I'm not really all that mysterious

The Erosion of the Doctor-Patient Relationship in the U.S. health care system

There are some deep cultural problems that underlie the brokenness of the health care system in the U.S.

Doctors Tell All—and It’s Bad • 2014 Nov • Meghan O’Rourke • The Atlantic

Health care in the United States operates predominantly on a fee-for-service basis, which rewards doctors for doing as much as possible, rather than for offering the best care possible.

In Doctored: The Disillusionment of an American Physician, Sandeep Jauhar—a cardiologist who previously cast a cold eye on his medical apprenticeship in Intern—diagnoses a midlife crisis, not just in his own career but in the medical profession. Today’s physicians, he tells us, see themselves not as the ‘pillars of any community’ but as ‘technicians on an assembly line,’ or ‘pawn[s] in a money-making game for hospital administrators.’

According to a 2012 survey, nearly eight out of 10 physicians are ‘somewhat pessimistic or very pessimistic about the future of the medical profession.’ In 1973, 85 percent of physicians said they had no doubts about their career choice. In 2008, only 6 percent ‘described their morale as positive,’ Jauhar reports. Doctors today are more likely to kill themselves than are members of any other professional group.

The demoralized insiders-turned-authors are blunt about their daily reality. The biggest problem is time: the system ensures that doctors don’t have enough of it. To rein in costs, insurance companies have set fees lower and lower. And because doctors tend to get reimbursed at higher rates when they are in a network (hospitals and large physician groups have more leverage with insurance companies), many work for groups that require them to cram in a set number of patients a day. Hence the eight-minute appointments we’re all familiar with.

Paperwork compounds the time crunch. Studies estimate that today’s doctors and ‘hospitalists’—medical practitioners who do most of their work in hospitals—spend just 12 to 17 percent of their day with patients. The rest of the time is devoted to processing forms, reviewing lab results, maintaining electronic medical records, dealing with other staff. Physicians in non-hospital medical practices in the U.S. ‘spend ten times as many hours on nonclinical administrative duties’ as their Canadian counterparts do, Danielle Ofri, an internist at New York’s Bellevue Hospital, reports in What Doctors Feel.

The alarming part is how fast doctors’ empathy wanes. Studies show that it plunges in the third year of medical school; that’s exactly when initially eager and idealistic students start seeing patients on rotation. The problem, Danielle Ofri writes, isn’t some elemental Hobbesian lack of sympathy; students (like the doctors they will become) are overworked and overtired, and they realize that there is too much work to be done in too little time. And because the medical-education system largely ignores the emotional side of health care, as Ofri emphasizes, doctors end up distancing themselves unthinkingly from what they are seeing.

Yet empathy is anything but a frill: not only is it crucial to doctors’ humanity and patients’ dignity, it can be key to medical efficacy. The rate of severe diabetes complications in patients of doctors who rate high on a standard empathy scale, Ofri notes, is a remarkable 40 percent lower than in patients with low-empathy doctors.

You may be wondering why the rise of patients’ rights in the 1970s and ’80s, hailed as a revolutionary advance in health care, hasn’t served us better. After all, empowered by both the law and the Internet, we are far more conversant with our medical options—and with the history of medical hubris—than our grandparents were. Yet the legal recalibration of power has unintentionally contributed to the uneasy standoff between doctors and patients, as Barron Lerner observes in The Good Doctor.

As Lerner comes to see, some of the overtreatment routinely found in hospitals is actually an outgrowth of the patients’-rights movement. In the past, when patients’ hearts stopped, or the terminally ill succumbed to infection, doctors typically would let them go. In our era of ‘defensive medicine,’ unless you have signed a ‘do not resuscitate’ order (and sometimes even if you have, but your family insists on treatment), you’ll be intubated, or defibrillated, or given antibiotics—on the off chance that last-ditch rescue is what you would want. And no doctor is likely to clarify the odds: roughly 15 in 100 cardiopulmonary resuscitations, for example, result in the patient living long enough to be discharged from the hospital.

And so each side [doctors and patients] exercises power passively (or passive-aggressively), and maybe even unconsciously: I’ll listen to you, but I won’t really believe or act on what you say.

To be sure, deciding who has the ultimate authority is a challenge: the patient, unlike the customer, can’t always be right, though few of us want to hear that. How far should doctors go to look for an illness they can’t initially find? To what degree should they privilege patients’ wishes for specific interventions? Satisfying answers to these questions have yet to be found. But the current balance of power is flawed.

But ‘slow medicine,’ as Sweet trenchantly argues, isn’t an outmoded, soulful indulgence. It might actually be a form of efficiency: more-accurate diagnoses and effective low-tech treatments help the system save money, and result in fewer malpractice suits.

Yeah, the mindless application of more and more expensive technology is probably the most wrong solution to the on-going crisis in the U.S. health care system.

Atul Gawande suggests much the same thing in Being Mortal, arguing that fast, solution-oriented care—particularly in the last year of life, which accounts for an estimated one-quarter of Medicare expenditures—has, in missing the broader picture, led to a great deal of ‘callousness, inhumanity, and extraordinary suffering.’

Medicine today values intervention far more than it values care

Gawande writes that for a clinician, ‘nothing is more threatening to who you think you are than a patient with a problem you cannot solve.’ The result is that all too often, ‘medicine fails the people it is supposed to help.’ The old doctor-knows-best ethos was profoundly flawed. But it was rooted in an ethic of care for the whole person, perhaps because physicians, less pressed for time, knew their patients better.

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