Obamacare fails by not listening to the voices of the caregivers

When an employee leaves a position, management might conduct an exit interview. The idea is obvious: one can learn a lot from those who are free to speak candidly.

This is why I think it’s worth listening to doctors who no longer practice medicine.

Enter Dr. Ed Marsh, a former pediatrician, who writes this poignant and relevant essay. His tone and candor is one of a man who still cares about healthcare.

A number of his points deserve emphasis. First the intrusions, then Obamacare in the real world.

Dr. Marsh’s most pressing concern is the loss of humanism in the practice of medicine. That too often, doctors are treating patients rather than caring for them.

This point cannot be underestimated. It is the essence of what is wrong with healthcare reform.

Taking care of patients is not like making cheesecake. You cannot automate everything about patient care. When I was in medical school, I took classes and attended seminars on how to better relate to patients as people. I was taught to make eye contact, ask open-ended questions and consider how a treatment might align with a patient’s values, including costs. I was taught to go slow and form a relationship with the patient.

Getting to good medical decisions has always depended on having adequate face time with the patient. This human-to-human time has never been more important. Technologic advances and medicalization of nearly every imperfection has fed the culture of doing (treating) more. Doctors need to explain (and patients must understand) that more care rarely equates with better care.

What we are striving for is rational care, and this takes time, and trust between doctor and patient. It takes a relationship.

Herein lies the problem with healthcare reform measures. Intrusions to the patient-doctor relationship make it tougher to get to rational care.

What intrusions?

Dr. Marsh writes about how the intrusion of insurance coverage created a culture of entitlement. Clearly, it is a good thing when health insurance prevents financial ruin from an illness. The downside, however, is removing a patient’s “skin in the game.” Sure, medical costs will never be as easy to understand as that of a toaster, but if all health care is free—well that’s a problem.

Another intrusion to consider is distrust. This morning I spent an hour with a coding expert. I learned that unless I used the right nouns and verbs in my documentation, I will be outside of compliance—an offense that approaches being fraudulent. The documentation of a clinical encounter has been made into a nonsensical digital invoice for services rendered. A compliant medical note is nearly devoid of anything human. My point about distrust and coding is that you can’t click a computer and make eye contact. What’s more, as the patient, do you want your doctor studying coding rules or medical studies?

When a cubicle doctor from a far away insurance company calls you to question your motives for ordering a test or treatment, there’s always an aura of distrust. The implication, however friendly the conversation, goes something like this: I know you are the one taking care of the patient, but we all know I am here to keep you from gaming the system. I don’t know about you, but honest people do not take well to false accusations.

Then there are government intrusions.

The results of the election are clear. The majority wanted to avail healthcare to all Americans. I’m good with that. Americans decided to let government control healthcare delivery.

My problem with Obamacare is not that government will control healthcare, it’s that it does nothing to deal with the rising costs of healthcare.

Obamacare fails in three major ways.

First, it does nothing to change the incentives to deliver more—not rational–care. As a proceduralist, it is far harder for me to discuss the possibility of not doing a procedure than it is doing it. The fee-for-service system rewards me for doing procedures. For instance, I start every discussion about a procedure by telling the patient that I am a proceduralist, and like a roofer who tells you about the need for a new roof, I am paid to do procedures. Patients laugh about this analogy but the fact remains that doctors are humans, and humans respond to incentives.

Obamacare ignored this basic tenet of human nature. In a typical hour, I make ten-fold more than my wife. I am doing a low-stress procedure; she is discussing death and dying with an emotionally distraught family. That’s a travesty, because palliative care doctors relieve just as much as suffering as atrial fibrillation doctors. (Probably a hell of a lot more, actually.)

Second, Obamacare ignored the effects of liability. A proceduralist who does not do a procedure greatly increases his or her own risk. Take the ICD example: Not implanting a device in a patient who is “guideline eligible” is risky. For if the doctor was wrong, the patient might die—painlessly and peacefully, but die nonetheless. Now, what if a family member not privy to the pre-implant discussion investigates the death? They may find that their mother was eligible for a defibrillator. It’s the same thinking with the last round of chemotherapy, the surgery for dying bowel in a frail elderly patient, the feeding tube in dementia and a host of other conditions.

