Tuesday, October 23, 2007

Physician Demoralization - Enough is Enough is Enough

This is about physicians rebelling against their loss of autonomy.

Gertrude Stein (1878-1946), American poet and writer, once famously said, “A rose is a rose is a rose.” By this she meant when all is said and done, a thing is what it is. In less poetic terms, she also might also have said, “A fact is a fact is a fact.” In other words, you can’t change reality.

There are two realities:

1) In this age of “accountability,” loss of autonomy – the freedom to treat patients according to their best clinical judgment – galls physicians because autonomy defines them\r role as medical doctors.

2) American physicians have had enough, which is why a broad and growing physician shortage exists, why ambitious and bright young people are choosing fields other than medicine, medical students aren’t choosing primary care residences, physicians are demoralized. A survey by the College of Physician Executives indicates lost autonomy, low reimbursements, bureaucratic red tape, patient overload, loss of respect, and an adverse malpractice climate discourages more than 60% of American physicians.

The reality is that American physicians have had enough.

• Enough unsubstantiated talk about killing 100,000 hospital patients annually.

• Enough chiding about failure to adopt electronic health records from vendors who may or may not remain in business.

• Enough general hospital and Congressional criticism about referring to facilities in which physicians have partial ownership and where care tends to be better and where they can be more productive and in clinical control.

• Enough impugning of their motives for investing in ancillary office-based services from which they derive revenues to meet rising overheads and shrinking bottomlines..

• Enough gratuitous advice about physicians teaching prevention as key to improve outcomes when the basic problem in improved outcomes is often lack of patient compliance – filling prescriptions, taking medicines as prescribed, eating properly, and being physically active.

• Enough mindless moralizing about their lack of compassion as they try to cope with increasing patient loads and demands.

• Enough lecturing from “experts” who have never been inside a medical office for any length of time about how to run their office.

• Enough assertions from Washington. D.C., pundits and Medicare officials about why fee-for-service should be abandoned and replaced by salaried positions where no “perverse” incentives exist to provide “unnecessary” and “unsafe” care.

• Enough cries for physicians to provide less care for patients face-to-face personal care in favor of impersonal, faceless, electronic communication.

• Enough Stark and other federal laws forbidding them to collaborate with each other and hospitals to establish such innovations such as bundled bills for hospital procedures, integrated care units for specific diseases, and convenient off –campus ambulatory care units..

• Enough stifling federal and state regulations that hamper clinical and technology innovation.

• Enough commentary about integrated computer systems, pay-for-performance, and electronic surveillance and compliance to quality guidelines are the final answers to improving the health system but with no mention of time, money, and training required..

• Enough blind beliefs that data mining of post hoc claims will yield sufficient information to separate and identify the “good”, i.e economical doctors quality performing physician following “the rules”, from the “bad” doctors, i.e. those who act independently following their own judgment based on face-to-face encounters with individual patients.

• Enough unproven investment in that concept that somehow “process metrics,” measuring what doctors do in their office or hospital settings, will automatically translate into better outcomes once patients leave the medical environment and return home to former lifestyles

• Enough third parties micromanaging care, setting fees capriciously and arbitrarily, dictating procedures to be done, and the process creating unneeded demand because patients develop an “entitlement syndrome” and have no sense of true costs.

As a conequence of these attitudes, a physician counter-revolution is brewing out there. This is taking various forms – organizing of more structured and larger physician organizations with the power and data to negotiate with payers, legal actions by physicians against HMOs to guarantee more equitable payment arrangements, establishing of “social networking” and “end-user” websites allowing physicians to talk to each other and to articulate why some “improvement” strategies don’t work and simply add more bureaucratic burdens, and a growing belief that physicians must establish some sort of national forum to air their grievances, present what is needed for health reform, and establish their own set of best practice guidelines. In the end, most physicians would prefer to deal with patients directly with full knowledge of costs, with patients paying at least a portion of the costs, and with both patients and physicians retaining their individual autonomy.


rlbates said...

Thanks for writing this post.

Richard L. Reece, MD said...

Wow! What a sweet sentiment.

Howard Luks MD said...

Great read.

drbazar said...

This should be translated into the doctor - patient bill of rights. Bravo, permission to quote you please?