Reflecting on my subinternship, I realize now that one of the areas of greatest learning was my exposure to the health care system from the perspective of a young physician in his first month ordering tests, writing prescriptions, and getting involved in the micromanagement of in-hospital patient care (and preparing for “disposition,” the patient’s immediate destination outside the hospital). In doing so, I have spent a great deal of time dealing with VA paperwork, striving to accurately document to maximize Medicare reimbursement (routinely less than expected), wasting time on hold on the phone while trying to schedule appointments for patients or reach nameless individuals with key details of the aphasic patient’s history, bargaining with nurses to fulfill the orders I wrote to keep deep vein clots from forming or delirium from settling on the mind of a sundowning patient, and struggling to work with patients straddling the thin line between impoverished despair and unpleasant death and to help them find a third (sometimes wispy and intangible) option. In this heart of darkness not emphasized on televised dramas or comprehended by patients and lawmakers accustomed to hospitals outfitted like four star hotels, I now pause to refine my perspective on the ways people would like to see health care changed:
• Pay for Performance – While this idea makes sense to economists and those less inspired by the motives of doctors in pushing for expensive interventions, a pure Pay for Performance system fails to account for the patient factor. On the one hand, some patients are needlessly demanding in asking for pricey “fixes” to problems that might be managed more simply and inexpensively, or they might demand an MRI when a clinical diagnosis (based on a good history, a physical exam, and a handful of lab tests) is sufficient. On the other hand, some patients, for whatever reason, are not inspired to take ownership of their own health: they do not cooperate with nurses and doctors in the hospital and do not comply with their medications and therapies outside the hospital. This is particularly troubling to me: I find myself more at ease caring for a patient on the verge of death than a patient who has given up on living. How do you convince a patient to take his medications to stay alive and reasonably healthy when his life is miserable? Instead of trading one perverse incentive (letting patients be sick so as to treat them with more expensive means) for another (not treating the sickest and most miserable patients circling the drain), it probably makes more sense to find a compromise between Pay for Performance and Fee for Service systems that increasingly incentives measures taken to improve patient outcomes while allowing for wiggle room in actual patient outcome (owing to contribution of patients and other factors).
• Government-run Health Care – I am not convinced that a single-payer system of health care is the right system for the U.S., but I tire of the conservative arguments that follow the “you don’t want the government to get between you and your doctor” line of reasoning. Someone recently pointed out to me this notion: currently, many patients with private insurance have entire companies (whose profits are built upon denying payment for medical services rendered to the patient) saddled between them and their physicians with virtually no protective measures in place. Is this truly better than having a government agency regulating the delivery of health care to a patient? Frankly, I don’t think either is desirable. However, government officials are elected and are supposed to be held accountable by their constituencies; who holds the insurance companies accountable for their actions?
• The Doctor-Patient Relationship – A lot is said by many people about the doctor-patient relationship, but few people are willing or able to discuss its many dimensions adequately. On the one hand, the time spent between a physician and her patient in the examination room is as sacred and untouchable as the confessional. On the other hand, the relationship is a complex financial transaction filled with billing codes, hundreds of forms, and dozens of parties pointing fingers at one another as to who should pay the bill. The physician, whilst not officially a civil servant, nonetheless has an unusual amount of authority: he can hold someone against her will in the hospital or take extraordinary life-preserving measures in emergency situations. The relationship can be one of respect, trust, and admiration, or it can be antagonistic and doubting. Those who distrust and dislike doctors like to point to their God-complexes, even when those same doctors deny such notions of grandeur: what, then, does that say about how we view those who arbitrate our struggles with sickness and death?
In entering the modern age, I don’t think all physicians have fully adapted their approaches (or their mindsets) to present needs. A direct physician-patient relationship is a rare find: there is almost always a layer between populated by receptionists and nurses in the clinic and nurses, social workers, case managers, therapists, and hospital administrators in the hospital. These people are there for a reason: they are supposed to help patients navigate an increasingly complex health care system and help doctors provide medical care. However (and this might be disproportionately biased by my own personal experiences), what you do not do with your own hands cannot be said to be done with 100% surety. There is always room for error or defiance or questioning. The additional layer, the payer (i.e. insurance companies or the government), is just one more question mark or checkpoint between the doctor and patient. The notion of a one-on-one doctor-patient relationship is ancient history. The question, now, is whether the infrastructure surrounding the doctor and the patient can be improved and streamlined to emphasize improved patient outcomes, physician independence in medical decision-making and delivery, and universal coverage, all at the same time.
This cannot happen without physicians taking leadership roles in the days to come.