While driving home from a weekend trip, my children were watching The Lorax in the backseat, and I couldn’t help but think how acutely applicable its theme is to the current state of medicine in America. Just as seemingly small changes in the name of “progress” slowly altered the environment in The Lorax, a handful of mostly well-intended modifications have transformed the landscape of medicine into something unrecognizable and unsustainable.
We now find ourselves in a place where primary care physician burnout is over 50 percent, and excellent physicians are leaving medicine for careers involving less stress and better work-life balance. But irrespective of the stress and the hours, the thing that ultimately pushes many good physicians out of medicine is the recognition that despite our best efforts, working within “the system” means providing substandard care. Our patients can no longer get in touch with us when needed; rather their calls are shuttled to an off-site facility with no first-hand knowledge of the patient, the doctor or the facility. Our larger organizations burden us with so many computerized housekeeping tasks that we are only able to fully engage with the patient about their concerns for half of our already constrained 15-minute appointments. At every turn, we are asked to improve efficiency and cost-effectiveness without sacrificing quality. But our patients are too smart for this. They can ascertain when their physician is burned out, and no longer has time to listen to their concerns. They know when they are not getting true “quality care.”
Unfortunately, instead of this feedback being directed back to the organization itself, the onus is placed on the providers in the form of a bad individual “rating” based on patient surveys. However, these surveys do little to reveal the bigger problem lurking underneath — the fact that providers no longer have control over anything that happens in the office: the schedule, the staff, the equipment, the billing are all determined by the organization.
So, what are the seemingly small changes that have led to our current health care reality?
Health insurance companies = the Thneeds in The Lorax. It is something we all need, right? Lured in by false promises, little did we know that this would be the start of the downfall. Initially, health insurance was designed to be there as a backup in case of a health crisis. This was, and still is, a great concept. But over time it has morphed into for-profit companies more interested in making money than providing needed care. It pains me to read articles stating, “Aetna, Anthem, Cigna, Humana and UnitedHealth Group — the big five for-profit insurers — cumulatively collected $4.5 billion in net earnings in the first three months of 2017,” reaping “historically large profits in the first quarter of this year, despite all the noise surrounding the Affordable Care Act’s individual marketplaces” — because I know that these earning are at the expense of patients. I am frustrated by the hours I spend communicating with insurance representatives with minimal medical knowledge trying to get a needed test or prescription covered. Administrative cost in relation to billing and insurance-related activities account for 1/3 of all medical expenditures in this country, and there is an inverse relationship between administrative complexity and quality of care. Billing and coding, and the documentation to support this has become such a big part of medicine that physicians often devote more time to this than to actual patient care. Not to mention the complete lack of transparency within health insurance companies. What other legitimate business can change coverage on a dime and can’t even provide an accurate estimate of cost?
Large medical corporations = the big business empire the Once-ler created in The Lorax, eventually killing all of the individual trees to keep up with product demand. Practices initially joined to form larger corporations to negotiate better payment from insurance companies and to relieve doctors from administrative tasks. This is another example of a good idea gone awry. In effect, we’ve created monopolies that push independent providers out of business and give patients less choice. Administrators often outnumber providers at this point. And in their effort to collect on extra incentives, they are continually adding tasks to the doctors’ day resulting in more “tasks” for providers than ever before.
Electronic medical records = the techno-savvy false reality advertised as a better way to live by O’Hare in The Lorax. Electronic records were adopted to improve communication between providers and improve accuracy of patient records. In theory, this sounds great, but the reality has many downsides. Buying into an EMR system is extremely expensive for medical offices and is often the sole reason why smaller practices join with larger organizations. There is so much emphasis on putting information into the computer that it significantly diminishes face time with patients. And finding needed information in these complex systems is often incredibly time-consuming. As for accuracy, checking boxes, using a pre-completed template, and cutting and pasting from one note to the next to document things in a pressured amount of time leads to more mistakes as opposed to less. Once something is entered inaccurately, it tends to be repeated over and over again.
In summary, what initially seemed like great developments and progress in medicine have ended up suffocating the true nature of medicine itself. Centralization, computerization, focus on efficiency and measurements of superficial indicators of “quality” may work well for business, but, as it turns out, is not the best way to provide good medical care.
Medicine in its purest form is meant to be a healing relationship between a doctor and a patient. Instead of improving this relationship and making it achievable for more people, these concepts, when pushed for their maximum profitability, have strained the relationship making it difficult to achieve for any. In the name of progress we have completely depersonalized medicine, or cut down all of the beautiful trees, and are now left with the choice of breathing polluted air or paying for O’Hare’s version of bottled air. O’Hare is trying desperately to convince all of us that this is the status quo, and the fact that we all glow green with pollution is a good thing. But we, the providers and the patients, are too smart for this, aren’t we?
So where do we grow from here? How do we plant more trees and produce more breathable air for physicians and patients alike? Do we really need all of these components that have made the practice of medicine so complex and expensive? Can we somehow get back to a simpler time when the focus of medicine was on the personal relationship and the patient? Or can we take these concepts and make them work for patients and providers as opposed to lining the pockets of those who have no personal stake in medicine? I don’t claim to have the answers, but what I do know is that “unless someone like you cares a whole awful lot, nothing is going to get better. It’s not.”
Stacey Searson is a family physician.
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