Improve the inequalities among physicians

Our current health care system will fail; it’s simply a matter of time.  Yet the delivery of efficient, quality, and progressive health care is quite possible once we shift our thinking.   A true paradigm shift in medicine begins with first establishing that each pillar in health care has an equal responsibility in making a new system work:  patients, providers, and places (facilities).

This article pertains to only the provider portion.

As providers, we must manage a health care delivery system that discourages stigma, rewards innovation, and reimburses complex innovative work.  We must also create and protect transparent self-policing strategies that rebuild trust with the other two pillars.  “Getting doctors to agree on any one thing is like herding cats” is true, but the failure to try worsens our current predicament (and unduly burdens the other two health care pillars).

For providers, the first (and most important) shift in thinking is to recognize that the 3 dimensions of medicine justifiably exist:  medical specialties, mental health, and surgical specialties; and that each dimension is as important and fundamental as the others.

For example, I found myself in an argument with a colleague who said that surgeons “justifiably make more money because they save lives.”  My reply: “Helping a child of divorce with their trauma and ADHD can be pretty life-saving as well.”

Completing a triple board residency, I saw first hand how drastic the respect, time, and reimbursement paradigms differed between pediatrics, adult psychiatry, and child psychiatry.  For instance, I would see complex ADHD kids in my pediatrics continuity clinic and have 15 minutes to do the very same work I had the privilege of doing in 30 minutes in psychiatry.  Yet the billing codes awarded a very different level of importance between medical and mental health.

Administrators in medicine also encourage dimensional stigma in many ways.  One recent example was a clinic supervisor attempting to force me to see a new psychiatric patient who was 30 minutes late to her 60-minute initial appointment.  My retort:  “Would you ask a surgeon to do a 4-hour long surgery in 2 hours without a preoperative evaluation?”

And for the other dimensions, the reverse is equally true: Asking a family practice provider to complete a suicide risk assessment, prescribe antidepressants in 10 to 15 minutes and see the patient back in 2 to 4 weeks is untenable given their scheduling.   Forcing a pediatrician to create a behavior modification plan for an autistic child during a 15-minute “sick” visit is equally unfair.

To combat this, one amazing attending during residency encouraged consulting services to call us early if there was an inkling that a psychiatric issue was at hand.  While admirable, this led to inappropriate consults (being asked to do social work) and to our thin psychiatric resources being triaged and rationed.

As a child psychiatrist and pediatrician, I’ll admit:  I’m a Pollyanna.  Yes, I think our health care debacle is a behavioral problem and I fully believe most behavioral problems can be solved or well managed.  The first step is to clean the slate and start with the basics.

My suggestion: Create a universal medical record, eliminate procedure-based reimbursement, and create dimensional expectations for reasonable reimbursement within and between the dimensions.  In other words, allow providers to easily talk with one another without fear of reprisal or lawsuit.  Decrease (but not eliminate) the disparity in salary between dimensions for providers of similar training, additional certifications and years of practice.  And allow intra- and interdimensional peer review to weed out those outliers that put patients, places, and other providers at risk.

Providers are not the only pillar at fault.  Patient nonadherence/miseducation coupled with overspending by facilities will push our teetering system right over the edge.  But improving inequalities between providers is a factor we can improve in the larger paradigm shift to overhaul our health care delivery system.  I encourage honest, open, and frank discussion so that we can avoid the known sentinel event barreling down on us.

Brian J. Dixon is a psychiatrist and can be reached at Progressive Psychiatry.

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