sign, that the value of a medical care giver who actually cares must be substantiated on the bottom line.
Am I really that radical to cry out that doing the right thing for people, as people, not things, in our hour of need, when all of the appurtenances of a modern civilization wither away, is its own redemption?
Caring for another – so simple – so elemental – is the sin qua non of our human existence.
If we cannot get our health care system which mediates our last chapter to grok this, even if it – gasp – costs more, we have failed, utterly.
"But what if hands-on medicine actually saves money — and lives?" you say.
Why the question mark?
Research repeatedly supports the clinical efficacy of a close relationship with a physician with the inclination and the time to pay attention to something more than that weird splotch on your arm.
There's no doubt such a practice saves lives, is more time-efficient over the long haul and most important, saves money.
But "business is our new God" America practices what it preaches. Healthcare-industrial titans want max returns today. By tomorrow they'll have moved on, bought a pharmaceutical manufacturer, so who cares about the long run?
Still you should be clear: you're not talking about "the U.S. health care system", you're talking about a random pile of profit centers with no concern for patients other than avoiding controversy and liability.
You're talking about a pharmaceutical industry which demonstrates its depravity every day. Yes the scientists are brilliant and caring, but they work for monsters of greed and deception.
You're talking about an insurance industry which offers nothing to the welfare of the nation but grabs a trillion dollars a year while perfecting the one thing it knows: denying care.
You can tie that up in a single issue: politicians so venal they literally don't care if their grab for influence and cash costs constituents their lives. Pols so doctrinaire they believe to their Calvinist core that if you can't pay the premium, you should die.
1
As a 67 year old Family Physician I can say that all physicians see this albeit from different perspectives. I was fortunate enough to enter medicine before the total commercialization and the subsequent erosion of primary care. I have a thriving practice of 30 yrs in the same town, currently have a wonderful Nurse Practitioner and only recently gave up my hospital practice. I have watched many colleagues sell their practices or retire in the face of current changes. The EMR never made sense to me nor did the fact that there are so many vendors with so many products...so I refused to comply. My practice is 50% Medicare and I am penalized 1 to 2 % per year. Next year it is 4%. So we watch overhead, get by with a bit less, but are by no means starving. I see 24 patients a day...mostly complex, and have an excellent Medical Cost Ratio as measured by some Medicare Advantage Plans. If we as physicians would commit to providing excellent care where listening is talking we will keep the costs down. We make enough money! When we allow commercial interests to govern our profession we spell doom.
I know I am a dinosaur, but thank God there a few left. Please patients, insist on more.
I am fortunate to have a hands on physician, who personal and professional attention I have been blessed with for over 15 years. When he retires, I will probably lose forever the thorough and compassionate service he provides.
In fact, his practice was recently absorbed into a much larger medical organization, which wanted him to significantly increase the volume of patients he saw, thereby significantly decreasing the amount of attention he could give them. To his credit, he refused and limits himself to the number of patients to whom he can continue rendering personal service. I am one of the lucky ones.
I wish the story could end there but it doesn't. Incredibly, the larger organization informed me that I would have to pay them an additional annual fee to continue seeing my doctor, apparently to make up for the revenue lost by his refusal to see the volume of patients they required. My doctor told me he doesn't see a dime of this fee, but that it was the only way the organization would allow him to see a more limited amount of patients. In other words, all the organization cared about was an economic target, no matter how they had to reach it, even if that meant imposing a "privilege tax" on seeing my doctor.
Medicare or expanded universal healthcare will do nothing to remedy a situation such as mine. Personalized care is the inevitalble casualty of the way our medical system is evolving. As the last family practitioner retires, they will become an extinct species.
1
I have been a nurse for 35 years. I can think off hand of 1 physician practice where the doctor, whose father had also been a doctor in the same town, knows his patients. He has treated many of his patients since they have been children and knows what their families and home lives are like. Yes, this makes a difference. I agree with the other comments that the electronic medical records do little to enhance communication, they are a series of check boxes and will never be able to replace a good narrative note.
1
Has there ever been a better agreement for Medicare for everyone than this article.
For decades physicians feared the intrusive arm of government into their practices but have now found to their dismay the intrusive arm of Health Insurance companies and their immediate large clinic employers are far, far more intrusive and demanding than the government ever was.
When I was a Pediatric sub specialist taking care of my patients in the hospital; patients in whom attention to detail and great knowledge of their pathology was essential for their well being I never would have considered abondoning them to a hospitalist. Making hospital in the AM and before going home from the clinic and perhaps in the evening was one of the joys of medicine to me.
A Harrison wrote in the introdeuction to his textbook of medicine " To care for the patient one must care about the patient".
2
I think a better perspective is to understand that the US health care system is not about saving money or lives. It is about maximizing profits. Hence, as Paul Krugman, and many others, pointed out we spend more and get less. Profits and humane care cannot co-exist.
I would be interested to see the results of the research. Personally while most of my doctors have been great, I find the 10 minute bustle in and bustle out visit frustrating. Especially as a woman whose symptoms often are minimized. Not having medical expertise, it is hard to know what symptoms to mention or bring up during a routine checkup. I feel like I have to bark out a list of things before I lose the opportunity.
