A Country Doctor Writes:

The general debate about how healthcare should be organized, measured, evaluated and paid for is about as useful as arguing about whether all food should be served hot, cold or room temperature.

Healthcare can be so many things these days, that I’m not even sure we agree on the definition of healthcare. We certainly have seen disagreements on what we expect our insurance policies to cover. This is an especially thorny question as we in the United States spend twice as much as any other country, and yet are worse off than the other industrialized nations in infant mortality, life expectancy and chronic disease burden statistics.

OBESITY AND SMOKING ARE NOW QUALITY INDICATORS, BUT ARE THEY TRULY THE DOCTOR’S RESPONSIBILITY?

The lines have blurred between public and personal health, and there have even been a couple of role reversals between medicine as we were trained to view it and what we used to think of as public health. For example, ancient physicians like Hippocrates put great emphasis on nutrition advice in sickness and health, but during my lifetime the government started telling us how many glasses of water to drink and what nutrients are good and bad for us. This was when the beginning obesity epidemic was blamed on high fat intake several decades ago by someone in the government. Since then, fat consumption has decreased steadily while obesity rates have increased. In a clever reversal of its stance, the government has now lobbed the ball back in the physicians’ court, since the official strategy misfired so profoundly. And they have cleverly built in a punitive mandate to make sure they don’t get handed back the responsibility for the epidemic they fueled with their ignorance. How?

Medicare now demands that physicians document a follow-up/action plan for every single obese patient they see. Is that really a priority for the individual doctor-patient encounter? Especially since there are no truly effective medical treatments for obesity. It is best treated with diet (higher fat, lower carbohydrate) and exercise. Or is it perhaps something better handled in the public health arena again, this time with better science behind it? When there is talk of shortages of primary care doctors as the baby boomer generation enters their senior years, as we struggle with high hospital readmission rates, and as we wring our hands over lack of access in primary care and inappropriate emergency room utilization, should we turn sick patients away because we are busy counseling even our most unwilling patients one by one on the dangers of soft drinks and breakfast cereals?

Similarly, smoking has been viewed as a public health problem, but it has now become a yardstick in healthcare, too. Doctors will now fail their quality metrics for any diabetic patient that smokes, regardless of their blood sugar, cholesterol and blood pressure control. Is that a fair and realistic way to measure physician performance? Will it cause “noncompliant” diabetics to lose access to care? I worry that it will.

Even gun safety has been put on the physicians’ shoulders. The Maine Medicaid well child visit templates have gun safety as a prescribed topic to cover. What the political parties have failed at, we are now supposed to do as an add-on item in our fifteen minutes with our patients. Interestingly though, a 2011 Florida law, which was upheld in a legal challenge this year, specifically prohibits physicians from asking their patients about gun ownership. So why is healthcare defined differently at the opposite ends of US Route One?

ARE IMMUNIZATIONS HEALTHCARE OR PUBLIC HEALTH?

Obvious Public health activities such as immunizing against contagious diseases were traditionally done by doctors’ offices in this country. In Sweden, where I trained, physicians in primary care did not usually administer childhood vaccines. Instead, publicly funded nurse-run clinics handled immunizations and routine screenings of infants and young children.

The difference I see between immunizations given in a government run clinic and in a physician’s office is that physicians, by nature of their training, tend to be patient focused and sometimes will support their patients’ decisions about forgoing immunizations, for example some of the newer, less studied vaccines that have much less than 25 years of study (it took about that long to find out if post menopausal estrogen decreased heart attack risk as it had been speculated – it actually increased it).

Now national pharmacy chains are giving adult immunizations with forceful promotion and obvious profit motives but physicians, who in some cases are losing the revenue from giving the shots, are still required to spend their time keeping track of who got what shot.

THE DIFFERENCE BETWEEN PUBLIC AND PERSONAL HEALTH

Public health puts the individual second and societal health, finances or well-being first. Doctors, just as in the example about immunizations above, have traditionally had an obligation first to their own patients. The more we are expected to be public health officials, the more our relationship with each patient may be challenged. We are also getting sucked into a pseudo-accountability that is more political than scientific. Just like we are measured by how many of our heart disease patients are on beta blockers and how many diabetics are on ACE inhibitors, both of which are considerations with some controversy and many exceptions, our public health and common-sense recommendations are now measured in absurdum. Even when it comes to what we say behind closed exam room doors to patients who drink too much or exercise too little, we are being measured as if we are the only ones on the planet who can tell our patients these things.

By holding physicians accountable for many of the global ills of our society, from obesity to smoking, alcohol use, distracted driving and sedentary lifestyles, we have entered an environment where others are doing or being considered for the jobs we were trained to do: Pharmacists treating hypertension, nurses dosing blood thinners, Nurse Practitioners seeing our sick patients at Walmart or CVS clinics. This will be the topic of my next post in the series “It’s Time We Talk…”