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The Conflict of Cultures in Health Care |
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The world of the physician, focused on the individual patient and oblivious to the larger universe outside the exam room, stands in contrast to that of the business man paying for health insurance for his employees. The doctor is angry over the intrusions into his life, while business in angry too. |
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| Author: Tom James |
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The business view of medicine and the practice of clinical medicine come from different cultures that must be resolved for health care reform to work.
His internist riffled through a chart of his 81 year old patient who was slowly dying—in a way that many seniors do—from a failure of several of his key organ. Charles himself was not fully aware that a train of specialists were coming through his room, leaving indecipherable notes in the hospital record and moving on to examine other patients. The internist had sought the opinion of a cardiologist for his heart failure, a nephrologist to manage his impending kidney shut down and a neurologist to sort out the reason for his confusion. The neurologist, in turn, had asked the general surgeon to place a feeding tube, to make sure the old man had sufficient nutrition. It was the job of the internist to manage the old man’s diabetes and to coordinate the care for this “gentleman”—a term used by all physicians in the hospital to describe any anonymous patient. The internist made hospital rounds at six in the morning so he could get to his office in time to see his patients there. He never saw Charles’ family. He never talked to them about their wishes. But he felt that he was to be the person who would make the decision on how aggressively his elderly patient was treated. But the specialists all made recommendations for care, hoping that it would not be the organ system failure or their own special interest that would lead to this patient’s demise. That would be a defeat on their part. So like the carriage in Oliver Wendell Holmes’ “The Wonderful ‘One Hoss Shay’: a Logical Story”—this patient was dying from simultaneous multi-organ failure. Rather than allow a dignified death, the doctors ordered a frenetic series of tests and procedures in an attempt to save this patient’s life or at least allow him to be transferred alive to a nursing facility. Their belief in the ethical position in medicine to preserve life provided the rationale for what would seem to be an illogical set of medical actions.
Meanwhile in the bed next to him lay Miguel, a 35 year old man who was facing dialysis for the first time and preparing for it alone. He had left Honduras a decade previously to work in America to create a better life for his family and himself. He toiled in the hot son laying shingles on roof after roof, all to provide for himself and his family. He had no health insurance and rarely saw a doctor except for the inevitable injuries of his trade. On one emergency room visit, Miguel had been told that he had high blood pressure that if not treated would create the potential for kidney damage. With limited English and with the belief typical of young men in their own indestructibility, Miguel never filled the prescriptions for blood pressure medications. But more recently his fatigue got to be more than he could understand and he sought the only place for care that he knew, the Emergency Room. In all of medicine, the ER is the highest cost and least personalize place for primary care But that is exactly where millions of Americans go for health care services that would be best treated in the office Neither the nuclear family nor Dr. Marcus Welby are realities of our contemporary culture. So Americans fill the waiting rooms of our nation’s ERs for minor injuries and illnesses that time will cure as quickly as medications.
But the emergency room has become the first site for diagnosis of serious illness. That was the case for Miguel who came to the ER with a level of fatigue that he did not understand. It was in place of frenetic medical activity that Miguel first was diagnosed has having kidney failure. Through these events, Miguel, with his broken English and lack of insurance found himself in the hospital bed. And when they are sick enough to be admitted to the hospital many Americans do not know the doctors on the hospital staff. The ER then assigns a doctor from a rotation of the doctors on the hospital staff based upon the specialty required to treat the patient’s condition.,. That is how Miguel was assigned to Dr. Joe Green, a thirty-something year old nephrologist, who had been the whiz-kid of his residency program. Dr. Green spoke no Spanish. He was a by-the-book kind of number-oriented physician. It was the science of the metabolic impact of kidney failure that attracted him to his specialty. So in an odd way, he liked having a patient with whom he could not directly communicate. It allowed him to focus on the electrolytes, the calcium, and the creatinine….all the numbers that were out of line in kidney failure. He figured someone from the hospital could talk with Miguel. Dr. Green just didn’t have the time.
Miguel had no pain, and other than fatigue he didn’t know why he had been admitted. He certainly had no understanding when he signed the consent form to have a fistula placed in his arm that would connect an artery with a large vein so that dialysis needles could more easily connect him to the machine that three times a week would
remove toxins from his system. But this was his first dialysis, and he was admitted to the hospital so he would know what to expect and so the hospital could make sure he became enrolled in the Medicare End-Stage Renal Disease (ESRD) program. That is a unique benefit established by Congress in 1972, as an amendment to the Medicare Act. Originally the costs were anticipated to be manageable. At that time the estimates for this program were around one-hundred million dollars annually. In more than 30 years that has grown to a whopping twenty-three billion dollars in 2008. This is a program that provides services for less than one percent of American—those with severe kidney failure.
