How physicians can take more responsibility in the care of patients

Medical care in  America isn’t doing so well when compared to other developed nations. Historically physicians did not want to take ownership of their  patients’ problems. Patients have  free will. They can “choose” to be non-adherent. They can choose to not take the medication the doctor prescribes — even if the one prescribed is $70 dollars a month when there is a $4 dollar generic alternative.

One could argue that this approach has not positively affected outcomes as much as it should given the amount of monies spent. Perhaps the doctor needs to have a stake here? Perhaps the physician community needs to think outside of the box and take some ownership in improving the health of the patients they serve.

In an attempt to  think outside the box, I suggest to the world the concept of responsibility based  medicine. I suggest we clinical physicians become responsiblists.

How does a physician obtain the  moniker “responsiblist”? The answer is simple. Physicians must first be obliged to do what they can to practice value based medicine as part of their job description in the new  health care age. Even though physicians get paid on quantity of patients seen, we must think and work as though we were getting paid on the quality of healthcare delivered. Those that practice medicine this way will be the valued physicians of the future: the ones that patients want to see, the ones that accountable care organizations want to associate with, and the ones that will survive in 2014.

Second, physicians must volunteer their valuable time and become navigators to affect change. We must steer more and row less!  This medical blog is a call to action!  The medical revolution will not be televised.

There is a belief in  American medicine that less is better. The “thinking” is that if we use less resources, we will save the system money. I agree. However, who should decide which resources to use? Using primary care physicians as gatekeepers in the past failed miserably. (“A rose by any other name would smell as sweet.”) Therefore, accountable care organizations cannot be the new, cool name for  health maintenance organization (HMO).

Although I’m suffering from a severe case of conflict of interest (I’m a kidney specialist), I think we need to change the paradigm of less is better and start consulting specialty physicians more! I know! I know you are going to say the health care bubble is going to burst, so why would Dr. Aaronson recommend consulting specialty physicians more? I am suggesting this approach not because I’m starving but because I know something that many do not know. I know how both the general internists and the specialists think.

While practicing as an internist (with some simple country nephrology on the side), I tried hard to avoid consulting specialists because I believed that was expected. I wanted to take care of patients my way, using  evidence based medicine. The problem with my thinking was that general medicine is a specialty in and of itself — too broad for me to know every detail about every medical condition. The fund of knowledge required to be a good primary care doc is quite large — arguably too large to successfully go it alone.

Internists and  family practice physicians work very hard to survive. Specialists work hard as well. Consultants tend to know their specialty well, but their knowledge is less with respect to other specialties. Therefore, even with  UpToDate, continuing medical education (CME), and access to all the review courses money can buy, there is not enough time in the day to know everything about everything. Clairvoyance should not be an expectation.

If I can help steer patients in the right direction if they have 60% of their kidney function or less, I would argue that I’m saving the system money — lot’s of money. Moreover, I’m slowing the progression of kidney disease and helping to prevent the need to place patients on kidney dialysis.

Early consultation is especially helpful in the hospital. Let me give you an example outside the specialty of nephrology. If you live in the  Omaha, Nebraska region, suffer from a respiratory arrest, and need to be put on a ventilator, who do you want managing your ventilator? I want a critical care, pulmonary lung specialist who is board certified in both.

If you are in a small country town with one family doc who tries his or her best, then I’m all right with the family practice physician managing the ventilator in the short term. However, it may make more sense for more complex critical care patients to be transferred to centers of excellence where the standard of care is higher: the nurses are more experienced, the pulmonary doctors are readily available, and there are more resources like 24/7 pharmacists. In my experience, the patients who get transferred later, are sicker, and end up costing the system more. Early intervention, preventing problems in the first place, is critical to successful patient outcomes.

Michael Aaronson is a nephrologist who blogs at his self-titled blog, Michael L. Aaronson M.D.

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  • http://med-path.blogger.com Chris C.

