Doctors should ask the people what they want for health care

Americans typically rely on elected officials to uphold the will of the people. Now physicians—traditionally confined to exam rooms—are taking direct action to fulfill community needs.

In 2004 I decided to meet face to face with citizens in my hometown. I thought, “Why wait for legislation? I’m a board-certified physician. What’s stopping me from serving the public?”

So I led town hall meetings and invited ordinary citizens to create the clinic of their dreams.

From living rooms and Main Street cafes to neighborhood centers and yoga studios, I met directly with people and listened to their wisdom. Bus drivers and businessmen, housewives and healthcare workers, teachers, college students and folks of all ages gathered to design a new model, a template for the nation.

I asked each participant to imagine walking into an ideal clinic in an optimal healthcare system. Community members shared their visions; most submitted written testimony. My job was to implement their ideas where feasible.

From nine town hall meetings over six weeks, I collected one hundred pages of written testimony, adopted 90% of feedback, and opened our clinic one month later. For the first time my job description was written by my patients, not administrators.

What do people really want? Surprisingly, it’s nothing too extravagant. Here are their top ten recommendations, many in their own words:

1. Real relationships. Be fully present and willing to touch patients emotionally, spiritually, and physically. One woman’s simple request: “Hug me!”
2. Physician role models. Happy, healthy doctors inspire patients to live happy, healthy lives.
3. Integrative healing. All healing arts professionals should work together. Add on-site complementary therapies such as massage, yoga, and acupuncture.
4. Sacred space. An ideal clinic is “a sanctuary, a safe place, a place of wisdom . . . a place where we rediscover our priorities.”
5. Easy access. Same day appointments offered and everyone receives care when they need it.
6. Relaxed appointments. Visits are, at minimum, thirty minutes. Patients want to speak uninterrupted and “feel heard, understood, and cared for.”
7. Patient-centered care. One citizen’s advice: “Abolish cookie cutter medicine—everybody does not need the same thing.”
8. Community orientation. A doctor is part of the community and “knows everyone by their first name . . . knows patients in a social context.”
9. Creative financing. Offer patients an array of payment options: Consider monthly stipends and sliding-scale discounts. Accept donations, bartering, and insurance when possible.
10. Heath education. Transition from an acute care delivery system based on intervention to wellness-oriented healthcare system.

Doctors don’t usually ask for help, but sensible solutions are literally right next-door.
 I invite you to talk with your neighbors, to engage with your community, and most importantly, to act on what they tell you.

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care.

 

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  • soloFP

    Some things that most rational patients do not want is the extreme ICU hospital care at the end of life. Why drop $100,000 or more of Medicare’s money to not extend the quality of life and die in the hospital. Most patients over 75 simply want basic comfort care. They do not want colonoscopies, mammograms, prostate exams, and other preventive medicine. Usually it is their children who push for the extreme care that often does not extend the quality of the seniors’ lives.

    • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

      Yes soloFP ~ What becomes so clear when Americans are asked to share their wildest dreams for health care is that they want less high-priced, high-tech intervention and more high-touch hand holding, honest conversation. If we were to ask patients to design an “ideal death” they certainly would not want these tests. What people want is so very different that what they are being offered. A real eye-opener for me!

      Pamela Wible MD

  • http://www.chiropractorguelph.com Dr. Mark Kubert

    Good for you for initiating the kind of change which truly supports a “patient centered” approach to health care. In his book Change Or Die, Allan Deutschman discusses the that this kind of approach between patients and doctors, more egalitarian than authoritarian, can help to encourage within the patient a sense of hope, belief, and control in their own health. It’s great to see it being put into practice in such a broad way. And although emergency care will always be needed, prevention as opposed to crisis care is always preferable. Thank you for sharing this experience.

  • http://fertilityfile.com IVF-MD

    These are some great points, Dr. Wible. If the doctor-patient relationship could return to the traditional model of two people agreeing to conduct a mutually rewarding transaction, without the third-party overinvolvement of insurance companies or politicians, then these 10 things and other desirable features that we haven’t even though of yet would increase. It’s interesting that we could take each of these 10 features and individually discuss how third-party involvement actually inhibits them. There are very few fields left in medicine where third-party involvement has not yet taken over and even with those, the threat is always there.

    • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

      IVF-MD ~ The first thing I ask myself before changing my practice in any way is:

      “Will this enhance the patient-physician relationship?”

      If my decisions uphold this relationship then I know I am on the right track.

      Pamela Wible MD

  • http://www.jinqiuyu.com QJ

    These would be great if we weren’t such ambivalent people.

    The doctor that hugs you could be considered caring and trustworthy. Or he/she might be “creepy”.

    The doctor who knows you in a social context might give you care with which you are comfortable. Or you might be too embarrassed to go altogether. Maybe you don’t want the doctor treating your gonorrhea to know you by your first name.

    Relaxed visits are great–until you’re waiting for the patient before you to finish and they just won’t stop talking to the doctor. But all you want is a painkiller for your migraine so you can go home.