1
This article is very well written. However, it ignores the very basics that came out of the first nursing...from ancient Greece. Nursing has always incorporated the connections that this writer finds astounding in a modern "retry" clinic. That is, nursing has understood the identification with the patient and that sameness is required between the caregiver and the patient. With their own modern reinvention, as nurse practitioners, everything in this article that the Meltzer clinic was just confirming was incorporated into the basis of every Nurse Practitioner program in the USA, and in the World. These basics, these mandates, have been understood for thousands of years, and were again identified within the groundwork for Nurse Practitioners. It is very wrong to focus on the MD, especially in 2018, as medical care is a team effort. And other parts of the team, like NPs, have gone ahead...while incorporating those thousands of years of experience, while MDs, as described in the article, were bogged down with the for profit model. Nurses, in general, start with a basic requirement that has been left out of MD prep in modern times. And that is that caring, compassion and sacrifice, in most cases, may be as strong as the best patented pharmaceuticals.
2
I would never let another NP touch another member of my family member again. One of them tried to send my sister home with appendicitis from her urgent care being told it "was just a bug" gave her a shot of antibiotics and NEVER touched her stomach. So much for caring and compassionate. And when I asked the medical records to pull her chart she lied and said she had done a pelvic exam too and my sister must have forgotten. She is a high school teacher so I think she would have known if she had a pelvic exam. Luckily I have a neighbor who is retired doctor and got him to examine my sister. He sent her straight to the ER and she had a nasty swollen appendix that needed to be operated on immediately. The surgeon said it was close to rupturing. Buyer beware. Ask the credentials of who is seeing you. You're paying for it with your insurance premiums, so you might as well get the doctor. My sister didn't even know she wasn't seeing the doctor because the nurse practitioner didn't introduce herself.
1
I have trained primary care physicians in doctor patient relationship skills/issues for many years. I've also watched them graduate and start working for large multi specialty groups in San Diego. They graduate wanting to know and care for their patients. They often pick primary care (which is less lucrative) for that reason. Within 5 years, they change. They just want to survive, have a personal life, and get home before 10 pm. They finish their charts electronically at home later that night. They are widgets in a heartless system where there is no encouragement to care for the individual patient. Their work is to make the business system more efficient and perhaps try to keep the "customers/consumers" nominally satisfied so they won't change medical groups at the next enrollment period. George Engel, the creator of the biopsychosocial model, said that the way (physicians and medical groups) treat each other will eventually be the way individual physicians treat their patients. The physicians are victims of heartless indifference as much as the patients and it is only getting worse. I could make a list of recent changes in the "supply chain" that prohibit physicians from developing relationships with their patients. I don't see much hope on the horizon at this point in time.
4
My last few primary care docs have barely looked at me. Their eyes are focused on a computer screen whose algorithms instruct them as to what to do. These PCP’s could easily be replaced by intake hostesses with six weeks of training, And after spending lots of hours in hospitals as an advocate for ailing family members, I would estimate that the nurses spend 25 times as much time looking at computer screens than time with their patients.
1
What really frustrates me about this is that I have to fill out paper forms in the waiting room, the nurse rights down info, and then the doctor still asks me questions showing that he/she has not read any of my records.
My provider became a part of the NYU Langone behemoth a couple of years ago and the next time I went to see my doctor, every square inch of the facility was now paved with screens, for purposes of data-entry. The technicians who weighed me and took my blood pressure, usually pretty straightforward, had to do so multiple times because they were so preoccupied with their screens and my doctor spent most of our time with his back to me, either consulting his screen for past info or entering new information, which I provided from eight feet away. I happened to like this guy when I first met him a few years ago because he actually engaged me in conversation, but now he was reduced to another cog in the NYU meat processing plant. I don't know who I felt sorrier for, him or me.
7
If it ain't money, it ain't free market capitalism.
How can I talk with my doctor, when almost all of his time is updating my records?
Money talks. Humanity and consideration walks.
4
We have a severe doctor shortage in the US which will only get worse with high medical school tuitions and the hiring of excess administrators and CEO's with the highest wages in decades. The DACA residents in training at Harvard and many other medical schools across the country have no secure futures. We have an even worse shortage of nurses. The US spends more than many countries on healthcare and our outcomes are worse. It's all about the money now, forget about health.
5
In Eugene, Oregon, the Ultra Sound and CT Scan has increasingly replaced the traditional "wait and see approach" for early diagnostic services. This "hand off to the specialist" practice results in needless patient distress, greater health insurance expense, and the loss of the hands on expertise of a coordinating primary care physician.
3
I had a primary care doctor for about forty years. He knew me, we talked. I trusted his advice. Unfortunately, he was older than I am and he passed away. I sought out a new primary with comparable style, but it is not the same.
2
Nothing will change: we have been duped to accept that health care is not a right but a very lucrative industry. Novartis and Mr/ Cohen of the Stormy Daniel payment is the latest grotesque example. We are just consider merchandise, so forget about any other "value" than profit in our relationship between doctor-patient.
1
“On a Monday morning in August 2016, I went on hospital rounds with Krishnamoorthi, as he performed the same duties a hospitalist would with one key difference: He already knew the patients.”
The true ”value of the Doctor-Patient Relationship” for me is an intrinsic, priceless one. My husband & I have been with the same doctor for 25+ years. We left the cheaper HBO so we could choose him, regardless of the cost increase of the medical plan. He actually saved my husband's life on more than one occasion.
We cherish our friendship with him as well as his honesty, integrity, knowledge of our medical history, and most importantly – we know & trust him. He does his homework whenever it comes to something new we might be experiencing; he is aggressive with ordering the correct labs or tests we might require; he never hustles us in our appointment, even if he is running behind schedule (which is often).
My biggest complaint when seeing a new doctor as a referral is that they are so young - I have shoes older than most. Also, they seem to parrot the medical textbooks with their opinion before even hearing me out completely as I describe my symptoms. I also get hustled out of their office because they seem intent on keeping appointments on time than actually listening to the patient.