    You make a compelling argument. Do you think that partnering patients in these decisions would represent a good balance? Particularly in rural settings where access to specialty care is more difficult, offering the patient the options could help both doctor and patient arrive at a plan together.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    I left practicing traditional high volume primary care because I did not want to be in the position of providing less care to save the system.I additionally did not wish to be in a capitated system that encouraged denying care to be profitable. Different patients have different needs. At the same time different practitioners have different strengths and weaknesses that result in referral patterns based on their knowledge and experience and what they are comfortable with at that time in their career. This changes with time as well. It additionally changes with years away from training.
    I will say with the new idea in general internal medicine training programs of creating outpatient primary care tracts vs hospitalist training we are further eroding clinicians skills, dumbing down the practitioners and making the dependence on specialty care more likely.
    In my community specialists who perform procedures do not want to care for patients but want to stay in the procedure room and perform more procedures. It is more profitable. As long as Medicare pays more for procedures than for cognitive services and prevention and as long as the Medicare Payment Review commission continues to be specialty heavy , specialists will do more to get paid more. They will continue to be consultants and will continue to demand that the PCP and or hospitalist admit the patient even if the clinical problem is one that they have been the QB and leader on as an outpatient. They will be there to perform the procedure but it is very rare today that they wish to provide the hands on day to day care.

    • Lil A

      It’s not only seen in your community. I can see some of this in just about every community out there. It’s sad when this happens because the patient may end up falling through the cracks and end up not getting the care that they need. It’s more efficient for one doctor to be the only one to treat a patient for one problem rather than passing off the care to one or more other doctor or healthcare worker. While most of the details can be remembered and passed off, there may end up being important details that are forgotten or missed. On top of it, one doctor’s way of treating may not be the same as another’s, which may end up causing confusion and frustration in the patient. When I get a doctor that I like, I personally would like to keep that doctor and not be handed off to another one that I do not trust. Each patient’s preference on how they want to be treated is different, and handing them off to many others that are polar opposites in the treatment realm is not beneficial to the patient.

  • Jackie

    We are fortunate to reside in a small town (pop. 50,000) in the middle of nowhere, yet have access to a 500-bed non-profit general hospital within 10 minutes drive. The hospital has its own affiliated insurance company and pharmacy, as well as 20+ sattelite clinics in other towns in the region. My doctors are focused completely on patient care and we never have to ‘second guess’ their ‘motive’.

  • Mark

    I went to my primary care physician for a spot on my forehead. He told me that it was harmless and nothing to worry about. At the time I also asked for a consult (my insurance at the time required PCP approval) to a dermatologist for another condition.

    When I was at the dermatologist’s office, he entered the exam room and from 10ft away said, “That is a basal cell carcinoma.” He walked up and pointed to the “harmless” spot on my forehead. He cut it out and pathology later confirmed that it was indeed a basal cell carcinoma.

    I changed my insurance so that now I can go directly to the dermatologist (and other specialists) first without the gatekeeper.

    • pcp

      I’ve never seen a patient killed by a basal cell cancer. I’ve seen two patients killed by acute liver failure from anti-fungals prescribed by dermatologists for ugly toenails. I was there in the ICU; the dermatologist wasn’t.

  • solo fp

    Docs can’t always be right. The difficulty with denying specialty care or denying that MRI/CT is that years down the line the patient may have something there that will represent a malpractice suit.
    The current system rewards bulk care and no penalty to send to specialists. Even the P4P system has minimal rewards, usually around 4% for quality care.
    Insurance comanies try to limit care, with the prior auth process but have failed overall to reduce costs.
    Patients want everything for the $20 copay, and rightly so, as most families of four have a total premium of at least $8,000 annually.

  • http://naturalhealthcare.web.officelive.com/africanmangoweightloss.aspx Dennis

    I also went to my primary care physician for a spot on my face but was referred to a dermatologist for further study. Some doctors will recommend a specialist for uncommon problems. It may be a pain but I think it is best for all involved.

    • Anon

      Good primary care is not “triage”, and yes, sometimes it does take a good primary care physician to make the best determination about referral to a specialist. I am sure there are some primary care docs out there that may have become complacent, but I guarantee you an excellent primary care doc is worth a lot more than he is currently being paid.

      • AC

        “..there are some primary care docs out there that may have become complacent,..” Some? That’s the majority of them!

        I always wonder what are the PCPs supposed to treat, when all they want to do is send you to a specialist?