    Sliding scale discounts seem perfectly fair until you realise that your friend, who spent all her time partying instead of working extra hours, pays a third as much as you do.

    And same-day appointments means that some people, who want to be able to be scheduled ahead of time, have to wait until the next month because too many hours are saved for last-minute visits.

    • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

      QJ ~ really interesting thoughts. First, we must be comfortable in our skin. I have a PowerPoint slide that reads: “Patients will fall to the level of dysfunction within a clinic.”

      If we are functional we attract more functional patients. If we run a chaotic practice with poor boundaries then patients take on the same behavior. I have discovered more about my flaws working as a solo doc that I would have ever discovered were I part of a larger clinic, shielded in some way from my true self.

      Interestingly, some patients do not want a caring, loving relationship with a doctor. Manipulative patients find that their needs are best met in a larger chaotic clinic. I once spent an hour with a middle-age male who probably only wanted an antibiotic prescription, but I continued to ask him about his diet lifestyle, marriage. Afterwards, I realized he probably thought I was flirting with him. I was not, but he probably never had a woman so interested in how his life was going – even his wife!
      Maybe most men don’t want these kinds of relationships with docs. But some do.

      This is where the art of medicine starts. I do believe we can perfect our art, our craft by spending less time talking and more time listening to what patients truly want.

      Pamela Wible MD

  • Dr Chris

    An d who will pay for this. We have patients calling in about their 9 dollar Medicare portion/ Or is the Yuppie care?
    I spend at least 20 minutes-I do mostly geriatrics and complicated chronic patients-and at least a third of them are 40 minutes. I do not get paid for the time I spend to keep these guys out of the hospital.
    Yoga, massage-great, but who will pay?

    • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

      At the end of the day we have the same pot of money to work with in the USA. And people with funds float the people without. My well-insured and well-funded patients float the patients who are less well funded on sliding scale.

      Sometimes I get tips:
      http://www.youtube.com/user/pamelawible?feature=mhum#p/u/4/b4aWpjPtRwA

      I know of other docs who receive unsolicited donations, tips by inspired, appreciative patients. I’ve had visions of primary care docs with “tip jars” at the front desk. Maybe that would demonstrate how undervalued primary care really is in America.

      One can always code for time spent in counseling if > 50% of visit. Can move up to 99214, 99215 based on time.

      Who will pay? Many insurers, many patients (as demonstrated by Americans willingness to buy concierge care). And, yes. . . sometimes primary care physicians absorb the financial hit themselves.

      Pamela Wible MD

  • http://www.queenanfamilymedicine.com Emily Queenan

    Thank you for your inspiring post, Pamela. I am a solo family doctor in Rochester, NY who has jumped off the treadmill of typical primary care to deliver high quality patient-centered collaborative care (all within the traditional insurance system, for better or for worse), and have never been happier. I love my IMP, and am so happy to see other IMP’s spreading the word!

  • http://www.drjoe.net.au Dr Joe

    This tells us that people want humanity in health. We have become too driven by technology and this is dehumanizing.

  • DF

    Hmmm, About the tip. a couple months ago I sent my doc a thank you card after 5 long months of warfarin therapy for a DVT. I say long b/c I was one of those folks who couldn’t seem to get in range (and I’m a pharmacist so I know the deal) so I was coming in every 1-2 weeks. Actually I think it was harder for me and his nurse (so she got a card also!) b/c I had to make the drive and she had to make the phone calls.
    He (and his office staff) also helped me with several other medical problems since last summer even though he was only been able to see me once due to his schedule. (He is in a multi-doc practice) But he’s been around to follow up somehow and even called me at home one night. He is a great family doc and even the kids go there.

    So while I hope there is no next time!, if I ever have the need to send a thank you from the bottom of my heart card, I’ll have to remember to include the “care package” lest he consider moving on to become a waiter instead.

  • Baba LIl

    I am not a doctor , but a patient. I hold dual citizenship, American and Brazilian, and since I moved in North Jersey 10 years ago, I noticed by the way, the difference of quality on patient treatment between the tow countries. I found that right the way that the doctors from area North Jersey offer a very poor treatment in all areas. I feel luck that I can afford to go to Brazil every 6 months for check ups and examinations just because the doctors offer a better treatment, and they look at everything and at the same time are extremely kind. This problem is making me stay way from my mom who is older, and I might have to move back to my country because I believe the health system there is better.. I hope America health system get’s better, since I have family and friends here too, that wouldn’t move to Brazil because they don’t know the language,.This is the number one battle that America has to win at the moment. It doesn’t make sense to many people knowing United States for being a first world place with a confusing health System along with many doctors with bad humor along with terrible service. I get a feeling that the recepecinist get very confuse with all the paper work and get a lot of pressure..I have seen nurses behaving like they are the doctors , but they aren’t . I feel bad for those who can’t afford good doctors , and I feel bad for doctors who are confuse with all of this situation . I have a feeling they don’t have time to read what goes on in the internet. I am a business owner , student and wife, I can be busier then them most of the time, but I realized I have to stay tune on these matters.

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