I can see myself seeing a doctor less and less once our physician (and friend) retires. It’s difficult for me to see a physician if that trust factor is missing from the equation.
16
Of course, we all want patient, caring doctors. And we all recognize that they need to be fairly, even generously compensated.
Yet, as far as I understand history, doctors' incomes began to rise steeply (some specialities more than others) when we shifted from patient self pay to the current insurance model. Doctors who don't want to be dictated to by insurance companies could opt out right now--but then they would only be able to charge what patients could pay. That's a tough adjustment to make.
And medical tuition increases paralleled physician income. We can't expect doctors to work for "reasonable" salaries when they are carrying unreasonable debt.
And unless we significantly increase the number of people admitted to medical school, even Medicare for All won't buy us more time with our doctors.
1
We must have a system where the doctor and patient have most control. I have experienced care that needed extra scrutiny from the health insurance: I also had doctors schedule procedures that were not neccessary, in order to gain more income. We have no trust any longer in our relationships.
It's frustrating to deal with PCPs when you have chronic conditions. I have a few, and in every single case the PCP I was seeing has told me "I don't treat that, here's the specialist". I'd love to have one doctor who oversaw my care and was able to coordinate my meds, but it's not going to happen. Why should it? A $20 copay for 4 doctors, each, is a lot better than a $20 copay for 1 doctor taking 4 times as long.
Follow the money.
4
It is curious how the industrialization of automobile production, aircraft manufacture and other goods actually brought the cost down, but in the case of medicine and pharmacology it has not. Your thesis subject for today, students.
3
My husband is a 60-year-old family physician in a rural area in Kentucky. He was bought out by a large healthcare company that didn't like his old-fashioned doctoring ways, didn't renew his contract and hired nurse practitioners in his place. Now he is struggling to start over in a medical world that absolutely does not value the doctor-patient relationship and we may go bankrupt. It's the saddest thing I've ever seen and it makes me furious.
43
Within the last couple of years, my spouse lost three (primary care)doctors--mostly because they were fed up with the system. They couldn't stand typing into a computer as opposed to actually examining a patient.
I've had my share of nurse practitioners and medical assistants who attempted to be stand-ins for doctors. Most did not help me one bit--in one case I had to file a complaint. The NP pretended to be a doctor. Not only that, she was one of the most derogatory health care providers I have ever had on my health journey.
American health "care" is the most infuriating system--both for patients and doctors.
4
Too many doctors profit. I'm concerned about the patient.
While escorting my aged mother to her various doctor's appointments we encountered several nurse practitioners. One had proudly returned from school where he had obtained his PhD in nursing, therefore he was a doctor, and that is how he introduced himself to new patients. He was a nurse and his medical charts were still signed by the supervising doctor. He wrote my mother a prescription for 60 Vicodin tablets with a refill for 60 more.
Two other NPs seemed to have a brain freeze in the middle of the patient interview. They just blanked out and stared into space for a few seconds. I've seen others comment on the same phenomena displayed by NPs or physician assistants they have encountered. Those vacant stares represent the vast chasms in their education, but they like to play at being a doctor.
I could go on with examples but I am convinced that nurse practitioners are still nurses and have limited ability to provide quality of care equivalent to that of a qualified physician, no matter how indignant they are and how much they protest in defending their "profession". In my state they are grossly incompetent.
as in emergency room nurse, and soon to retire,i can honestly say that EHR computer charting is 100% data entry purely for billing puposes. the drop boxes, " smart phrases" and so on just make every patient look the same. i miss the days of real assessment and pen to papaer.
20
Recently had the unfortunate experience of having to use the emergency room @ Cornell in NYC. Amazingly brazen ripoff. Charge the ranch to train new parasites and accomplish zilch.
It is true that the Dr./Patient relationship is paramount to care. However, Drs. have too many patients to care. They must form a close relationship much too quickly to meet the number of appointment quotients of the day. Drs. need to have a trusting relationship, or patients will not confide or ask questions. Drs are too busy and too required by the larger organizations that own them and their time to have that relationship and quite frankly, the younger generation will not notice. Their care will always be such. I can clearly see that any Dr. I go to is distracted by their computers. The best ones try to bridge the divide, they try to bring you in to their conversation with the computer yes, but if there are other Dr. reports in your file under the Umbrella organization's viewable file by any Dr. or other office worker, my Dr. is often double distracted by their and his own visit requirements. Thankfully, a Dr./patient relationship will never be of import to the next generation who are just as distracted by technology as their Dr. and as the Dr. Patient relationship goes the way of parking meter poles, Bridge and Highway toll boths, writing paper checks, things change, its the way it is.
3
It is possible to have such doctor-patient relationships in a single-payer system. In Taiwan, you can choose your doctor, and the system encourages everyone to have a primary care physician. I now have a regular GP, cardiologist, and ophthamologist. Because each prescribes long-term medications, I see each one four times a year, to renew prescriptions and do annual screenings. Medical records are digital in Taiwan, but each doctor has a nurse assistant to input data and schedule the next appointment while the doctor talks with the patient, referring to the medical record on his/her computer screen. Since the doctors know me so well, it doesn't take long for me to mention any recent concerns, and the GP and cardiologist easily keep track of tests and medications the other has ordered. After my GP's initial diagnosis of pulmonary hypertension, he referred me to a cardiologist, who conducted an extensive series of tests to find the cause and started treatment. At my next regular appointment with my GP, I expected to fill him in on all that had happened, but before I could start, he gave me a detailed report---he had been following the cardiologist's entries in my medical record in the intervening 3 months to see how I was doing. I was deeply impressed by his concern! And the costs of all this are completely covered by the NHI.
