Archive for the 'Reflections' Category

Where is Relationship, Authority and Trust in Healthcare Today?

Healthcare is on a different trajectory from most other businesses today. It’s a little hard to understand why.

In business, mass market products and services have always competed on price or perceived quality. Think Walmart or Mercedes-Benz, even the Model T Ford. But the real money and the real excitement in business is moving away from price and measurable cookie cutter quality to the intangibles of authority, influence and trust. This, in a way, is a move back in time to preindustrial values.

In primary care, unbeknownst to many pundits and administrators and unthinkable for most of the health tech industry, price and quality are not really even realistic considerations. In fact, they are largely unknown and unknowable.

The real price in primary care isn’t just the cost of each doctor visit. It is the cost of the total number of visits needed to solve a problem, and also the cost of the various tests, procedures and treatments each primary care doctor orders when solving that problem or managing a particular condition. This can vary enormously.

In Accountable Care Organizations, actual costs are compared to presumed or projected costs, which are based on Hierarchical Code Categories (see my post), which aren’t well known or commonly used by primary care doctors. To a degree, you can game this baseline cost calculation by mastering HCCs (Medicare Advantage plans’ financial well being hinges on making the most of this; this is why they offer doctors $150 to sign off on a list of each patient’s known or suspected expensive diagnoses).

Quality in healthcare is largely in the eye of the beholder. I’ve said it before and I’ll say it again here: A patient population’s immunization rates or aspirin use or non-use (depending on shifts in knowledge) are not comprehensive measures of quality. Accuracy of diagnosis, if anything, is. But who is measuring that? You might say “those who can’t practice medicine measure it”. That’s why most quality measures these days are of things you don’t need a medical degree or license to accomplish.

Primary care, in the eyes of our patients, is instead about relationship, authority, trust and (gasp) convenience. This is what people in most other businesses talk about all the time. It is what even tech and medicine pundits, EMR companies and many other middlemen want for themselves. They don’t want to be evaluated on the basis of price or quality standards set by others. Yet they want mass market medicine for the masses, not relationship based care.

Driving 200 miles between my two clinics, I often listen to audiobooks. Once I finished my Board Review, I turned to business books. “Influence”, “Authority”, “Brand”, “Story” and “Content” have replaced “Quality”, “Six Sigma” and “Excellence”. In business now, it is all about standing out and setting your own standards. It is about building relationships with and listening to consumers.

In healthcare, I see the paradox that insurers are now reaching out to patients to check up on them while at the same time making doctors work so hard and so fast producing “encounters” that there is less and less time for us to talk with our patients when we are with them, and never mind on the phone in between visits. Do they really think patients wouldn’t rather see their own doctors having enough breathing room to talk to them than have some strangers from out of state they never met calling to check in?

We have data that the doctor-patient relationship influences outcomes. From hospitalization rates to prescription adherence to effectiveness of treatments for mental health diagnoses, it is well known that the doctor is a large part of the treatment.

Doctors have increasingly become part of multicenter systems that, in spite of efforts like Patient Centered Medical Home recognition, simply have become too large and impersonal to foster the kind of customer relationships the business world is now realizing are necessary.

Between the bottom-line objectives of such healthcare organizations and the bureaucracies of health insurers, doctors and patients are clearly not in complete charge of their own relationships anymore.

So what happens with those relationship dependent outcomes when so many doctors feel like lineworkers, rather than professionals? What happens to their ability to nurture those relationships, gain that authority and earn that trust?

What happens if they lose it altogether?

There are modern, big companies who listen to their customers, even research and anticipate their customers’ needs. There are companies that empower their employees to solve customer problems, give refunds and do extras. There are companies who treat employees like owners or even offer them actual ownership.

Healthcare could do some more of that.

But there is more, lest we forget: Doctors aren’t just employees.

Who has the license to practice medicine? Who places the needle or scalpel? Who selects the medication? Who says “I’m sorry, we did everything we could” or “Congratulations, it’s a beautiful baby girl”?

Salespeople, YouTube stars and business leaders give a lot of thought to their customer relationships, their personal authority and the essentials of building and maintaining trust.

Are we doctors doing enough of that? Those things are ours to claim, and to strive for. Even if a big corporation issues our paycheck.

Be the Doctor Each Patient Needs

Doctors need to be true to themselves but at the same time they must be chameleons.

A doctor fills certain roles in the lives and stories of patients. It is a two-way relationship that looks different to each person we serve throughout every workday and even in the most casual interactions we have.

Some patients need us to take charge for a while because they’re exhausted, others need us to listen quietly while they vent or process something out loud.

Some patients need reassurance and empathy, others thirst for detailed information. Some patients thrive on viewing us as equals and friends, yet others need some distance because what they need to share with us is something they couldn’t even tell their best friend – only a priest, rabbi or doctor without the familiarity of a friend.

I may be naturally analytical, intuitive, reserved or outgoing, but I must get a sense of my patient and the situation he or she is in and understand how I can fit into that situation.

This is not acting or being dishonest. I don’t dress the same way for a day in the office as I do for a day in the barnyard or a night at Chateau Frontenac. Neither do I conduct myself the same way in every situation in my life. It would be selfish and inconsiderate of me to act exactly the same way with every patient – “take it or leave it”.

I work at being chatty and cheerful, but that is no more dishonest than practicing another language. I may know the perfect word for something in Swedish but that doesn’t do my English speaking patient any good.

The roles we play in people’s lives are necessary for them in those moments, in their personal journey. Many people need someone in an archetypal role to carry them to the next level or the next chapter in their lives by saying or doing something they cannot do themselves.

Doctors are performers, not only when we perform procedures, but also when we deliver a diagnosis or some guidance. This is the premise of an audiobook I listened to a while ago during my commute between my two clinics: Dr. Bob Baker, retired physician and an accomplished magician, draws parallels between the two professions in “The Performance of Medicine”.

I have done a lot more thinking lately about these two P-words: The Practice of Medicine and The Performance of Medicine. Both words, both concepts, point out that what we do in this job is much bigger than we ourselves are, something that transcends time and place. We have to continually work at it and it takes place in the energy field of two people in a therapeutic encounter.

Quoting Dr. Baker: “The magic of medicine begins with the doctor/patient connection.”

That connection requires us to be what we Swedes call “lyhörd”. There is no single word I know of in the English language that conveys the same notion. Literally, it means “of keen hearing”. Google Translate suggests three words: responsive, keen and sharp.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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