Two recent pieces struck a chord with this blogger. While they seem disparate, I believe they represent 2 sides of the same issue.
Yesterday morning I read a wonderful piece by Abraham Verghese. As I read the piece, I wondered if he read this blog on a regular basis. I suspect that he has never seen this blog, so I must assume that my thoughts and his thoughts come from the same place – an understanding of patient care. Reward doctors for spending time with patients
Time is the scarcest commodity of all. Patients, particularly when it comes to their routine, day-to-day care, want a physician who has time to understand them as people first, and then as patients.
The problem though is less with the physician than it is with a payment system that penalizes the doctor for spending much time with the patient. There is so little reimbursement for a regular office visit that a primary care physician has to churn through large numbers of patients per day in order to cover the overhead. (It is the reason many physicians are going into concierge practice, where they can spend as much time as they want with a limited panel of patients).
By contrast, a procedure of any sort – biopsy, stress test, endoscopy, cardiac catheterization, minor surgery, major surgery – generates a payment that dwarfs the regular office visit. Is it any surprise that fewer medical students each year opt for primary care as a career? Is it any surprise that there are so many posh freestanding surgical centers and birthing centers and cancer centers and cardiac centers and pain centers? They emerge in Darwinian fashion when we pay well for physicians to do to patients, and pay poorly for physicians to be with and do for patients.
Has anyone seen a freestanding geriatric center with a fabulous lobby and valet parking? I haven’t. And yet, care of the elderly is so important to all of us; that first office visit must take a fair amount of time if the doctor is to get some measure of the individual.
Expanding health care coverage was a laudable goal and will happen, but what must come next is payment reform, rewarding primary care physicians for time spent with the patient and taking away the fee-for-procedure incentives. Getting to know a patient and having the time to do so is a critical step; I am convinced it prevents unnecessary tests and saves money. It’s just good practice. And it’s what patients want.
We have lost time because of the payment system. Patients want to spend time with their physicians. Patients want physicians who understand them as people.
Most physicians would prefer to spend more time with their patients, at least most internists and family physicians. I believe that time is the real attraction of retainer medicine practice. This blog is replete with posts about time.
Then last night after dinner I read this blog post – Are relationships being lost in medicine, and are hospitalists partly responsible?
This brilliant post, written by an ER physician, describes the downside of hospital medicine.
See, the hospitalist is driven by admissions and discharges. And he or she has no abiding relationship with these patients. In the same way, the family physician who won’t admit has severed his relationship. ‘So, I see you were admitted last week!’ He’ll get a report. But the next serious illness that comes around will still be a situation in which the patient is admitted to a stranger with a lack of personal interest (I don’t mean that they don’t care, just that they aren’t personally connected over a long period of time).
I see both sides. The hospitalist has a focused mission and a busy service. The family doc has a focused mission and a struggling office to run. But somewhere in between is the patient, who has been left afloat between two continents. I guess the ER is the ‘desert island’ in between.
As I have written previously, hospital medicine exists because it benefits primary care physicians, many surgical subspecialties and hospital administrators. Many have written that hospital medicine benefits outcomes, but those studies are difficult to replicate.
I only do hospital medicine and I feel this problem. As I supervise students and residents, I still try to develop a relationship with our patients. However, I know that these short term relationships lack the nuance of a 20 year relationship that many primary care physicians have.
Our payment system and our focus on performance measurement are but two causes of this problem. The policy wonks, insurance companies and Congress have created this medicine. Physicians do not have the time to spend time with patients (I think that qualifies as a koan). Physicians are discouraged from providing continuity across locations. And I believe medicine has not advanced – both physicians and patients express dissatisfaction.
None of the physicians that Dr. Leap describes are doing their jobs poorly. The job is poorly designed, yet designed perfectly to fit our payment system. Methinks the payment system is the problem. But then I repeat myself incessantly.