9
Doctors have been losing to hospital administrators in the battle for resources for the last thirty or so years, which I've never understood because a hospital only actually needs one of those two groups.
To all the doctors out there: Band together, recognize your value, negotiate as a group, and a you'll be able to dictate just how much time you get to spend with your patients.
14
That's exactly how medicine got to where it is.
What a fascinating and wonderful article Ms. Tingley. I'm on a project with a major insurance carrier and I've forwarded this article around the office. Awareness can bring about change. I'm hopeful.
2
As a physician for many years, I can state that there is nothing new or surprising in this. The problem that the author seems to overlook is that nobody has any incentive to save money.
Hospitals want to fill beds and have their doctors do as many as tests and procedures as possible because that gets them money. The doctors that do the most of these procedures and tests such as surgeons and cardiologists are viewed as being at the top of the heap. Doctors who spend time talking to patients for which they receive little compensation and don't use expensive testing much less procedures such as primary care docs and psychiatrists are at the bottom of the heap.
We don't have a healthcare system; we have a healthcare business system where the first and most important thing is to make as much money as possible.
Our current insurance paid system reinforces this as it doesn't care about preventive care because companies figure that it doesn't pay because by the time someone they cover comes down with a disease there is a good chance another company or a government program will be covering them. If we had a single payer system where all costs come out of the same pot, things might be different. But, of course, this makes too much sense so its unlikely this country will ever adopt it.
44
Kudos. Wish there were more than 47 like you.
This is not news. Over 100 years ago the founder of modern medicine, William Osler wrote: It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has. The EMR is an efficient data gathering and billing tool, but a huge impediment to getting to know patients. Getting to know patients requires visiting with them, looking them in the eye, talking about the things they want to talk about - not completing a series of checklists from the EMR. The system we have now is delivering exactly the results it is designed to - exorbitant cost, dissatisfied patients, and burned out physicians.
25
We may need to put a $ value of the doctor-patient relationship. But we also need to value the doctor-patient relationship. Unless both parties are willing to hear and engage with the other, quality of care and outcomes will continue to decline.
1
Thank you for this article. A doctor visit is not just another consumer product that can be governed by "free market" principles where patients shop around to get the best price; a doctor visit is a long-term relationship that improves health by being stable, familiar, and trusting.
13
How timely this piece is! I'm a pediatric subspecialist (neurology). Just yesterday, I attended a coding/billing meeting where a consultant explained to myself and other doctors why our EHR notes needed to be "beefed up" to justify the amount we billed. She then gave examples of how to earn points that justify billing, for example, a 30 minute visit. Some of the ways doctors can rack up points: ordering lab or radiology tests, prescribing medications, and referring to other physicians. She seemed incredulous when I explained that my visits take 30 minutes even if I do none of those things. Many of my patients have severe developmental and behavioral problems, and their parents just need to vent, or discuss what we could possibly do to improve their quality of life.
According to Coding lady, none of this face time was billable. I would only get paid for 15 minutes even if I spent 40 with the patient, because I wasn't earning enough "points"
This perverse system is everything that is wrong with medicine today. I only started practicing 12 years ago, but already am disillusioned and burned out. And so are my colleagues. There is even a Facebook group called "Physician Side Gigs" because doctors need to supplement their income by selling cosmetics (I kid you not) or get out of clinical medicine when they can take no more. This is not what I signed up for.
59
Anjou, the coding consultant should have explained that you can bill by time. Any competent coding consultant should know that. But the perverse part is that you can only bill for time if you spend over half the visit performing “counseling or coordination of care.” So if you spent 21 minutes of a forty-minute visit counseling the patient, you can bill at a higher level. If you spent forty minutes analyzing a very difficult case, you get no credit for that.
Even more perverse is that if takes longer for you to do the exam or take the history because of physical or developmental issues, you can’t bill by time unless you do the counseling also. But now the counseling has to be longer because the length of the visit is longer and the counseling has to be at least 51% of the visit. Which makes no sense.
Wow! Thank you for illuminating what really goes on in medical practice today--very, very dispiriting. What can we do to change the system? I've noticed changes in the way medicine is delivered, but didn't know what was happening because patients aren't informed of these behind-the-scenes billing practices.
1
I'm a primary care internist. It's surprising that the coder didn't mention that there is a way to bill for time. For example, 99214 CPT code has a time of 25 minutes, and 99213 has a time of 15 minutes. But it is true that we may be questioned less by insurance companies when they audit our charts if we order many tests, meds to justify our billing.
Does anyone know of someone who praises his/her doctor anymore? Does anyone know of a doctor who touches their patients - with kindness and care - and puts the patient first? I imagine not many people, especially older people, can say yes.
Medicare and Medicaid have become nothing but overused credit cards for government welfare to corporations and academics.
Right now I'm experiencing serious trouble with my eyes from what doctors call an "autoimmune disease". Of course, they have no idea what causes these diseases - which are primarily women's diseases - but they keep giving unproven drugs after checking their computers. I have to see four "doctors": one for allergies that might be causing the problem and THREE for my eyes. One for the back of the eye, one for the cornea and one for the outside of my eyes. It's simply ludicrous. They are breaking our bodies down and one day, unless we stop them, they will have a doctor for every cell in our bodies.
WE THE PEOPLE need dedicated, honest, humble medical providers. They are nothing without OUR bodies and money - personal and government.
It is time to take the profit out of the medical complex. Reward true professionals like the doctor mentioned at the beginning of this article. Send the rest to work at McDonalds.