In our system, not doing is always riskier than doing. And this is just the view of a proceduralist: put yourself in the shoes of an ER doctor or primary care doctor. I have no idea how they do it. Well, I guess they order tests and consults, or, they worry a lot.

Third, Obamacare’s mechanism for cost saving is foolish. Reformers chose to blame “highly paid” caregivers. Cut doctors’ pay, turn us into data-entry clerks, monitor our e-data and replace us with more malleable non-physicians was a politically easy cop-out. Was it a calculated decision? Or were the smart people in charge of reform so ill-informed about the real world that they made an honest mistake? I hope it was the latter.

The problem with fixing healthcare on the backs of caregivers is the unintended consequences of creating a distrustful and joyless profession. It takes nearly two decades to make a physician. That’s a big investment. The health of our society argues for more skilled physicians—not fewer.

I think everyone should pause and think about healthcare reform. Make yourself the patient. Put yourself in the ER or in the doctor’s office. Give yourself the mass that needs removal–or does it? What do you want for yourself?

Compassion. Empathy. Skill. A relationship with a caregiver.

Kind, caring and unrushed nurses and doctors don’t just appear. Young people dedicate their life to medical careers because it is joyful, rewarding and financially sustainable.

Let’s listen to the voices of caregivers. Those of us who dare to write and speak do so because we still care. It matters.

John Mandrola is a cardiologist who blogs at Dr John M.

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  • Anthony D

    The Downgrading of the Medical Degree: The new world order under Obamacare will see a paradigm shift wherein government-empowered administrators and other non-physicians make de facto medical decisions effectively ruling over the practice of medicine by physicians. Throughthe abuse of “standards” imposed by the Feds, the AMA, and the pseudo-independent accrediting body, the “Joint Commission” (JCAHO), doctors are increasingly losing the freedom to exercise independent thought and the independent practice of their profession. By utilizing peer review practices which would not stand muster under standard constitutional law, hospital and health systems can label anyone a “disruptive,” “unruly” or “uncooperative” physician and destroy their ability to work.

  • Anonymous

    What about the Value Based Purchasing Program. Through this, more care will no longer be the right answer. The quality of care will only matter.

    • LeoHolmMD

      What is “quality”?

      • mmer

        2 examples..

        1) Exceeding your group peer in certain metrics (ie. error rate) by 2 standard deviations

        2) Given similar patient populations in terms of socioeconomics, managing your patient’s diabetes more effectively

  • ErnieG

    Excellent post. I think it points out several key fundamental failures of ACA. In my opinion, the ACA pushes medical care towards an industrialized model of medicine without reducing the costs nor improving the profession. I am cynical about Mr. Obama’s intentions- I think he was more interested in defining himself as the president who tackled the healthcare problem, rather than addressing the fundamental problems with healthcare. –ErnieG

  • Anthony D

    545 vs. 300,000,000 People-By Charlie Reese

    Politicians are the only people in the world who create problems and then campaign against them.

    Have you ever wondered, if both the Democrats and the Republicans are against deficits, WHY do we have deficits?

    Have you ever wondered, if all the politicians are against inflation and high taxes, WHY do we have inflation and high taxes?

    You and I don’t propose a federal budget. The President does.

    You and I don’t have the Constitutional authority to vote on appropriations. The House of Representatives does.

    You and I don’t write the tax code, Congress does.

    You and I don’t set fiscal policy, Congress does.

    You and I don’t control monetary policy, the Federal Reserve Bank does.

    One hundred senators, 435 congressmen, one President, and nine Supreme
    Court justices equates to 545 human beings out of the 300 million are
    directly, legally, morally, and individually responsible for the
    domestic problems that plague this country.