Miguel with his new venture into chronic disease and Charles with his multi-organ system failure both have Medicare to help provide financial coverage. Both have entered a health care system that tends to isolate them at the same time that they become the centers of independent medical activities. Patients with chronic dialysis tend to have a standardized approach to care but hospitalized elderly patients with failure of multiple organ systems often receive services based upon invisible organizational relationships between physician practices within the hospital rather than through the coordinated and logical approach one would expect from a profession based upon science. This mismatch of the provision of services underscores the current culture of medicine as found throughout many American communities. The culture of American Medicine today stands toe-to-toe in opposition to the values found in American business and even those within the federal government. In this post-Flexnerian era formal medical training has focused on disease and an approach to diagnosis and treatment of the illness—not an approach to the patient as a complete person. Miguel’s assigned nephrologist, Dr. Green, is partially caricature, but still is representative of doctors so focused on a single organ system that they cannot see the whole patient. Physicians are trained to isolate the condition and to think objectively about that disease. The cultural, value-driven elements of the patient are not part of the lexicon of most physicians trained over the past several decades. It is science and the “art of medicine” that forms the bed rock of clinical decision-making. Doctors have limited training on recognizing their patients’ values and incorporating them into the clinical decision-making process. Charles’ internist may become impatient if the morning lab tests are not on the chart for his 6 am hospital rounds; but he has no concept that his way-too-early morning visits to his hospital patients frustrate the families of his patients. They are anxious for information about their loved ones. While HIPAA may have limited some of the inappropriate information exchange between doctors and families, it was never intended to prevent the sharing of information and values that bring solace to families. The internist may view himself as a martyr putting in long hours, casting himself as though he were in some Norman Rockwell scene, but families become frustrated by what they perceive is the lack of true compassion by medical professionals. This has been a focus of the American Academy of Family Physicians in programs springing from its Future of Family Medicine analysis. The concept of the “medical home” directly deals with skepticism from patients that Dr. Marcus Welby is no longer with us. The medical home represents changes in clinical practice. In this new model physicians receive reimbursement for spending time with patients and coordinating their care. The current system rewards doctors more for doing medical procedures than for spending time with the patient. Physicians who get to know their patients well and coordinate their care should have better patient outcomes and lower costs. The Medical Home is a small movement, but one that is taking hold with insurers and primary care physicians alike.
Aside from the Medical Home, the communication failures in the doctor-patient relationship are exacerbated by the pressures of time. With shrinking reimbursement for individual services, doctors who are paid on the current fee-for-service system try to maintain their income by seeing more patients and providing more services. For physicians in primary care—such as family medicine, pediatrics and internal medicine—the average time in the patient exam room has shrunk to six minutes. There is little time to get to know the patient, understand his or her values, establish a relationship, AND perform a history and examination. Something has to give. For many doctors, it is the warmth of a human relationship that is sacrificed. Questioning and conversations are discouraged through brusque body language that lets the patient know that this physician is just too busy to allow chit-chat.
Other physicians allow more conversation but skimp on the examination. They come from a philosophical approach that believes less in what the doctor may discover through a careful examination of the patient than in what information the patient may
provide by sharing his medical story. Other doctors make up for lost time by ordering batteries of tests and high tech imaging studies. After all there is a belief among physicians and the public that blood tests and x-rays are accurate and can lead to a diagnosis faster than just listening to the patient. FOX television’s Dr. Gregory House epitomizes the physician who considers a diagnosis and orders a lab test or performs a biopsy only to repeat the process multiple times when a diagnosis is not supported.
This technology-driven health care is what the public has come to expect and the physician has learned to rely on. It is also a driver of today’s health care crisis. When I hear pundits or physicians brag that the United States has the best health care on earth it is usually based upon the high level and volume of technology available. US citizens rarely have to wait for an MRI or an elective surgery. There are as many PET scanners in most mid-sized cities as there are in many eastern European countries. Yes, we are a country of plenty. We love to display the “miracle” patients--the one pound premature infants who survive the hospital stay or the patient with a functional hand transplant.