        • Anon

          The contempt and disrespect PCPs feel as evidenced by some of the above comments are part of the reason you will not be able to find a good PCP soon. Patients have no idea how much PCPs do “behind the scenes” that is unappreciated and under valued (by patients and insurers). Many patients are disappointed if you refer them out, and many are disappointed if you don’t. I am sorry if you don’t have access to a good primary physician now, because I fear it will get more difficult in the future to find one taking new patients.

        • AC

          Anon,

          The fear factor not really working with me…Anyway, you haven’t answered my question as to what the PCPs treat. The fees are astronomical compared to the value you get from them. I’ve seen specialists charging less then PCPs and I wonder for what.
          Teh European system is: PCPs are the main physicians; specialists are only reserved to more complex cases. You can’t have that in the US because of lack of knowledge, complacency, etc among PCPs.

        • Anon

          Good PCPs treat a lot of acute and chronic illnesses (infections, diabetes, hypertension, cholesterol, depression, etc) for a lot cheaper than specialists, and are more accessible to their patients than specialists. They are more likely to look at the big picture. Some will still manage you in the hospital. I am sorry you don’t see that. Maybe you don’t have access to a good FP or IM doc where you live, and that is a shame. I don’t think I can convince you otherwise.

      • gzuckier

        Yes, an excellent primary care doc is worth a log more than he (or she!!) is being paid; but by the same token, his/her time is worth a lot more than looking at freckles and telling the owner they are nothing, telling people with a cold they don’t need antibiotics, and giving flu vaccinations. Any decent NP or PA is capable of recognizing where a problem needs to be escalated to the PCP MD or even to a specialist, even if the odds are 99.99% that it’s really nothing.

    • http://www.BocaConciergeDoc.com Steven Reznick MD

      It depends on the training and experience of the provider with the problem you have. Like everything else, we are all human with different strengths and weaknesses. The difference between the outstanding ones and the average ones is that the best know their limitations and are not afraid to ask for help and say ” I don’t know” when confronted with a problem beyond their level of comfort or competency.

    • gzuckier

      I’ll join the club; went to PCP for spot on cheekbone (at my mother’s insistence), got told it was nothing, as I expected. Visited parents again, in Canada… ended up going to dermatologist, at mother’s insistence. Dermatologist, knowing my mother, said she wouldn’t give up until the thing was removed, but I would have to pay out of pocket, not being on Canadian health plan, so that’s what we did. Of course, biopsy was it was nothing. Punch line: it cost me $40, all included, Canadian money. This was a decade ago, but still…….

  • pcp

    I saw three patients last week who were having side effects from treatment that the prescribing dermatologist could not evaluate and manage.

    So what’s the point?

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    If you believe ACO’s are the answer would you be willing to purchase a bridge between Brooklyn NY and Manhattan?

  • Angela Caffaratti, MD

    Mark,

    I don’t know how well you knew your pcp, but your dermatologist benefited by the history… Usually those types of cancers grow very slowly and had you gone back with time, it becomes more likely that your doctor would have figured it out and it would not have made a difference clinically. Doctors just think differently about problems than lay people. I’m always amazed that very good problem-solvers have a difficult time understanding how doctors prioritize. I would suggest the book entitled, “How Doctors Think”

  • solo fp

    I am amaze at how many specialist rx meds but then it is up to me to monitor the thyroid, cbc, lfts, or other labs. When the patients jave side effects, they often call me. They tell me that I am easier to contact than the specialist is. That said, medicine is still a team effort between the patients and the “providers” to provide reasonable care.

  • Lil A

    I have seen this a lot in America, and it sickens me. Sometimes if doctors sense a patient desires something but that something isn’t in their best interests (and they know it isn’t in their best interests), they will play to that patient’s desires rather than telling them the truth. While I know that physicians fear losing something because of poor patient satisfaction, I think we need to get out of the commercial mindset that dictates to us that the more we make the patient satisfied, the more money we will get. While there is some truth to this, it isn’t the end of the world to be honest with patients and deny what they want as long as we explain why it’s not the best. While it is up to the physician to lead the patient, it is also up to the patient to hold the physician responsible as well.