    I excluded the members of the Federal Reserve Board because that problem
    was created by the Congress. In 1913, Congress delegated its
    Constitutional duty to provide a sound currency to a federally
    chartered, but private, central bank.

    I excluded all the special interests and lobbyists for a sound reason.
    They have no legal authority. They have no ability to coerce a senator, a
    congressman, or a President to do one cotton-picking thing. I don’t
    care if they offer a politician $1 million dollars in cash. The
    politician has the power to accept or reject it. No matter what the
    lobbyist promises, it is the legislator’s responsibility to determine
    how he votes.

    Those 545 human beings spend much of their energy convincing you that
    what they did is not their fault. They cooperate in this common con
    regardless of party.

    What separates a politician from a normal human being is an excessive amount of gall.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Maybe 545 is to small a number for representing 300 million, but I think the problem is that it’s the same 545 for way too long. Reelection concerns is what allows lobbyists to gain unfair advantages. Everything those 545 people do is about the effects on the next election cycle. Maybe we should just have one term and you’re out, so being a politician is just a brief time off to serve the public, instead of a career.

  • Tom

    This was a terrific article, Dr. Mandrola. I’m sending it on to my Congresscritters. Thank you for writing this. Because you are right. It matters.

  • Robert Luedecke

    I understand your frustration because there is a LOT going on right now and some was not at all well coordinated. I do believe it is possible to have the relationship with patients you talk about under Obamacare. My internist does a great job of being very personable despite computerization. Standardization of medical care is one way of reducing the cost. It may not always be more fun, but it should reduce
    the cost, which is very necessary. I see nothing in the ACA that says nurses and PA’s should replace physicians and I do not feel threatened by them providing more help to physicians.

    The structure of Obamacare was intended to be fine-tuned in the legislative process, but there was no way to bring about any of the good changes without passing it in its original, very rough format. There is not a bipartisan effort to improve anything in Obamacare, so whether you blame the Democrats for passing what they could pass or you blame the
    Republicans for claiming it can’t be fixed without throwing the whole thing out, is a matter of perspective.

  • Bob

    While I agree fully with your analysis, what caught my eye was the line about it taking two decades to make a physician, as I see this in terms of generations, as in 60 years grandparents, 40 year parents, 20 year children. So as I see it, half the physicians who have spent a long time schooling 20 to 40 years ago, have now reached their most productive years when others are retiring “after 40 years service”. Having paid off debts and reaching a good financial setting, I would believe most “boomer” physician and nurses now in short supply, wouldn’t have to work and are looking for ways to “slow down” and smell the roses; while newly licensed physicians and nurses want this up front and won’t work more than 40 hour weeks.
    So this looks to me to be a perfect fit as the new docs will leave a lot uncovered providing more than enough for “semi-retired” to use as “side jobs.” But less physicians, and nurses caring for more patients doesn’t work in my math.
    Good thing all medicine is rapidly changing with biotech and stem cells and such that few physicians or nurses know how to apply; so I believe we all face “A Brave New World”!

  • mmer

    //Americans decided to let government control healthcare delivery.//

    The Affordable Care Act lets the government have more control over the financing of healthcare, but not so much the delivery. If the government were in control of healthcare delivery, then doctors would be government employees.

    It’s important to make this distinction in the context of the healthcare debate. For example, a single payer system says nothing about the delivery of healthcare, only the financing.

    In the UK, a doctor can be employed by the NHS which also governs financing; in this case the government controls healthcare delivery (to the extent that most doctors are employed by the NHS). In Canada, the government controls financing of healthcare, but for the most part, care is contracted out to private doctors; in this case, the government controls financing but not the delivery.

  • Guest

    Thank you for speaking the words that need to be said, loud and clear. As a registered nurse, it goes the same way.

  • drgh

    I don’t think Obamacare or any politicians are able or willing to address fixing the underlying problems in Healthcare, because that would entail confronting the true leaders of this country–special interest groups. i.e. pharmaceutical and insurance companies and the likes.
    Look how they deal with increasing PCP shortage. It involves everything but actually increasing the pay of PCP’s.