11
a recent Harvard study confirmed the US Healthcare system is extremely expensive compared with other high-income countries :
"Health care spending in the US and other high-income countries", Commonwealth Fund (Publications/Journal Articles Summaries section of the website), 03/2018.
and a 2011 study showed that the US are last on preventable deaths :
"New study : the US ranks last among high-income nations on preventable deaths", Commonwealth Fund, Newsroom section of the website, press release dated September 23, 2011.
Money doesn't align with value, as the article states.
2
Clinicians are in a bind: becoming truly skilled & wise physicians requires great dedication & focus. Fighting risk management, hospital administrators & insurers so they can do a good humane job caring for patients is a full time job in itself.
Common sense should reveal that a long term relationship with a primary care MD reduces errors & cost. Infatuation with autonomous app-based health technology is the naive preoccupation of young& healthy millennials.
Can physicians, nurse practitioners and patients restore sanity & efficacy to basic care? Can activism & resistance coexist with meticulous attention to each patient’s individual complexity? Can medical education revive training for more than canned empathic statements and prioritize knowing & understanding each patient?
Yes. Social justice & unconscious bias now preoccupies many med students. What they must confront is that no decent therapeutic encounter can unfold in 10 minutes under an assembly line management production pressure.
10
I would like my Dr. to be a skilled,competent,clinician period. I have little interest in "bedside manner". You can be pompous,arrogant,standoffish, just be highly skilled at your work. The rest I'll leave to family and friends.
3
FJS--I've worked for a lot of doctors and I can say that the majority of them with "poor" bedside manners were the tops in their field.
One of the physicians I worked for is an award-winning, well-educated, experienced clinician/surgeon. I had to constantly assure patients who complained to me about his bedside manner that he was truly a caring, more than competent, doctor who loves his patients. Not only that, I didn't get one complaint from a patient AFTER their procedure was finished and they were on the road to recovery.
1
As a physician, I agree to some degree with FJS with regard to the comparatively unimportance of bedside manner. You want doctors to be doctors, not friends.
The problem with what he or she says is that I've never met an arrogant or pompous doc whom I would trust. The great physicians I have known and the ones to whom I have entrusted my health and that of my family have neither of those characteristics. Generally I have found that those who possess them usually do so because they have to cover up deficiencies in their knowledge.
2
A recent book, "God's Hotel," about the Laguna Honda care facility in California discusses this very subject. The author is Dr. Victoria Sweet. It is very readable and eye opening.
1
There are solutions.
E.g., "...He objected to the increasing industrialization of medical care, in particular a new Medicare mandate that he update patients’ medical histories electronically — not because he was old-fashioned or contrary (though he was both), but because the idea of dividing his attention between a computer screen and a patient offended him.".
Use a medical scribe. My PCP does; make a huge difference.
And no one requires a doctor to use electronic notes during the interview. The reason docs do so is to save time so that they can see more patients. There is no law or regulation that prevents docs from taking paper notes during the interview and putting it into a computer after the end of the visit.
1
My primary care spends two hrs, uncompensated, of her own time, every day after work doing this. Not a good idea.
4
Of course, medical scribes are not free.
Private patient advocates like myself who bridge the communication between patient and physician have long wished for a quantitative measure of the cost benefit to delivering more patient-centric medicine. With medical error being the third leading cause of death and communication errors being the number one contributor, the results come as no surprise. Doctors are only as good as the information at hand. Our job as patient whisperers is to efficiently deliver all the clues so that he or she can make solid recommendations for their patients. My experience is that the story isn't usually in the numbers tracked on the computer screen, but rather in the home environment where life plays out. Bringing forth that nuanced information is often life preserving and even life saving. Everyone wins.
1
As the widow of a physician who thought nothing of spending his Sunday afternoons visiting patients in the hills and forests of western Oregon just to check blood pressure and see how they were doing, I resent living in a town where very few physicians are taking new Medicare patients. And I can't afford the outrageous fees that health care givers charge these days. I really miss the caring, intelligent, sincere doctors of the good, old days.
20
If we had a single payer system where it didn't matter what type of insurance you had the doctors would get paid the same, it would solve that Medicare problem that is growing at a rapid rate as our population ages. We don't train enough primary care docs and the problem with Medicare is finding these kind of docs because Medicare pays a lot for tests and procedures and little for talking with patients and psychiatrists, whom are paid so little by Medicare that few bother to participate in it. You can easily find surgeons who will see you because we already have too many,
3
My physician husband wants to accept Medicare, but they dropped him out of the computer system when he was not practicing due to a dispute with the large health care company he worked for. Now he's back on his own, wants nothing more than to take every Medicare patient who walks in, and cannot. We've paid thousands of dollars to companies and now a lawyer to get this solved. If Medicare cared about patients, this would not be a problem and everyone would have the doctor they want and deserve.
Few Doctors like that are left! Additionally, when some of us realized that the central part of a regular office visit, was having our Blood Pressure taken, we went out and bought a BP monitor, and checked our own! Amazing, how much money and time that can save.
1
The goal of medicine is to push you thru the system as fast as possible, while spending as little as possible and making sure the billing is maximized. Care givers are assembly line workers and nothing more. The next time you see "your doctor" watch how much time he/she looks at you vs how much time they look at their computer ( and that's about checking boxes for billing). They are rushed to get you out the door so the next person on the assembly line can get in. Some one has to pay for the bloated overhead of administrators, middle management, regulators and others who contribute nothing to health care except cost, and you're it. Ask your doctor what stresses them most. It won't be keeping up with the latest medical info, it will be ehrs, not upsetting a manager and not spending too much time with you or getting you out the door before your insurance runs out. This is medicine as a business, not health care. Think I'm wrong? Google who makes the most money in health care. It isn't someone who went to med or nursing school.
