The following was sent to me by Ben Fischer, MD of the Fischer Clinic in NC:
When circumstances require that we see a doctor, most of us would of course hope to see a good doctor. By that we generally mean someone who is kind, patient, compassionate, wise, well trained, thoughtful, and skilled. We would hope that doctor would take the time and interest to understand us and our problems well and then apply himself or herself to seeking the best solution for our problems. We would like our doctor to keep us informed about changes in our health or treatment plan, we would like him or her to communicate well with other members of the medical community who may be involved in treating us, and we would like to be able to contact that doctor when we perceive trouble ourselves. In seeking to fulfill those expectations, doctors are aspiring to time honored standards of excellence in medical practice.
Increasingly, when we go to the doctor in hopes of encountering a doctor like the one described above, we encounter instead a medical professional who is rushed, seems to be more interested in the computer than in us, often does not physically examine us at all, and with whom we have no way of continuing a relationship outside of the unsatisfying and hurried office visit. We may be surprised to find that such a doctor may be highly regarded as a “good doctor” according to various ratings and commendations from corporate and government-based insurers and the larger health systems they fund. This is so because there is a new set of criteria for defining a “good doctor” – criteria set by the insurers and health systems, and criteria that drive a very different sort of physician behavior than what we have traditionally held to be excellent.
In response to the financial unsustainability of healthcare expenditures in the United States, the government and corporate insurers who pay for healthcare with our tax dollars and insurance premiums have set efficiency as their highest aspiration – serving many people without unnecessary waste of time or resources – and those healthcare payors seek to form efficient physicians in pursuit of that goal. Efficient physicians from the vantage point of the health systems move quickly through their tasks, stay within standard pathways, and adhere to institutional protocols. These are measurable actions, and the computerized medical record makes it possible to monitor those actions and reward compliance or punish non-compliance very effectively. Compliance with institutional dictates may make an efficient physician and the doctor who complies will earn institutional accolades, but will he or she be a “good doctor?”
Most doctors I know went into medicine aspiring to be the sort of doctor I first described – the sort of doctor most of us would want to see as patients – and those doctors have found themselves caught up in forces trying to remake them into institutionally efficient doctors. I am a primary care physician, and like many of my colleagues, I have sought to maintain adherence to the old standards of excellence, while also doing the tasks the health systems required of me. Though I once believed that I could both comply with the time-honored standards of excellence as well as the newer modern standards of institutional efficiency, in practice it became clear to me that the two professional standards are irreconcilable. I could not take the time to know my patients and their situations well and see a patient every 10-15 minutes. I could not see individual nuances in each patient’s situation and treat all of them with the approved standard therapy. I could not do what I knew to be best for the patient when institutional priorities dictated a different action, as often occurs with testing or referrals (health systems limit where and how often a physician can refer patients). I could not give my patients my complete attention while also paying attention to all the required institutional protocols and voluminous documentation demanded of me in each patient encounter.
What happened to me in practice is that I made some compromises: I did less than my best for my patients in order to at least partially keep up with the institutional demands.
When my interpersonal instincts told me to linger in a situation or conversation I would overcome those instincts and find a way to shorten interactions in order to give myself time for the other tasks demanded of me. I would bring the computer into the exam room with me and out of self-preservation complete some of the required documentation while I was with the patient even though I knew that distracted me and diminished the connection with my patient. I handed off my patients to hospitalist and hospice providers at their most critical times because maximized efficiency in the office allowed no space on the margins of my day to make hospital rounds or house calls. Even if I had inclinations to do those things, the weight of incomplete data entry and the knowledge that it awaited me whenever I got to it kept me from making those visits most of the time. I also had come to accept that this institutional toil was my true work. Inside though, I was aching for deeper connection. I knew that the physician should be present in the midst of his patient’s suffering, not somewhere off behind a computer cataloging and codifying it. The time I spent during and after work hours trying to do all the computer-based tasks required by the health insurers left me with little time or energy for my patients or my family. I knew that I was a diminished version of the doctor I could be, but out of both financial necessity and a misplaced sense of duty I strived to comply with all the institutional requirements. I became what many of my colleagues have become, embittered, frustrated and exhausted.
