Is there a physician you consider to be “your doctor?”
Do you feel like this doctor is invested in you, and knows you/your family well enough to understand what your health goals are?
Do you trust him/her?
In your last visit with this person, did you feel like he/she had enough time to address everything you wanted to talk about and provide you with comforting solutions?
Is it easy for you to reach him/her in any type of communication?
During your last stay in a hospital, did you feel valued, listened to, and included in all the decisions your team of doctors made about you?
If you answered yes to all the above questions, you are either extremely lucky, extremely wealthy, or don’t live in America.
The broken patient-doctor relationship is getting a lot of attention, and rightfully so, as it is the visible above-water part of the iceberg that is our broken healthcare system. I have been a part of this problem at times – too rushed to give a family the amount of time they wanted, too depleted/distracted to make the next level of meaningful connection beyond moving through the motions of delivering care. Anger and frustration from both sides ensue.
For patients, it’s a bewildering, frightening, infuriating experience. For physicians, this is the draining part, the real burnout – nobody goes to medical school with the goal of withholding compassion and failing to heal. So if both providers and patients are miserable in this dance, why hasn’t something changed already? Why don’t we just do better?
We will have to get off the shore and take a dive to see the ugly structure underneath.
If you asked me to list, in order of decreasing agency (defined as the ability to act to produce a certain result), all the players of our healthcare system, it would look something like this.
The cloud of ellipses above contain some combination of payers, legislators, regulatory groups, litigators, etc., in a flux of power struggles. The physician is the face of the healthcare system, but actually has very little agency.
Let’s go back to my original example. In a dysfunctional restaurant where line-cooks have to operate within the organization’s profitability goals and desire to avoid lawsuits, a chef putting together the food does not actually have the power to control its quality, much less influence its value. Healthcare has become more like fast food and less like an authentic culinary experience. That disconnected relationship on opposite ends of the assembly line is bad when we’re talking about food and hunger, and catastrophic if we’re talking about health and illness.
The majority of today’s physicians are doing their jobs with one hand tied behind the back. Our knowledge of how to bill for different levels of reimbursement and what to prescribe given a patient’s particular insurance rivals the complexity of the human body itself. The EHR is a glorified billing/legal protection platform, and our time, not to mention attention, is forced to be directed at the computer on tasks that have no intrinsic value. The pressure to squeeze more patients into the clinic day, just like the airline industry trying to squeeze more passengers into an airplane, comes not from clinicians but from those who decide which services get paid. Doctors are distracted, and a distracted person cannot connect.
In the perfect world I imagined physicians to work in, the one that led me to apply to medical school, doctors would focus their entire energy on the well-being of the patient and would always have the power to do what was best for them. This idealism was written all over my application essay. The calling of medicine seemed irresistibly pure – health, life, period.
Obviously, I was wrong, but I am not discouraged by the naïveté of imagination. That might not be our reality, but it can still be our goal. The path to get there, in a nutshell, is to flip the order of agency to place patients and providers at the top of the list.
Revolutions are never started by those who are already in power. Those who benefit from the status quo wouldn’t lead the movement to change it – and the important point is we shouldn’t expect them to. There is no slogan and no plea of morality that will effortlessly change a system that’s controlled by those who thrive on its dysfunction.
It’s time to be strategic, and the momentum has to come from the two groups who shouldshare ownership of the healthcare system:
Providers (despite the article title, this includes all providers – nurses, respiratory technicians, social workers, speech pathologists, home nurse aids, etc., anyone who cares for patients) We are the professionals in this industry – we don’t work for insurance companies or hospitals, we work for patients. Don’t make room for more bureaucracy at the patient’s expense by spinning faster under micromanagement. Organize. Mobilize. We can’t afford to stay confined to the increasingly assembly-line-like clinical interface, which is not the type of practice most of us signed up to learn. Since 99% of those who make the laws, regulations, fee structures and technology platforms that govern us are not providers, we can’t blame them for a user experience that doesn’t make sense if we don’t do better at actively taking control. Instead of waiting to be reimbursed for value of care, let’s start to create our own value-based system.
Patients You are the reason the healthcare system exists. Demand a different experience. Be your provider’s partner in taking back ownership for both of you. Let’s think critically about health privacy – own your health information, and don’t let HIPAA continue to be an excuse for conglomerates to monopolize data and create barriers to open collaboration. In the debate about health insurance, remember that insurance ≠ access, and current health insurance is dictating access to healthcare in an arbitrary way. Push for transparency and simplicity. Say no to seeing doctors who haven’t slept in 24 hours. Use your dollars as votes to set up value-based reimbursement.
The antagonism between the burnt-out, detached doctor and the disappointed, unhealthy patient does not exist in a vacuum between these two individuals. It’s a byproduct of layers of things between them that shouldn’t exist. I am critical of myself and of my colleagues in our contribution to the poverty of this relationship, and medicine has much existential identity work to do in understanding health + wellness, but our growth at the moment is stunted by lack of freedom.
I am glad to hear the emerging narrative from patients and providers center around the word “partnership,” because that’s the relationship we should have. The best partnership, and indeed any genuine relationship, require both parties to first be free and autonomous.