4
You're right about almost all of this, except it's not just the "bloated overhead of administration etc." that they're paying for. It's their own bloated compensation which is far greater than in any other country in the world. Google it.
May I suggest one small correction: it should be "the goal of the healthcare industrial complex", not of 'medicine'.
Physician take home pay is 10% of total health care spending (nyt source). So cut them to zero. You save 10%. And the highest paid people in the medical-industrial complex are not MDs, they're CEOs. Do some MDs make too much, probably, but not primary care folks, I stand by my statements.
"Surprisingly little is known, though, about what the relationship between a patient and his or her primary-care doctor is actually worth, in terms of that patient’s overall well-being or medical costs, regardless of who bears them." There is actually much known about the effect of personal caring on health by other professions, its just that personal caring is not valued by medicine. There is abundant research concerning the effectiveness of the "caring relationship" established by nurses with patients, and how this has a positive impact on health outcomes and money. This is also true for other professions. Medicine is paternalistic. "Caring" has always been relegated to the "women folk", like nurses. I doubt that any research will change the paternalistic business model that controls medicine. Doctors are uncomfortable when patients cry in the office. Today's medical students have a clear eye on the most lucrative professions, not a crying patient. Too few see their profession as a vocation, or understanding the value of listening, taking a careful history, and actually touching a patient during an examination. What is the value of a doctor-patient relationship? When physicians see 40 patients per work day, not much.
1
There's no billing code for personal caring.
9
Personal caring may not be valued by the healthcare industrial complex, but that's very different from 'medicine'. And why must you tear down doctors in order to promote nursing? Can't we all support one another or is that too kumbaya in this dog eat dog world? Btw, half of doctors are women, as am I. Furthermore, guess what, the men care too, if you just let them. Yes, men have feelings too, surprisingly! Lay the blame for any lack of caring on the MBAs, the CEOs of insurance, the admin and all the parasitic layers interfering, but why blame doctors who are victims of all this?
It doesn't matter to the insurers. There is a strong likelihood that when early symptoms become a "must treat" diagnosis, the patient (sorry, member) will be another insurer's problem.
6
I've been a family practice physician for 35 years and wish I could have found a practice like Meltzer's. Spending time with patients is the one thing that makes medicine enjoyable for me and effective for my patients. When a patient brings in a list of 20 symptoms, instead of blowing them off and only addressing the "most important" as my colleagues would do, it was clear to me that all the symptoms are likely connected and addressing all of them is the only way to figure out what they mean and what to do about them. By spending time, among many other benefits, I've prevented patients from committing suicide, identified elder abuse, diagnosed severe depression and anxiety, tailored treatment to best fit with patients' lives and schedules so it is more effective, and kept patients out of the hospital. By spending time, I obtained much for information from my patients so that my diagnoses were more accurate without requiring testing or referrals. The current health care climate is profit ahead of patients, and demands short visits, excessive referrals and excessive testing in order to boost profits for health systems. Resident trainees are told that every symptom requires a prescription, and every diagnosis requires a referral. Medicine has become so stressful for me, always trying to buck the system, that I have given up. Hopefully articles like this and studies like Meltzer's will provide support for a better kind of practice.
25
Great comment. We need more physicians like you. I have watched my favorite doctors go from being happy and enthusiastic, to grumpy, rushed and judgmental. More and more I make a specific point of asking how they are doing (I don't expect any particular answer) and letting them know I appreciate their time with me, hoping this will make their day a bit easier.
If we don't stem the causes of physician burnout, everyone in this country - even those who make high profits off of sick patients' backs - will receive poor medical care.
1
Obviously having a personal connection to a doctor is cost efficient. Just witness the billions of dollars (usually taxpayer's) wasted on ER visits yearly by patients who do not have such a connection. Often for a small problem which could be resolved in five minutes on the telephone.
4
It is interesting to me that a lot of the comments blame the doctors. To me, this is a sign that you haven't really talked to your doctor. I've lived in vastly different regions of the country and dealt with a variety of doctors. Very few of them went into medicine for the profit aspect and they do not like where medicine is going. Many have developed a variety of workarounds to try to get back to caring but are overcome by a financial system that limits their ability to care. "For primary-care doctors — paid the same for a simple exam of a relatively healthy patient as for a more involved consultation with a chronically ill one — this created a perverse incentive: see as many healthy people and as few sick people as possible." If you actually HAVE the conversation with your doctor, you will discover they don't like being factory workers measured by production -- they want to care for patients.
19
Anita
I agree so totally with what you say here.
But from a historical perspective, doctors did this to themselves. They lobbied, through the AMA, for practices run by administrators, not physicians. They lobbied for group structures that allowed greater efficiencies and more income.
They never wanted to end up here, I know, but once they opened the door to practice for profit, once they handed off supervision of every detail of a medical practice, they sealed their own fates.
Now, having lost the social prestige, the autonomy that marks a true profession, control over their decision-making and their time, they are in little better position than cashiers and clerks.
And they haven't hit bottom. With the advent of internet medicine, the take-over of patient information-giving by pharmaceutical giants; the solidification of administrators with no medical sensibility in positions of authority, doctors really are just cogs in a machine that will never be able to provide suitable care until it is dismantled completely.
Some commenters asked "So what do we do, put millions of employees out business and give them benefits?"
Yes. Exactly. They had a run of a hundred years and profits that few ever dreamed of. Time's up, boys.
Health insurance alone siphons a trillion dollars a year from our health care system, and returns not a thing. Those corporations, those jobs, must go. They can work in our new single payer system.
