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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