Sunday, August 24, 2008

Physician Culture, Physician Demoralization - Twelve Physician Sensibilities

The capacity to feel or perceive: the capacity to respond emotionally or aesthetically.

Sensibility, Dictionary definition

The average physician perspective is this. I went to medical school I’m loaded with debt. I’ve got an office full of people pushing paper every day. I don’t have time to talk to anybody. Nobody in Washington seems to care what I think. I can’t function this way. I don’t egt reimbursed enough.

Arthur Caplan, PhD, Professor of Bioethics at the University of Pennsylvania, “Shattuck Lecture: Health of the Nation” Coverage of All Americans, “ New England Journal of Medicine. August 21, 2008

Research suggests that the presence and support of a robust primary care system is a major characteristic of an efficient and high-quality health care delivery. However, the future of the US primary care system is uncertain at best and is perilously close to collapse at worst. Fewer medical students and residents are choosing primary care specialties, and physicians in practice are leaving internal medicine faster than their other colleagues with a subspecialty.

Michael S. Barr, MD, MBA, VP, Patient Advisory and Improvement, American College of Physicians, “The Need to Test the Patient-Centered Medical Home, “ JAMA, August 20, 2008.

People tell me I clearly grasp physician sensibilities. That may or may not be true. You be the judge.

Sensibility One - The public and policy makers have little understanding of the depth and breadth of physician demoralization and dissatisfaction, particularly among primary care clinicians. This misconception may be remedied soon by a survey of 300,000 primary care physicians by the Foundation of Health System Excellence, a nonprofit organization representing state and local medical societies. The survey covers physician attitudes, levels of satisfaction, socioeconomic status, and state of U.S. health care.

Sensibility Two – Physicians are either not entering or fleeing primary care in record numbers. This will soon lead, if it has not already, a widespread primary care shortage and will precipitate an access crisis.

Sensibility Three – Universal coverage and comprehensive coordinated care is meaningless with access to primary care physicians, a problem now manifest and playing out in Massachusetts, and beginning to be addressed by policy makers and members of the medical academic establishmment.

Sensibility Four – Dissatisfaction with care is rampant among primary care physicians, who yearn to spend more time with patients and to bet off the current productive line practices, requiring them to see 20 to 30 patients a day. Much of this unhappiness stems from a reimbursement system that rewards high-tech procedures rather than cognitive care and time spent with patients.

Sensibility Five - The reimbursement system falls to pay physicians for such vital things as same-day appointments, and telephone and email consultations. In the case of telephone calls, this is absurd since many physicians spend at much as ¼ to 1/3 of their time on the phone.

Sensibility Six - A growing and unknown number of primary care physicians are opting out of HMOs, PPOs, and other third party arrangements, seeking refuge in concierge and cash-only practices to escape the harassment and overheads involved in dealing with third parties.

Sensibility Seven - Malpractice fears reap havoc, both psychologically and economically, because it engenders mutual distrust and fosters defensive medicine to avoid future malpractice actions, while doing little to protect patients against harm..

Sensibility Eight - Medicare and other federal programs, because of their size, scope, impersonal, and bureaucratic nature, are recipes for fraud and abuse. Scam artists – and rarely opportunistic patients, doctors, hospitals, and entrepreneurs – often “game” the system, resulting, among other things, in vast overruns in Durable Medical Equipment businesses.

Sensibility Nine - Many physicians instinctively distrust information technologies as instruments for savings and safety because they tend to benefit health plans and because of high costs of installation, training, maintaining, practice disruptions, low returns on investment, limitations in communicating with colleagues and hospitals, and their secret suspicion that these technologies may serve as vehicles for monitoring, punishing non-compliance, rating doctors, and excluding doctors.

Sensibility Ten - The potential value of virtual e-medicine in treating and consulting with patients over the Web rather than seeing them face-to-face is squandered and is often meaningless because Medicare and most health plans do not pay for virtual visits.

Sensibility Eleven - The savings of prevention, with the exception of smoking cessation, may be over-estimated because physicians are not paid for counseling patients, many patients do not like to be lectured on life style, and many resume harmful behaviors after they leave the doctor’s office or hospital. Besides preventing disease, though it saves money in the short run, may cost more in the long run because of costs of treating the elderly.

Sensibility Twelve – The Medical Home concept, is laudable because it places patients and primary care doctors at the center of coordinated care. Current pilot studies should be continued, but doctors fear the process has become too “political” and too bureaucratic. Doctors are acutely aware of the tremendous investment in information infrastructure and staff required and uncertainly of rules and rewards entailed.


Steven Knope, M.D. said...

I couldn't agree more with "Sensibility Three – Universal coverage and comprehensive coordinated care is meaningless without access to primary care physicians, a problem now manifest and playing out in Massachusetts." The problem with all discussions of "nationalized health care" is that insurance is not synonymous with health care. More insurance will not create more primary care doctors.

I am one of those doctors who left the fast-food medicine world for concierge medicine 8 years ago. I just authored the first book on the subject and I believe that the free-market holds the only hope for saving primary care medicine.

Steven D. Knope, M.D.

Author, "Concierge Medicine; A New System to Get the Best Healthcare" (Greenwood/Praeger, May 2008)

Richard L. Reece, MD said...

Gee, thanks for your positive comments. I will llok up your book, and maybe even review it.

kevinh76 said...

Excellent post, as usual. While I can see how a medical home might improve outcomes or at least numbers, and might save money for the insurance companies, I don't really see how it will increase satisfaction with primary care docs or attract more physicians to primary care. With the medical home, I take financial responsibility for mid-levels who will likely often be out on disability, maternity leave, FMLA, vacation, sick leave, etc... Still being paid by me while I do their work. Then, I see only the sickest, most complicated patients - still 20-30 per day at 15 minute appointments for each. Then the phone calls, paperwork, complaints abount the midlevels. I don't cared what the pilot projects show, this is what will happen under the medical home. Not going to attract new docs to primary care that way.

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