I used to have conversations with my doctor. But he "retired." No prizes guessing why. Now its, "Fill out this ten page form before your physical, it will save both of us time." On that basis, I have been seriously misdiagnosed because there was no discussion of the "why" I was having certain symptoms. Kaiser's obsession with "evidence based medicine" is a euphemism for "let me look that up on my computer and the algorithm, intermediated by the bean counters and statisticians, will tell me what treatment to offer."
It's not really the docs, it's the system. But the new docs are being educated in the system, are brainwashed by a big data mindset, and most will never know what a real physician-patient relationship looks and feels like.
Value? No. Increasingly worthless to docs and patients, big bucks for bean counters and administrators who are choking off health care.
Thanks for your thoughtful response. I agree, it's the system and the education and I'm not too happy about the bean counters either.
AFter my doctor went into concierge medicine, I went to another doctor in the same location. Within 10 minutes she had written three prescriptions which were questionably needed and denied information regarding an antidepressant I was taking. When I arrived home, I faxed to her the article proving my assertion regarding the antidepressant as correct. All she knew, as an internist, about antidepressants was what the drug sales person told her. Her husband, a neurologist has a well known reputation that several doctors have told me that this doctor is only in it for the money and is interested in easily billed procedures. The only other neurologist in town, studies the eeg's done during the week on the weekends. I have never received a bill for that extra time. The internist I have now spends all the time you need but you pay for that by waiting two hours to see her. I saw a specialist about a long list of problems and she told me when each 10 minutes had passed as we continued the lengthy appointment. I do not know if she charged medicare for each 10 minutes. You pay for the care you want, one way or another.
3
Nowhere is this trend more sad than psychiatry. We, too, are reduced to 15 minute "med checks" which also include time to document (on a screen). Trying to really know the patient and understand them in the context of their depression or bipolar disorder is frowned upon. Appointments are double booked in case there is a no show. In psychiatry, like all of medicine, we can only do so much on the biologic side. Once their "meds are tuned" there is a wealth more to talk about: their relationships, their children, their frustrations with work - so many things. And yes - they can go to "someone else" for that - but isn't that why most of us went into psychiatry in the first place? There is an active blog post on one of the physician sites right now that starts with the premise that psychiatry residents shouldn't be trained in psychotherapy at all - it should be an elective. While many on the board pushed back...many others did not. Sigh. One of my early mentors said the most important thing you can do is "be with the patient". Just be there experiencing their feelings in that moment. Something happens in that interaction that cannot be quantified - and yet is so valuable.
36
Yes! It's absurd. I've been ranting about it for years to no avail. It is impossible for any decent, thoughtful person to work in the 'public' system (which has mostly been farmed out to private for profit corporations run by MBAs). When people go on and on about a shortage of psychiatrist, I laugh. The only shortage is of doctors willing to be abused. In the current situation the only way to survive is to establish your own niche practice.
I've never understood why a surgeon saving a patient's life is worth tens if not hundreds of thousand dollars but a psychiatrist's doing the same thing is barely worth a few hundred. And the truly crazy thing is that if you surveyed the general population most would think that psychiatrists make the most money of all physicians instead of near the least.
I know that at one San Francisco Bay Area highly regarded medical facility where the pyschiarists just prescribed drugs and a little chit-chat in a 15 minute appointment. Apparently there is constant pressure to push more patients through and more record keeping requirements that eat up time. If the pyschiarists have more time maybe they could discuss some of the side effects of the drugs they’re prescribing.
"This shift to electronic health records, intended to improve communication between a patient’s various physicians as well as “automate and streamline provider workflow,” "
What the EHR streamlines is not communication or provider workflow, but billing. You will not find a single doctor who feels the EHR makes their workflow more efficient. It detracts from patient care, is cumbersome and a waste of time. It is also a prime factor in doctors in their 50's and 60's retiring. As for communication, on clinic's EHR does not connect with another or with the hospital so communication is not improved.
The EHR is great for medical coders as all the little boxes are checked automatically and allow maximal billing for each encounter.
I don't use a computer in my exam room. I talk to the patients, listen to them and examine them. Afterwards I struggle to work with the tedious, cumbersome EHR.
33
This was another failure of Obama, his failure to recognize the hazards of electronic health care records, when he mandated that all medical records be digitized by 2015. I know you will reflexively say I am being political but it was the government and that president who forced that change, just like Reagan started us on the current road to ruination of our medical system today.
8
I have recently had a long session with a teaching hospital. Strangely enough, such a situation with Fellows and students seems to result in more personal interaction than with the normal office visit. My wife has also received hands-on care from her cardiologist who really does care about her. I am not personally interested in being fussed over and think that the Medicare physical where you state health goals for the year is a total waste of time. Given the cost pressures, less attention is probably more valuable than too much attention and being fussed over.
2
I usually try to stay on script and be on point, in general, and with my doctor. When he recites his computer checklist of questions to me, each requiring a Yes (problem) or No (no problem), if I ever try to qualify 'No' (some things aren't always black|white), a glaze of boredom sweeps over his eyes after my first two words; and if I ever answer 'Yes', an expression of irritation comes to his face. Now in my seventies, I've had more than a few doctors. All have implicitly shown a desire to see their next patient as soon as possible, and get me out of their office ASAP. Not that I haven't gotten RXs or referrals when needed. So my medical issues are attended to, but never me as a person. I've never been anything more than a co-pay to any of them, and know that if I shopped 100 other primary physicians, the result would be no different. We're living in a 100% transactional world. Fortunately I'm basically healthy. Doubtful if things would be any different in my doctor-patient relationship if I weren't.