    • AC

      I’m not so sure that doctors even think about the hapiness of the patient so much. Not from the evidence that I have.

      Anyway, as a patient I would much rather prefer the doctor to come up with the diagnosis and treatment instead of me, since I’m paying for the “expert” opinion in the first place. If I have to do it myself, then why would I need a doctor for.

      • Lil A

        I prefer this too, but I think that physicians should be allowed to be able to say that there is nothing more that they can do, because that might very well be the case. I think, though, that it is also up to the patient to advocate for their own care. They should research a bit about their condition on their own, and work with the doctor on finding a means of treatment that is effective. There may be some doctors out there that don’t want to treat because they sense that the patient will be “difficult”, and it should be up to the patient to get a second and maybe even third opinion if they think that they are not being treated right or to question their physician’s judgment (the worse that will happen is that you are referred out, which is a blessing to the patient). If all of them come back with the same conclusion, then that says that there probably isn’t anything that can be done at the moment. However, with the ever-changing nature of medicine, this might not be the case a couple of years down the road.

  • AC

    You are so right! It’s true that the players in this industry are overpaid by insurance companies, so they in turn stay in business. What I don’t get is why Medicare overpays for many of these services.

  • http://www.youtube.com/watch?v=foXQbmZxWYY Fragmented American Healthcare

    I treated a patient for years with multiple advanced problems. A few months ago, his nephrologist authorized him a scooter, which he no doubt needed. As his PCP, I was surprised the nephrologist went through the hassle of getting him the scooter. The patient came to see me later and told me he couldn’t use his scooter without a lift for his car and a ramp, so he’d asked the VA Hospital for it (he went to the VA to get his rx’s cheaper). They told him they couldn’t give him a lift and ramp without giving him a scooter, so he ended up with two scooters, a lift, and a ramp. He died and now his widow has this $10K taxpayer funded fleet of new scooters and supplies to deal with. This is an example of why PCP’s are important to lower costs of fragmented healthcare to taxpayers, at least until we can make sensible changes to the system.

    • AC

      Tony,

      The pay-4-performance concept is good, but if you look at who will be in-charge, hospitals and insurance companies-will the cost really be lower?
      We’ve seen what a “good” job ins. companies did thus far and how they skyrocketed the cost. Also, if you take a look at the price hospital outpatient facilities charge you will know what I mean.

      Lastly, anytime you have certain companies monopolize the market say good bye to lower prices.

      • Lil A

        Not only hospital outpatient, but inpatient. I went to the ER for lower right abdominal pain this January, in which I was admitted for observation for a day, and do you know what it would have cost me total, including the second ER visit due to recurrent pain (turns out I had a staple left inside me, and I forgot to mention to the surgeon that I have a metal allergy)? It would have cost me a whopping $45,000 total without insurance. Is that cost-effective? I think not!

        • AC

          Yes, the inpatient hospital prices are the icing on the cake. Their fees are totally unconscionable and, as some of them admitted, have no relation to the actual cost. I’ve seen a bill for 2 days hospitalization, cardiac catherization with 2 stents, with a price tag of $107,779.59. The insurance company paid $23,462.16 or 21.77% of the rack rate. Nowadays hospitals offer a 35% off the bill if you are self-pay and they call that a “discount.” So if I’m uninsured I get to have the privilege of paying 65% of a price that has nothing to do with the cost, but if I’m an insurance company I pay only 22%. That makes a lot of sense. This one hospital charged $467.05 for a CMP panel where at a physician’s office or lab this would cost $16 – $27. Chest Xray (1 view) at $504.39 when I got a 2-view Xray through a physician’s office for $29. And the list goes on….

        • Lil A

          It wasn’t me that was paying the bulk of the cost, but my insurance, but either way, I shouldn’t have to pay for it. If I needed an MRI for something, such as my knees for example, I risk injuring myself, which is total fluff. And part of it is my fault for not making triage aware of my metal allergy. However, when you have intense, worsening abdominal pain with nausea and you are on some really strong anti-nausea and pain meds (I was given Dilaudid for my pain, which is 4-8 times stronger than morphine), there are some things that you don’t remember. That is why it really can’t be assumed that one patient will have a similar reaction to something. But hindsight is always 20/20 and I will be sure that should I have to undergo another surgery, that my surgeon will be made aware not to leave metal inside me, as I have a bad reaction to it.