I do not believe doctors reached this point of professional malaise and uncertainty of purpose by an intentional campaign with nefarious intent. Rather, doctors gradually slid to this current state of affairs along a path of good intent, not recognizing that the goals sought and the means by which they were pursued were in conflict with other, older values. In the abstract, doctors and patients alike have wanted our health care system to be efficient, but many of us have not wanted in practice what the pursuit of efficiency has brought us. Patients want to be cared for, treated as individuals, known by those who are treating them. Most doctors I know want the same from the other side of the relationship – we want to know and care for our patients. We want this because we are body and soul, and we resist being treated and treating others mechanistically. The proper goal for living creatures and for those who tend to them is health, not efficiency, and health cannot be produced in living creatures by the efficient workings of a machine. At times of course, healthcare may be appropriately mechanistic, such as life supporting treatment on a ventilator during critical illness. Over the long arc of our lives though, achieving health is a slower, more complicated process, requiring personal knowledge of individual circumstances and barriers to health that must be worked through in a collaborative process between patient and physician.
I have come to believe that the only way to keep “good doctors” of the traditional sort, and the only way to keep our health care system from dehumanizing us, is to de-systematize it. We have all become so accustomed to thinking that you can only get health care if it is sponsored by very large institutions (governments and corporate insurers) that this seems reckless and radical, but massive institutions are not needed to provide good, basic medical care to our local communities. The possibility of small-scale, low cost, locally owned and operated health care is being demonstrated at the primary care level by a grass roots movement called “Direct Primary Care.” Doctors in this type of practice are paid directly by their patients and are accountable directly to their patients and to the professional standards of their respective medical specialty. Critically, though, their medical practice is not constrained by or accountable to the public and private healthcare financing entities that control and constrain the professional activity of all doctors who are funded through them. The fees in a direct primary care practice are typically modest and affordable to the majority of the population – in my practice 25-100 dollars/month, depending on age. Patients who value the care but cannot afford the monthly amount barter or pay us in reciprocal services, just as was the norm before insurance companies and government agencies took over healthcare financing in the 1950’s and 1960’s. There is no outside entity dictating how much time the doctor spends, which specialists can be referred to, nor how the doctor documents the care provided. Such controls benefit the system, not the patient, and once the health and well being of the patient are the physician’s only focus, everything begins to make sense again. The doctor can look away from his or her computer screen, true and therapeutic relationships between doctor and patient can form, and the patient has an advocate in the pursuit of health.
When the physician has time to understand his or her patient’s situation more fully, specialty referrals are less common and more targeted, emergency room utilization goes down, and patients are much more satisfied with their care. Ironically, the institutionally driven pursuit of efficiency in patient care produces care that is often very inefficient for the patients, who have long waits for short appointments, excessive numbers of specialists to manage their conditions, and no single doctor with the bandwidth to help them hold it all together. In addition to being inefficient for the patient, it remains very expensive for the government and corporate insurers (and ultimately for all of us citizens since it is our tax dollars and insurance premiums that are being spent). In Direct Primary Care the physician strives to make the care maximally efficient from the patient’s standpoint rather than from the health system’s standpoint. The doctor spends the time needed to know his or her patient and the patient’s medical condition, and then shepherds the patient through whatever medical issues may arise, all of which takes a lot of time and attention. That time and attention invested by the physician is part of what makes a good doctor, but in the eyes of the insurers and health systems that time spent makes an inefficient doctor (which is the worst thing a doctor can be according to contemporary institutional standards). One of the best written statements on the high calling of being a physician was written by Sir Francis Peabody in the 1920’s, and his instructions to his audience of young physicians was a call to give generously of one’s time, which stand in stark contrast to the modern “call” to move efficiently through the day’s work. His article published in The Journal of the American Medical Association in 1927 concludes with these lines:
The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.
