Our dysfunctional system: Both doctors and patients are at fault

I do not argue with my patients.  Rather, I teach, outline options and explain my point of view, as each person must choose their path.  However, the other day, Audrey and I got in a tiff when she was in the office to discuss her breast cancer.  We had an enthusiastic discussion not of chemotherapy, x-rays or surgical options.  Nope, we disagreed about what is wrong with healthcare.

It seems to me that the primary cause of dysfunctional medicine in this country is in my face every morning.  Big Pharma?  No. The United States government? Nope. Insurers?  Not really.  How about capitalism verses humanism?  A distant second.  No, the major cause, the big problem, the central failure in healthcare is doctors.

Nothing in medicine happens without a doctor’s order.  Nothing.  Directly or indirectly, every pill administered, test ordered, patient admitted, hospital built or insurance payment processed, was ordered by a physician. We have the ultimate power and can control or change medicine, if we wish. Therefore, everything good in medicine we created.  However, everything bad is also our fault.

If the pharmaceutical companies make too much money on copycat drugs, selling them at too high a price and pushing them on patients without adequate research or safety trials, physicians write the prescriptions.  If insurance companies put restrictions on over ordering of tests, so that the whole system bogs down in pre-certifications and denials, it is because doctors do not emphasize quality over quantity.

If hospitalizations are too long, it is the physician’s failure to discharge.  If antibiotic resistance and iatrogenic infections are sky rocking, it is physician’s failure to be conservative in antibiotic use. If there is too much emphasis on crisis medicine and fighting disease, and too little lifestyle prevention, this is the medicine doctors practice.

We have always controlled it all, but by failing to use that control to keep cost down, limit unneeded testing, police our own and by jumping on every shinny new technology, no matter the cost or the unknown side effect, we have failed to live up to the Hippocratic goal of the finest care. Moreover, the occasional rotten physician, who builds their practice on big bucks, taints the barrel.

Audrey says I am wrong.  She thinks that blaming doctors is a copout.  Audrey believes that there is only one person responsible for healthcare and the problems are all their fault.  That person is the patient. She believes that healthcare and healthy living are every person’s responsibility.  Patient’s demand excessive, expensive and ineffective care.  Patients fail to practice basic preventive medicine, such as exercise, good diet, rest and not smoking.  Patients, instead of working with their doctors, threaten them with malpractice humiliation, producing an adversarial relationship instead of a team.  It is patients that fail to understand their bodies and do not take the time to comprehend their medical problems, so that instead of leading in their own care, are lead blindly down the wrong path

Audrey believes that if patients did not always look for the newest, brightest and most exciting cutting edge therapy, that if they emphasized good basic care, that patients would avoid bizarre complications, confusing outcomes and out of control medical bills. If patients understood science and disease better, they would be more effective consumers and avoid quackery and confusion.

Finally, Audrey contends that patients must not see precious healthcare resources as a commodity over which to fight, but should work together to assure that every person has access to the medical treatment they need. Audrey said that if patients did not deny that bad things happen and that miracles are rare, and instead focus on achievable outcomes and on quality of life, that healthcare would be appropriate, available and affordable.

Of course, in the end, we are both wrong … and we are both right.  The future will only be one of quality, compassion, low cost and healthy living, if patients and doctors work together.  Whatever their good intentions, we cannot depend on any other player in the healthcare space to have a full understanding of the issues that each person experiences in achieving and keeping health.  The penultimate expression of the physician–patient relationship must be this: working together to build healthy lives for everyone.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • ErnieG

    Nice try—if it could only be so simple: the patient and
    physician, alone in the room, with nothing but the patient-physician relationship. A self-hating doctor, finding salvation in
    the patient who tells him it is not his fault but mine, then resolution…what a movie!

    While true, physicians order labs and meds, and discharge
    patients, and patients may have unhealthy lifestyles that lead to disease, there are simply players too large NOT to get involved I in this pie, that essentially dictate what must come out of that patient-physician relationship. It all starts with the third party payer and their intrinsic schemes to deny payments, and dictate “outcomes”, then trickles
    to big pharma, then to hospitals. Perhaps the problem with health care is that medicine got too good, extending lives with fancy pills, state of the art machines, and greatest lab tests, needing more than physicians and patients to support these
    services, such as big pharma, comprehensive insurance, and state of the art hospitals. The problem, I think is that
    all the players in medicine, except general physicians, got too big, and started to look after their own interests, government included. Obamacare cemented those players; and government, not able to tell its head from it’s a**,
    legislates without a care to the unintended consequences—see Dr. Grumet’s entry yesterday. Mr. Obama can make a claim he was able to do what no other president before him did- offer health care to all Americans. What a tool.

