Doctors in the Crosshairs

We're in trouble.

No, really. We're in a lot of trouble.

We're an aging population. Health care consumes an increasing amount of our budget. And we're undermining our strongest allies.

I became a physician in the HMO era and was encouraged to minimize the tests I ordered and specialists I consulted. The consequence was that some patients didn't receive prompt care. One young man, treated for cancer a year earlier, yelled at me when I explained that his referral to an oncologist would require three weeks. While I hadn't selected his insurance plan, I understood his frustration. When I suggested he pay out of pocket to see the oncologist he already knew and trusted, he angrily left my office.

"Patient-centered care" is now in vogue. I believe strongly that the patient's wishes must be central to any evaluation and treatment plan. But a twisted version of this concept is encouraging dangerous behaviors. Health care organizations, eager to ensure their doctors are the best, rely on patient satisfaction scores to assess quality and pressure doctors to generate high scores. If patients want an MRI, even if it won't provide relevant information, or if they want a particular medication, even if it won't help, physicians are afraid to say no, lest patients give them a bad rating. With online ratings, patients can mar a good doctor's reputation if the doctor falls short of a patient's expectation, such as refusing to fill out a disability form if the patient isn't disabled. Doctors find themselves caught between their ethics and the chance of being fired or having their reputation smeared by an unhappy patient.

As expensive technologies become commonplace and our aging population requires more care, insurers have reduced payments to doctors. To maintain revenue, healthcare organizations ask doctors to see more patients each day, decreasing the time doctors can spend with each patient. There is just enough time to check the most important things and write out a prescription, order a test, or send the patient to a specialist, where care will be even more expensive. If doctors do spend more time, they are penalized because of their diminished productivity or because patients have to wait. Shouldn't we all want a doctor who will spend the extra time with us when we need it, even if it means we have to wait while someone else is getting that type of attention?

In the last few years, healthcare has implemented electronic record keeping. While this has advantages, doctors are asked to enter most of the data. Why do we ask the most highly trained people in the system to spend hours each day, inputting data? It's because the other members of the team would have to be paid for the additional time, while doctors are not paid a penny for this. This extra time cuts into their ability to live a balanced life. It's one of many reasons why more than 50% of American doctors are burned out, and why that number is rising rapidly.

I'm not excusing my profession's shortcomings. There are times we don't listen well, make poor judgments, or are uncaring. What I am saying is that demanding that we put productivity above care, that we satisfy the whims of patients, and that we spend precious hours doing work that doesn't utilize our knowledge and skills is compromising the vitality and effectiveness of this important part of society. And that's dangerous.

Doctors spend countless hours learning and training to take care of us. We need to give them the time they need to listen, to consider what is really going on, and to do the right thing. We need to value their skills and let them focus on interacting with patients, not a computer monitor. We need to appreciate the experience and perspective they bring and not rush to judge or penalize them if they refuse a request that isn't medically indicated.

As a society, we get what we reward.

What behavior do we want from our doctors, and how do we reward that?