      • AC

        I totally agree. The latest number on uninsured and underinsured is 86 million (and that’s only what’s been reported a couple of years ago). They say that with a single payer the care would be rationed – what do they call this?

        It’s going to get even worse because now many companies are looking to hire contractors since they don’t have to offer benefits. They are estimating that 35% of the workforce will be in this situation.

        http://www.msnbc.msn.com/id/36826679/ns/business-careers//

        Insurance companies have no value whatsoever and should not exist. “Benefits” have been reduced more and more throughout time, yet the premiums kept climbing so their CEOs can rack in hundreds of millions in compensation every year. They don’t even provide good benefits for their own employees – the only options they have is the non-sense high deductible plans.

        We’re the only industrialized country that does this to its citizens. It’s an inhumane system.

  • Lil A

    The single payer option is not the way to go either. If you talk to doctors that are on the Medicaid program, you will get some complaints about how Medicaid and Medicare doesn’t pay enough, and that they would prefer private insurance over Medicaid and Medicare.

    Private insurance makes healthcare more affordable, as patients cannot afford (usually) to pay for all their visits in one lump sum. Insurance allows patients to finance their healthcare, spreading their costs over a period of time. Insurance also spreads costs for emergent care over a larger pool.

    I do agree that insurance does need to be reformed. I believe that pre-existing conditions should be treated no matter what, because it is the person we are treating. What do we classify as pre-existing conditions? If a link to it arising out of childhood is found, would it be ethical for the insurance company to refuse to cover care because of this fact, leaving the patient in pain and suffering? Not only that, but insurance companies also should not require a diagnosis in order for something to be covered. There are some things that cannot be labelled because the body is organic and constantly changing. There are so many diseases out there that have similar symptoms that trying to pin down a definitive diagnosis is difficult. Then you throw in the fact that some people can exhibit atypical cases, and you are just breeding disaster and misdiagnosis.

    I think that single-payer is a step in the wrong direction, and that there needs to be reform in the insurance industry, and not just a forced institution of a Medicare-for-all policy that will end up costing the taxpayers and patients dearly in the end.

    • AC

      Medicare prices are not low as some may want you to think. The problem is that insurance companies have artificially inflated the physician reimbursement so much so the docs are dependant on them. This way they ensure that docs will keep contracting with them and in turn they (insurance companies) stay in business. I’ve seen a payment of $150 for a 10-minute visit – this type of reimbursement is super high and beyond inappropriate.

      In terms of other fees (labs, hospital, radiology, etc), Medicare’s payments are pretty much in line with what insurance companies pay.

      There are some doctors complaining about Medicaid to the point that you may think they’re on the brink of bankruptcy because of it. Not true. Most physicians, if they even participate in the program in the first place (not all do), they probably don’t have more than 10% of their business coming from this market segment. The rates are nowhere near that low to cause such a devastating impact.

      “Private insurance makes healthcare more affordable” – quite the opposite, Lil. They have to make a profit, and that actually ADDS to the cost we are paying. Have you not seen the headlines about the billions of dollars in profits they take in every year? As a society we could provide care to a lot of people with that money.

      The insurance companies manage to keep a third of the population from getting the necessary care by making this care unaffordable. To me that is cruel and unusual punishment.
      As far as I know this doesn’t happen in countries with a single-payer system where everybody has access to care and they are in better health than us here in the US.

  • AC

    We should have single-payer, but that will never happen in the US because the there is too much money at play and the powers to be will not give that up.

  • Lil A

    By the way, the single-payer system was outlawed and declared a violation of basic human rights because of the amount of people dying that were waiting for essential, life-saving treatments. Personally, I would not want that here. On top of it, Canada is now moving towards privitization and are building hospitals. If it was so effective, why is Canada starting to shy away from it?

    • AC

      “By the way, the single-payer system was outlawed and declared a violation of basic human rights because of the amount of people dying that were waiting for essential, life-saving treatments.”

      What countries are you talking about?

      • Lil A

        Canada, in 2005′s Chouillie (sp?) vs. Quebec.

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