8
Money doesn't align with value? Are you kidding me? Is this piece satirical?
Value does not exist in medicine.
Value is not sought after in medicine.
Medicine is a business and business exists for one reason, profit.
Everything that happens in the doctors office and especially in the hospital is done to maximize revenue and its resulting profits. It's all based on fee for service so they use the maximum number of services.
They even have a name for it. They try to disguise the theft by making it sound official like it is done in the customers best interest. It is called "protocol medicine".
If a customer presents any symptoms of any kind, a battery of tests are automatically ordered regardless of the patient's history and individual condition. Everyone who presents these symptoms is treated the same. This is "rule it out medicine". Instead of "ruling in" the most likely cause, they spend a fortune ruling out everything else.
By utilizing protocol medicine, the family physician becomes obsolete. There is no reason to know the customer. Everyone gets treated the same.
OK, if everyone is being treated the same, why bother with the doctor. Just type your symptoms into a computer and it will generate the required tests. Heck, you don't even need a computer, just a book that lists symptoms and tests.
Medicine has ceased to exist to help people as its core function. They can save your life, but will charge you a lifetime's income.
23
Doctor humor: What's the definition of a healthy person? Someone who hasn't had a full workup yet.
Silly but revealing.
4
I believe that a personal relationship with a primary care doctor generates fewer unnecessary referrals to specialists which in turn generates fewer unnecessary tests and procedures. It would be interesting for an economist to study this aspect of restoring the old model.
The very word "provider" suggests how much things have changed.
I am a neurologist and I believe the issues raised in this study might be applicable to my field as well. A simple question such as "What do you do all day?" can often lead to unexpected medical information. If the doctor has the time to ask...
18
“ONE OF THE tragedies of American medicine is that the money doesn’t really align with value." The same could be said of higher education in general, where adjunct instructors are more cost effective but are rarely able to develop any kind of relationship with students across four years. In both cases, the quality of the relationships affects the outcomes, whether better health or successful and timely graduation, but neither is really measured or rewarded by the current systems.
My brother is a general practitioner. By all accounts, he's a great one: an excellent listener and diagnostician. After a couple of decades of too little time with patients and too many forms, he opted for concierge medicine a few years ago. His wealthier patients could follow him, but most could not. I can't blame him. To use the appropriate metaphor, he is a single symptom of a larger disease. Let's hope there's a cure rather than palliative care.
25
While as a child, I recall several instances in which doctors contributed to the death of a relative, they were perceived as a service to the public. The role of doctor has lost its moral calling. It is a business like any other out for profits. I have come to see many as car salesmen wary of what is being sold to me. The doctor wants it both ways.
2
Unfortunately, a great deal of what doctors must do is insurance-driven, not personal profit-driven.
2
A line in this article says it best, "One of the tragedies of American medicine is that the money doesn’t really align with value." While the patient/doctor relationship is very important let's not forget that doctors are an important part of our current health care system and have largely been complicit in their acceptance of the status quo. Doctors are notorious for their resistance to change. Their resistance to Medicare during its founding is well documented.
This article is important as it points out the very really and important benefit of having a human relationship with a patient in the healing process. However, this relationship only works if there is trust. This trust is eroded when doctors keep silent about the continued excesses of the medical industry.
5
Lets also not forget that ultimately it is a doctor who writes the scripts for opioids. These scripts are then converted by pharmacies to shipping orders for pharmaceutical manufactures. These pharmaceutical manufactures are not randomly shipping 700-800 million pills to an individual state - they are PROCESSING ORDERS, completed by pharmacies to fill scripts written by Doctors. The USFDA found that three major drug manufacturing companies—McKesson, Cardinal Health, and AmerisourceBergen—made $17 billion by sending 423 million opioid painkillers to West Virginia between 2007 and 2012. West Virginia has less then 2 million residents.
How is there any semblance of a doctor-patient relationship in this environment? It is clearly demonstrated that is someone like El Chapo does this then he will be hunted to the ends of the earth. Corporate pharmaceutical manufactures they get profit sharing with gets passed down to drug reps and ultimately Doctors.
Patients are merely a revenue stream to be milked until death. I observed this first had with my fathers nearly thirty years of dealing with heart ailments. In the last six months it was basically "lets try this - we think it will help". When pressed for the "why" the Twinkies (our term for his cardiac care interns) would offer little. Yes I'm am jaded, BIG TIME, after watching this for nearly 4 decades.
This article offers false hope. The whole point of American healthcare is to be expensive. It's one of the most powerful engines of our capitalist economy. Economic, political, and even psychological forces are directed toward increasing costs, not controlling them. We are all part of the problem. Not only do powerful vested interests such as drug companies benefit from high prices, but Americans believe that something, anything, must be done when we are sick, even if it does no good. We also believe that it is a crime to keep us waiting for treatment or to deny us the latest drug, procedure, or device. There is no way to reduce healthcare costs in the United States without a revolutionary change in our culture. Good luck with that.
34
Kaleberg: The business of America is business. Given our demographics and socioeconomic state, the US has about the same health as European countries. Should we follow the European example and become more efficient in healthcare, throwing millions out of work, and then just give them a Universal Basic Income to sit at home?
1
I have no idea where you are coming from with this inhumane rant. You appear to think that access to medicine/doctors is an incentive for people not to work. Why you think such a thing I can't understand.
2
Julie: You misunderstand. I am all for medical care for all. I am referring to the issue of our system costing so much more than those in Europe because of inefficiencies. Mostly this consists of doctors' office staff and insurance companies' staff bickering over payment. But they are good, if not needed jobs. Access to care should be universal, I agree. Two entirely separate issues.