Frequently those who tout the US health care system as the finest in the world place greater value on technological achievement and easy access to elective procedures than they do on basic access to primary care coverage. Hospital advertisements take advantage of this position. Most people assume that if a hospital can provide high tech services that they must be able to perform the basic ones well. But the processes involved in performing a successful organ transplant for one patient are not the same ones as ensuring that all patients in a hospital receive ordered medications on a timely, error-free basis. Hospitals advertise daVinci robotic surgery and artificial disk replacement but not the quality markers posted on Medicare’s “Hospital Compare” website. If a hospital does include comments on quality awards, it is frequently from for profit survey groups such as HealthGrades and not from organizations whose processes are open and transparent.
The current culture of medicine is based upon creation of market-place brand distinctions. Some hospitals advertise high tech services while others tout high touch caring. In a form of laser wars competing for your eyes, ophthalmologists place competing billboards along local highways. The implications of brand image extend to the doctors’ lounge in the hospital, and place the high tech surgeons and interventional radiologists at the top of the pecking order while the family physicians and pediatricians caring for many more people must stand in deference. Medicine today has continued the hierarchical structures that are reminiscent of the greats of medicine from Sir William Osler to Eugene Braunwald. Even today the order of prestige in medicine is symbolized in the hospital by the length of the ubiquitous white coats.
Medical students traditionally wear a short lab jacket. The more senior the physician, the longer and more starched is the coat. A few decades ago only surgeons on their way to or from the operating room wore scrubs. Now that, too, is symbolic that the physician is a “do-er.” Not just the surgeons but cathing cardiologists, endoscoping gastroenterologists, and intensive care pulmonologists—all the “do-ers” of medicine—wear their scrubs throughout the hospital. That provides a level of status to be reckoned with. The order of prestige within the house of medicine places senior medical “thinkers” and invasive “do-ers” at the top of the heap. Meanwhile the pediatricians, family doctors, and general internists—those who see the majority of patients—are all viewed as the worker bees of the profession, ensuring that the queen bees in scrubs and starched white coats have an ample supply of patients.
The existing fee-for-service payment system reinforces this hierarchy through greater financial rewards for doctors who are the “do-ers” that far exceed the reimbursement for the “thinkers.” Today’s young doctors enter practice with a debt that is typically around two-hundred thousand dollars. Why should even the most altruistic resident want to go into primary care with a debt that will take a decade or more to erase when the average income for specialists in fields such as cardiology, radiology, and anesthesiology may be three times as great.
Upon entering practice in this post-Flexnerian period, physicians learn to practice medicine based upon consideration of the “what if” philosophy. What if that “worst headache” were a subarachnoid hemorrhage, “what if that blood tinged cough” were a sign of cancer, or “what if the sinus congestion” represented an esoteric disease such as Wegener’s Granulomatosis. Thinking of all possibilities and weighing the relative probabilities of each condition is an important an exercise for physicians. Considering all possibilities helps ensure that nothing is missed in considering each patient’s condition. But in today’s medicine, these possibilities are frequently acted on even if the pre-test probability of a positive test is quite low. This is no simulation. Our fascination with high technology applies both to the public as well as to physicians. This think and test mentality is epitomized by the name-sake role in Fox’s hit TV show, “House.” The practice of ordering tests, biopsies, or “doing” is costing Americans billions of dollars. The United States is now the most expensive country for health care while only achieving a 16th place among industrialized countries for population health.
On another side of the world from the physician is the employer, who offers health insurance to employees both because of the tax advantages and because health coverage is important to offer perspective employees. Even in a down economy where there is a surplus of qualified job applicants, and the most qualified are demanding health insurance. So the goal of the employer is to provide a competitive health benefit that does not break the bank. In times past, employers offering health benefits worried about the size of the network and whether the employees were happy with the offering. Today, employers are working to control costs while still offering competitive benefits. While employers may in private, marvel at medical technology, they worry about the additive costs. There still remains a mystique about medicine embraced by both employers and their employees that high technology results in better care. There is an assumption that basic health care is excellent throughout the country, unless it is proven through medical malpractice that a particular physician is substandard.
This myth of a universal high standard lives on despite the more than twenty years of research out of Dartmouth on the marked variations of care around the country. Jack Wennberg, Elliott Fisher and others have demonstrated that medical practice may be consistent in its quality only in small areas but is not practiced consistently or in a universal fashion. Even the rates at which surgeries from appendectomy to coronary by-pass surgery are performed are at different rates throughout the country.