There is clearly a need to restrain healthcare spending but the systematic destruction of the doctor patient relationship at the primary care level does not solve that problem. Decentralized and small-scale primary care imposes no cost on the “system” and allows people access to good, personal, dignified healthcare. How much high-cost, high-tech care we can and should afford as a society is a separate question which no amount of system engineering will allow us to avoid asking. Rather than go at those questions of limits directly, we have tried to take all the “inefficiencies” out of the system and thereby transcend any need to set limits. In pursuit of a perfectly efficient healthcare system we have created a centrally controlled and financed healthcare system so vast and costly that the need for it to sustain itself often seems to overshadow the initial mission it was created to serve. Working within that system as a primary care physician, which I did for 10 years, I felt a divided loyalty – did I owe my allegiance to the system and serve its needs, or to my patients, and serve their needs? Now that I am financially independent of the corporate insurance and government financed healthcare system, but still fully able to negotiate within it on behalf of my patients, I can help my patients navigate through systems of care with undivided loyalty, ever keeping the good of the patient as my goal.
Given the vast scale of our healthcare system and its emphasis on maximal system efficiency, the work of doctors has become akin to assembly line work, in which the doctor is responsible for only a small part of a process, whereas traditionally the work of doctors was akin to craftmanship, in which the doctor took ownership over the whole work. Many physicians resist this industrialization of patient “care,” but the conveyor belt keeps moving and unless the physician keeps up he or she gets buried by the piling up of work that the belt keeps delivering. I experienced that phenomenon in my practice, and I found that I could not do careful, attentive, and thorough work on the assembly line. I had to change the process in order to do the work the way I felt it ought to be done. Happily, I found the Direct Primary Care movement, and in it a band of similarly minded physicians who have encouraged me and advised me as I built my own practice with the help of my wife, my nurse, and my two partners who have since joined me. I am the same doctor I was before, but now I am free to be the best doctor I can be. When I fall short of my best now it is because I am human and fallible, not because I am systematically inhibited from doing my best work. I continue to work hard but I work hard at the things doctors are supposed to work hard at – taking care of their patients – not at bureaucratic toil that is of no benefit to my patients.
The industrialization of healthcare has also changed the education and training of doctors, similar to the way industrialization of manufacturing changed or eliminated the formation of craftsmen. When I was in residency training 20 years ago, our training emphasized thorough and exhaustive study of our patients, long days and nights in the hospital in order to facilitate long knowledge of individual patients, in addition to the expected accumulation of medical knowledge and honing of complex problem-solving skills. Since the practice of medicine is changing to emphasize efficient processing of people over long study and understanding of people, medical training has changed to fit that reality. Current residency rules forbid any training doctor to stay longer than 12 hours at a stretch in the hospital, normalizing and mandating the assembly line approach to care from the get-go in the formation of physicians, and outpatient clinical visits are compressed and time limited to train the residents to move faster through their appointments, since that will be required of them upon graduation. The words of Sir Francis Peabody are completely lost in this brave new world of physician efficiency.
The work of physicians ultimately cannot be made maximally efficient because it is relational work that requires time, attention, and presence if it is to be done well. The possibility of doctors being generous with their time can only happen if they are dispensing their time at their discretion without having to account for it – financially and otherwise – to anyone but their patients. That in turn can only happen if doctors maintain a desire to be generous with their time, a desire to serve rather than to produce, a desire to care for people – in short if they maintain a true sense of calling. We have nearly lost the possibility of a physician seeking to fulfill his or her calling in our culture, but there remain some in the medical community who will not let that possibility become fully extinct. Like a lot of things that are dismissed as “old fashioned,” the time-honored and noble ideal of the good doctor remains an ideal worthy of seeking to uphold and preserve in our time. My partners and I, in alignment with the Direct Primary Care movement, will seek to uphold it.
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