Improving health care: Are physicians knights or pawns?

Improving health care: Are physicians knights or pawns?

How do we motivate physicians and other health professionals to work at their best? How do we create systems of high performance? Is it by a series of top-down highly specific mandates or by setting up general guidelines and providing tools?

I believe it comes down to one’s vision of physicians. Are physicians knights to be empowered in their service of patients or knaves not to be trusted or pawns to be manipulated?

Consider the goal of reducing inappropriate use of antibiotics. A policy aimed at physicians as pawns or knaves would be based on micromanagement at the point of care. Create a system of hard stops and drop-down boxes. Make the doctor justify each prescription. Limit options based on the diagnosis and duration of symptoms. Force the doctor to document in discrete data every element of the clinical encounter (date of onset of symptoms, fever or not, x-ray findings etc.) and only if the tick boxes align with the algorithm can the order be completed. Create a system where there will be many real-life circumstances that fall outside of the algorithm, and put physicians in a bind of trying to fit a square peg in a round hole. Results: workarounds and cynicism, and ultimately despair at another straight-jacket.

Alternatively a policy aimed at physicians as knights might be based on empowering physicians to act professionally in the best interest of their patients. Create a higher level expectation: for example, that each hospital or clinic have an appropriate use of antibiotics committee. Give guidance as to how that committee could be structured and work, with sample measures that could be tracked and sample communications to use with patients and providers. This approach treats physicians as knights, who want to do the best for their patients and community, and will do so when given support and guidance.

Much of the burnout of physicians can be traced back to an external environment that increasingly treats physicians more as knaves and pawns, and less as knights. And I believe the more physicians are approached as knaves and pawns, the more knave and pawn-like behavior there will be.

Conversely, when the external environment approaches physicians more as knights, and gives the tools to help improve, this will draw on physicians’ desire to provide the best care possible for their patients, and we will provide better care, not just in antibiotic usage but across the entire spectrum of illnesses managed.

Do you have any experiences, pro or con, with either the top-down or the bottom-up approach to improvement?

Christine Sinsky is an internal medicine physician who blogs at Sinsky Healthcare Innovations

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  • Dr. Drake Ramoray

    I did the abence of patient satisfaction surveys included in your discussion of abitbiotic use a glaring omission.

    That being said I find this analogy entirely appropriate for Dr Sinsky’s view of physicians. The false choice if pawn, knave, or knight, all the while illustrating that to her, doctors are nothing more than pieces on a board to be moved and manipulated by some higher controlling power be that the government, insurance, pharma, or the ABIM/ACP

    It’s group think and pieces like this that encourage arduous and meaningless requirements like MOC.

  • Margalit Gur-Arie

    Just curious: Do doctors not know when to use antibiotics? If not, what type of education and training will produce a professional who knows how to properly treat a person with a sore throat?

    • Dr. Drake Ramoray

      We don’t learn that in medical school. Only if someone with an MBA, an administrator, our EMR algorithm suggests it or under the advice of a consultant physician who doesn’t see patients full time can we possibly prescribe antibiotics in an appropriate fashion. /s

    • buzzkillerjsmith

      I really don’t remember seeing sore throats much in training. Liver failure yes, myelodysplasia yes, metastatic lung cancer, yes, but not much in the way of sore throats. Saw some of it in peds.

      I learned after I got out. Took about a half hour or so.

      I had a buddy who was an EMT. He wanted to be a doc but was a bit put off by the whole med school thing, so we decided to teach him how to become a Kaiserdoc in 4 easy lessons:

      Sore throat–> erythromycin

      Safeway worker or postal employee–>work excuse

      Ear pain–> amoxicillin

      Chest pain–> “Dammit nurse, haven’t we already gone over how to manage this? What are you, a chucklehead? Leave my office now lest I give you the back of my hand!”

  • DeceasedMD1

    “Force the doctor” to document in discrete data every element of the clinical encounter.”

    Really? Force the doctor? Treatment through oppression?

  • buzzkillerjsmith

    I’m a pawn that has been taken en passant.

    • Arby

      If there was a comment of the year award, I would be nominating this. You have said so much in such a simple statement. And what you’ve said is sad, but true.

      • Dr. Drake Ramoray

        Agree, I would have given it 100 up votes had I been able.

  • Dr. Drake Ramoray

    Very true. Don’t forget the patient satisfaction survey though. Patient A not given antibiotics gives the physician a poor review. This results in a lower patient satisfaction score for the doctor, who then gets paid less and subjected to meetings with his MBA managing overlords.

    The doc then either learns and writes scripts more often thus boosting his/her patient satisfaction scores and earning a pat on the back, or tries to explain and work through the system about proper antibiotic usage and be labeled a “disruptive” physician.

  • ninguem
  • Arby

    I’m not sure exactly what you are saying here, yet I can say that erythromycin is pretty hard on the stomach, and this from someone who can take Augmentin on an empty stomach with no issues.

  • buzzkillerjsmith

    No doubt. This was in 1989 at Kaiser. We played by our own rules, baby!

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