The employer may get a bit jaded in looking at these numbers and may feel that they are being ripped off by the health care system. Why should not the standard of care be applied universally if it is, indeed, a health care standard based upon science. The fact is that much of what is performed in medicine is not based upon science but upon gut feeling--the art of medicine.
Now the employer is facing a quandary. The Robert Wood Johnson estimates that this year the average family health insurance premium is $13,375. At this price, the employer wants to know that their employees are receiving scientific or “evidence based care.” If doctors talk about the “art of medicine” the employers often feel resentment for their support of such expensive art. However their employees develop allegiances and expectations with physicians that are also not based in rational terms. The physician, through the power of the scalpel or the might of the prescription, obtains loyalty from the individual patient in a way that cannot be achieved in business. Strong loyalty can develop even if the doctor and patient don’t really know each other as complete individuals.
The employer now is faced with the dilemma of needing to conserve cash by restricting health care only to services which are medically necessary but recognizing that many of their employees, as patients have developed the kind of close relationships with their physicians that can be found only in real trust relationships. If the employer tries to restrict services or access to physicians so as to have a higher percentage of evidence based medical care, then the employer must be prepared for the consequences of angry employees and physicians as those two groups still believe in the power of the “laying on of hands.”
A tug of war exist between doctors who want unfettered their ability to make independent judgments about individual patients and those paying for care who are in of need of constraints on a health care budget gone wild. It is the patient—the employee—who is in the center of this tussle Even 15 years ago I talked with a Long Island orthopedist who told his patients that if their insurer restricted his judgment on the frequency of physical therapy, that the patients should quite their job to find one with different insurance benefits. Was this spoken out of an ego-driven sense of self-importance or from a true concern that the patient receives the medical services that the physician felt was best?
Physicians have traditionally trained at the bedside. Each patient is unique and needs an approach that is geared towards both the medical and social facets. The needs of the individual patient must be paramount, regardless of the cost, so as not to let finances trump medical requirements. But the employer looks at the practice of medicine as a 19th century cottage industry. Few medical practices have yet to adopt standardizations of approach, or achieved more modern concepts of driving out defects to the six-sigma level or allowing computer technologies lead the way towards process improvements. Many doctors take a twisted sense of pride in their computer ineptitude while the businessman wonders how do doctors ever come to correct diagnoses.
Large businesses have tried to influence health care processes. The National Committee on Quality Assurance (NCQA) is the leading private organization for the measurement of quality performance by health plans and physicians. The NCQA was restructured in the 1980s to include a number of large employers such as GM and GE. Ford Motor Company, General Electric, UPS and others helped form Bridges to Excellence as program that monetizes incremental improvements in the health of populations of employees with diabetes, heart/stroke, or back pain. The initial concepts brought by business to the practice of medicine are that doctors will make improvements in the processes of care if the reimbursement makes it more favorable for the medical practice to change than the cost of the efforts for such an undertaking. But Pay for Performance programs, such as Bridges to Excellence and other similar projects, have failed to demonstrate that financial incentives result in sustained clinical improvements. Those physicians who adhered to guidelines continued to do so and collected additional reimbursement; and those who did not measure well felt the cost of retooling their practice was greater than any potential reward.
Not infrequently the media publishes an article or airs a story that involves cost containment efforts by insurers, government or purchasers. Rarely are these portrayed in a positive light. The story is never even-handed when some unfortunate sole does not have access to a special doctor or service. It is always set up in David vs. Goliath fashion so that the dint of public sentiment always vanquishes the anonymous bureaucracy. Many doctors know well how to play this trump card on their own behalf. Shining the spotlight on ill-conceived programs can lead to reforms. But other situations occur where well thought out efforts to control the excesses in health care spending are demonized under the label of “rationed care.” No need to acknowledge that American society today rations care by allowing 47 million of us to be uninsured. Several years ago, as a medical director in a local health plan, I denied coverage for a cosmetic surgery on a teenage boy. His doctor and parents went to a local radio to announce their outrage. The story was picked up by NBC Nightly News who included it with two other medical denial stories as part of the “Fleecing of America” series. While the Chicago film crew was taping my interview in my clinical practice over this denial of a cosmetic surgery, several children were coming in for follow-up. One had severe burns from a house fire but had no coverage for rehabilitation and so was left with severe contracture and deformities. There was no coverage for this child with much greater problems, but the problem of no insurance was not the focus of this NBC story, so the film crew declined to talk with that family. The abuse of the media comes when special interest groups use the human suffering of one person to paint broad brush strokes that may ultimately be harmful to the larger society. Health policies can be checkmated by the media attention on a few.