    • guest

      Could not have said it any bette Ernie. Very thought provoking . I am with you. That article from Dr. Grumet was the most concise blog putting all the pieces together. Gov’t make these legislations that create a PCP crisis but then the ones to get blamed or targeted for these bad legislations are indeed the doctors themselves.
      The article before this one is a great example. A California law to prosecute PCP’s for elder abuse if they don’t refer to a specialist. This is ludicrous but it creates a Cold War feeling of paranoia for PCP’s. FRANKLY I THINK WE ARE THE ONES BEING ABUSED. Feels more like a McCarthy witch hunt. It’s awesome. The legislatures create the PCP crisis and then turn around and blame the PCP’s for abuse! Just beautiful logic.

  • http://frugalnurse.com/ Frugal Nurse

    Physicians and patients have both played a part in the over treatment and over spending so prevalent in our health care system.

    But I think patients are victims of really effective marketing by pharmaceutical and medical device manufacturers who push their products by instilling fear (You might have this disease! You might miss this diagnosis!) or implying rationing on the doctor’s part (Ask you doctor about the newest treatment/drug/test/device! You deserve the best!).

    And physicians are victims of increasing government involvement (and litigious attorneys) that only seems to make issues of patient care, time management and reimbursement more and more difficult.

    Physicians need to be able to spend time with patients as they think necessary to build trusting relationships and be able to counsel and educate more effectively. Patients need to listen to their physicians and not the media.

    I’ve been a nurse for 30 years and it’s been very disheartening to see the disintegration of the doctor-patient relationship over the years.

    • Suzi Q 38

      So true.

  • wiseword

    I’m with Audrey. You can’t live a junk life, then expect a physician to fix it.

  • Dan983

    Every component in the system is partially wrong! However, if one wants to target the main contributor, I believe it’s resident in our Wall Street financial system! Up front, I have to credit the “great” Harvard Business Professor, Clayten Christensen. He is the first to note this change in long-term corporate strategy. Here’s what changed to totally screw up our health system!

    The delivery of healthcare is patterned after the practices of our public, stockholder owned insurance/MCO firms. These companies operate to maximize shareholder value. One may believe the interests of shareholder profits closely align with the practice of maximizing levels of human health? 25-40 years ago this was true as Americans held stocks for years and company managers developed long-term strategies to benefit shareholders. The move to 401K plans taught individuals to buy and sell stocks over much shorter time periods thus company managers starting adopting short-term strategies to demonstrate profit on a quarterly basis!

    Suddenly, insurance companies are implementing plans/strategies completely misaligned with longer-term human health realities. Anyone think web-based wellness programs are effective? How about MCOs employing one nurse per 50 thousand members?

    What’s the answer? Dr. Christensen says to remove the management of health strategies from the quarterly profit rat-race? Keep operation results in a stealth mode, reporting earning every 2 1/2 years? One successful private enterprise venture in healthcare is the Medicare Advantage business! Why? MA members stay with the MA provider for an average of 7 years, thus health improvement strategies pay off with profit for the public firms! Maybe members should be required to stay for 5 years?

  • MakeThisLookAwesome

    Blame Harvard Economist, Dr. (PhD) Hsiao. He redesigned Medicare guaranteeing this debacle. Even though 60.5% of visits made are made to primary care physicians, and even though the most frequent principal reason for visit is a general medical examination (National Ambulatory Medical Care Survey: 2008 Summary Tables, tables 1, 9, 13), the government has guaranteed that there will be fewer primary care doctors available. Additionally, the government has guaranteed those doctors will be pressed for time, due to cost constraints.

    See, as Medicare goes, so go the insurance companies. And he was the guy who changed the payee system for Medicare. He came up with a new model in the 1980s. This model determined how much a doctor got paid, based on how difficult a task it was, modified by how expensive their education was to know how to do that task, modified by how much stress and/or risk was involved in the task. (Check out the book, Next Medicine: the Science and Civics of Health, for a more complete history.) Listening? Not hard—if you don’t come to med school knowing how to listen, you probably shouldn’t be there. Amount of special “doctor training” needed to know how to listen? Zero. There are no med school classes on listening. Stress involved? None… at least not when comparing it to anything else, and especially not as stressful something like trauma surgery. Risk involved? None—no one as ever been killed from listening. Payout by insurance? Let’s see… Nothing, multiplied by nothing, carry the nothing, comes out to… nothing! (Big surprise.) The same goes for reading files, and organizing care following a major procedure. Doctors don’t get paid for these things, so they turn into low priorities. Low priorities, even though these are possibly the most important parts of medical care: gathering information so you know what you’re dealing with, and disseminating information so that things are done right!

    But “how important is the task?” never mattered to Dr. Hsiao. It’s not his fault, really. For one, everyone underestimates good communication and documentation… until they need it. (It’s why I get paid so much as a technical writer.) And second, Dr. Hsiao wasn’t paid to care either! The government signed his checks, and the government was looking for ways to save money. Dr. Hsiao was paid to come up with ways to save the government money on health care. The easiest way to save money? Don’t spend it. The next easiest way? Find a way to pay less for the same things. The only problem with this, it changed doctor behavior. And it changed medical school behavior too.