Wednesday, December 12, 2007

"Total responsiblity to our patients"

Dr. Robert Centor in his DB's Medical Rants hits a home run. Read his essay here. He reminds us that physicians have responsibility to patients and not to systems. When I am sick I want a physician who cares about his patient; I do not want to be embraced by an efficient,evidence based,EMR facilitated system that like a pig with lipstick calls itself my medical home.

He speaks of the crisis in internal medicine. Clearly there is one. The crisis is bigger than that though, all of U.S. medicine is in crisis or nearly so. The primary care folks are the ones currently most affected, but the radiologists and surgeons et al who are fairing relatively better might be as concerned as the forces battering primary care have their addresses as well and the big single payer (CMS) influences more than Medicare fees for the office visit.

Dr. Centor is referring to the fiduciary duty of the patient which I believe is in danger not only from the hegemonic strength of the third party payers but from the self destructive rhetoric of many of the professional organizations and academics who strongly influence the emerging generation of physicians.A glaring example is the "new professionalism" as pushed forward by the ABIM foundation and the ACP- and mindlessly or perhaps innocently accepted by many other professional organizations- which eviscerates the duty of the physician to the patient replacing it with some type of impossible balancing act where in physicians are cajoled into being instead stewards of the finite medical resources that seem to be owned by everyone and no one and advancing the cause of a nebulous social justice. Recently an editor of the Annals of Internal Medicine seems to equal professionalism with the imperative to meet the third party payers in their effort to improve "quality and efficiency." See if you can find a general internist in private practice who believes that the third party payer are interested in real quality.

Physicians take care of their patients and are responsible for them. Systems do what systems do and cannot care or be responsible for individuals.

A commentor writes DB asking to begin at the beginning and tell what is broken with internal medicine.

I offer this great summarizing quote from DrRich. which speaks of what is wrong in general and which I believe disproportionately impacts primary care folks including internists. The links are his.

These reverse incentives, we’ve seen (we being readers of this site), ( the reference here is to DrRich's website "Covert Rationing Blog")are aimed at actively stamping out, eradicating, and punishing any self-motivated physician who tries, despite all obstacles, to deliver excellent
healthcare. Among these are the mandate that primary care doctors spend only 7.5 minutes per patient encounter; invoking
the magic of P4P to determine exactly what must and must not take place during that 7.5 minutes; grabbing the right to interpret clinical science in order to formulate the “guidelines” that inform P4P; coercing doctors to agree to egregious adhesion contracts that any sane person would find unconscionable; forcing doctors to practice under a set of coding “guidelines” that prevent good patient care and serve as traps for “fraud;” and in general, making every patient encounter subject to a web of regulatory speed traps that force doctors to concentrate on keeping the OIG ( Office of Inspector General)at bay rather than on what the patient needs. In short, in their efforts to gain control of physicians’ behavior in order to covertly ration healthcare, American Wonkonians (You will need to read more from Dr.Rich to learn what a Wonkonian is ) re creating insurmountable, systematic disincentives for excellence and penalties for non-mediocrity. They have placed doctors in the untenable position of being utterly unable to fulfill their professional, traditional, legal, and ethical obligations.

The only way doctors have a realistic chance of attaining excellence under such a system, so as to service at least the rich, the connected and the quick-witted, is to abandon the system altogether.

Is not gradually disabusing physicians of the notion that their prime duty is to the patient part of the package deal (the above mentioned disincentives plus watering down their fidelity to the patient) to control physicians?


The Happy Hospitalist said...

Beautiful prose

Robert said...

The question is how did this "coding" acquire legitimacy? Where else in this world has a system been put in place and worked? The answer is nowhere and never. Administrative pricing systems never work. It is an issue with the present system which needs more attention. See link below.