So where did the business model proposed by these large companies go wrong? Much of it goes back to the training that physicians undergo compared to the MBA training of many executives. While incentives work for most humans, including physicians, not all people respond to a financial incentive. Of course one cannot pigeonhole all physicians or businessmen into a single stereotype. But there are cultures that surround medicine and various businesses that give insights into trends. Physicians often go into private practices specifically for the self-actualized benefits of autonomy. As such external incentives are effective only if generated through values that the individual physician holds close. Herding cats!
Now with health care reform gaining momentum, there are those in Congress who believe, as does the business community, that use of carrots and sticks will have a logical, predictable impact on care. Proposals in the Congress that would use financial incentives and disincentives to change the practice of medicine are running into the same barriers that employers met. Proposals that are strictly financially based will fail to move significant numbers of medical practices.
There are solutions which can take advantage of the cultural values of medicine. If doctors are paid for outcomes, then it is the physician’s choice which route to take to improve the health of a specific population. While doctors are trained to think independently and to abhor what many consider “cookbook” medicine, there is a growing recognition that using evidence-based medicine drawn from rigorous scientific studies may be preferable to making clinical decisions based upon samples left by the pharmaceutical company representative or past anecdotal experience. Doctors may be willing to accept payment based upon whether their patients with hypertension or with diabetes meet the performance goals of control, but the wild cards for most doctors are whether those patients will follow recommended care and how advanced their illness is at the beginning. Such a system of outcomes based payment must have valid statistical means to adjust the populations based upon degree of associated complicating factors such as other illnesses or how advanced the condition is. Medical groups around the country with whom I have spoken are willing to accept such a payment for outcomes process as long as there are good controls to ensure a level playing field.
Most doctors believe that they provide good care—but payment for outcomes now allows the doctors to prove it. Such processes are really more successful in large group practices where there are electronic medical records, and staff who can focus on collecting practice data. But where does that put the small physician office? Fifty percent of Americans receive their care from medical practices with five or fewer doctors. These practices cannot afford the investments in the infrastructure necessary to assume the risk for payment for outcomes. These practices will become disadvantaged in comparison to the large groups or networks with the analytic capacity. These small groups may have a smaller pool of patients to draw from as employers or CMS move to new payment models. More doctors will feel the pressures join larger groups. The image of the Norman Rockwell physician who spends time listening for a heartbeat in a doll is becoming more fuzzy. Doctors who have enjoyed the autonomy of the small practice will have to balance that value with a lifestyle that allows more time with family and be away from the practice. The financial picture is already better for most doctors in large group practices than for those in small ones.
The character of medicine is changing. As doctors enter into salaried arrangements or ones based upon impact to the group, they leave behind that self-image of the
overworked doctor who has sacrificed his family life to care for his or her patients, and who deserves to be honored individually. While they still care for their patients’ individually, physicians are increasingly recognizing that modern medicine must be a team activity. No one person can know enough or have enough hours to really provide all the care in this age of medical knowledge overload. The role of the physician in the new organized medicine will be much more aligned with the directions sought by government and by employers. New business arrangements will need to be developed. The American Medical Association has broken away from its rank and file members to advocate for the Obama health plan, and is now dealing with the outrage of its members. The President’s master plan does not take into account the existing cultural force of auto my in the physician community
There is hope that the new doctors, those who place value on balancing work with family and personal needs, will be the ones to adapt to a new medical order that is built upon a team model--a model not based upon the individual accomplishments but upon the collective organization of many people of varying skills. Personal doctor-patient relationships are independent of payment method, so there is no reason to think that trust relationships will not persist as the health care system becomes reshaped. The cultural differences between physicians in the current order and policy makers and employers must become reconciled if America is to have a viable new system to provide medical care into the future.
About Author
Dr. Tom James is the Medical Director for National Network Operations for Humana, Inc. In this capacit he is responsible for providing the clinical input into the quality and efficiency measurement of health care providers within the Humana network. Dr. James works closely with national and local professional organizations and societies to explain Humana's goals and to seeing physician input.
Dr. James is board certified in Internal Medicine and in Pediatrics. He received his degrees from Duke University and from the University of Kentucky College of Medicine. He performed his residencies at Temple University Hospital, Pennsylvania Hospital and Children's Hospital of Philadelphia. Dr. James has been i clinical practice in Philadelphia, Louisville and Norfolk.
He is active in multiple medical and non-medical organizations in Louisville.
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