Changing relationship between doctors and patients
- From: "Lance" <LanceGary@xxxxxxxxxxxxx>
- Date: 22 Mar 2006 02:51:06 -0800
NYT
March 22, 2006
Op-Ed Contributor
The Doctor Will See You for Exactly Seven Minutes
By PETER SALGO
WHEN politicians speak of America's health care needs, they often miss
an important point: the doctor-patient relationship has become frayed.
Patients aren't unhappy just because health care costs too much (though
they would certainly like it to be more affordable). Rather, people
sense a malaise within the system that has eroded the respect they feel
patients deserve.
There has been a shift in attitude within the profession. I see
examples of it every day. I was making rounds in my intensive care unit
recently when one of the interns presented a case. "This is the first
admission for this 55-year-old male," he said.
"Stop," I said. "He is a man."
"That's what I said," the intern replied.
"Not exactly," I answered. Clearly, the intern didn't get it. Neither
do a lot of other health care professionals anymore.
The problem has been sneaking up on us for almost two decades. As
health-care dollars became scarce in the 1980's and 90's, hospitals
asked their business people to attend clinical meetings. The object was
to see what doctors were doing that cost a lot of money, then to try
and do things more efficiently. Almost immediately, I noticed that
business jargon was becoming commonplace. "Patients" began to
disappear. They were replaced by "consumers." They eventually became
"customers."
This may seem a trivial matter, but it is not. You treat "patients" as
if they were members of your family. You talk to them. You comfort
them. You take time to explain to them what the future may hold in
store. Sometimes, that future will be bleak. But you assure them you
will be there to help them face it.
You treat "customers" quite differently. Customers are in your place of
business to purchase health care. You complete the transaction such a
relationship suggests: health care for money. And then they aren't your
customers any more. Taken a step further, you can make the case that
the less time you spend with your customers, the better your bottom
line will be. This gets everyone's attention.
"Length of stay" became a buzz phrase in hospitals in the 1990's. So
did "throughput," an awful neologism for the number of patients per
hospital bed per week. One of my colleagues joked that a hospital stay
was a lot like a taxi ride. The institution collected a big fee when a
patient got admitted, just as a cab driver saw most of his fare when he
first turned the meter on.
The additional money collected over time wasn't nearly as impressive as
that initial charge. The economics of the situation favored short
trips, or lengths of stay, and lots of new riders, or throughput. The
arithmetic worked, but I didn't notice a lot of people laughing.
Doctors in hospitals all over the country began hearing the same
business language and facing the same pressures to "keep things
moving." I used to be asked how well my patients were doing. Suddenly
administrators were asking how long I was planning on keeping sick
people in the intensive care unit. Each day a patient spent in my unit
was a day some other paying patient would have to wait for a bed.
Eventually, I was warned, some of those patients "in orbit" would go
elsewhere, and we would not only "lose their business," but we risked
losing future referrals from other centers.
It wasn't just hospitalized patients who were taking up space other
"customers" could use. Outpatients "consumed" health care "resources,"
too. Publicly traded H.M.O.'s, for example, began restricting doctors
to an average seven-minute "encounter" with each customer. This
apparently kept shareholders happy. But it reduced the doctor-patient
relationship to a financial concept in a business school term paper.
Doctors know you cannot provide compassion in seven-minute aliquots.
But we have felt powerless to change things. The medical establishment
has, many of us feel, simply rolled over and gone along to get along.
It has sacrificed patients' best interests on the altar of financial
return.
This leaves the solution to the problem in the hands of our patients.
You, the patient, are the system's best hope. In the age of
seven-minute health care, you need to realize that you employ doctors.
That is, your doctor works for you. Although doctors shouldn't think of
patients as customers, you can, and should, adopt a business mind-set
when shopping for health care.
Evaluate what it is you expect from your doctor, then ask for it. If
you are unhappy with your doctor, fire him. If you cannot get more than
a seven-minute face-to-face encounter with your doctor, he needs fewer
patients. The true power in the health care economy rests not with the
doctors and certainly not with the backroom business staff. It rests
with you. If you insist on being treated with care and respect, you
will be. And the system will improve as a result.
A pediatrician I know put it quite succinctly. "There are a lot of
doctors in town," she said. "There's no need to settle for one that
doesn't treat you well."
In one respect the business people are right. Restoring the
doctor-patient relationship will not save anyone any money. But I
submit that it doesn't have to. There are other ways to curtail health
care costs. Some involve high technology; others do not. None of them
requires patients to sacrifice their self-respect.
We can and must reduce health care expenses. But we cannot do it at the
expense of patients' well-being. The doctor-patient relationship is
critical to the integrity of the health care system. It is not
disposable. Turning doctors into shopkeepers who regard patients as
customers is unacceptable.
How will the M.B.A.'s and the politicians respond to what can only be
termed a "patient-driven revolution"? They will have to cope. I suspect
doctors will be thrilled.
Peter Salgo, a professor at the Columbia University College of
Physicians and Surgeons, is an internist and anesthesiologist, as well
as the host of the PBS series "Second Opinion."
.
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