Saturday, August 29, 2009

Finding the Care In Health Care

In the midst of the debates over health reform, it is sometimes hard to remember that medicine is practiced on a very individual basis between one patient and one health professional (doctor, nurse, pharmacist) interacting in a very human manner. The Journal of the American Medical Association does publish a column called "A Piece of My Mind" and many of these pieces are by physicians who remember that imperative to care for the patient and not just diagnose and treat the disease.

"The Other Person"

This week, Dr. Paul Rousseau reveals himself, in writing "The Other Person" to be the caring physician we all wish we could have. In that "Piece of My Mind" article from this week's JAMA, he describes his meeting with a family to discuss the way to support the matriarch of the family, now 83 and infirm following a stroke, through the end of life. Read this and you find a discussion much more about life than about death. Much more about triumph of the person rather than pain control and advance directives. You read about a physician caring for a family and for the patient by understanding their lives, not only their deaths and not only their diseases.

Medicine, Productivity and Lowered Costs

When I read this piece, one thought jumped out at me. This session with the family is very unproductive. It probabaly took too long as talking with someone and just letting them talk about their past, takes a long time. A doctor with fifteen minutes per patient would be deemed an unproductive one by most business and management measures delving into items as irrelevant as the husband's background developing the GPS system for the military and the wive's background as a homemaker and librarian. Well at least under the advanced care planning reimbursement in the HR3200 bill the physician would be paid for that. Well maybe.

Advanced Care Planning Requirements

If we review the 1,493 words in that section of the proposed HR3200, we see specific requirements that must be fulfilled to be paid. Did Dr. Rousseau be sure and fulfill the requirement of providing "The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965)"? I did not notice it in the article but he may have. Would, under a new law, Dr. Rousseau be required to have someone sign a form certifying that all had been done (that was mandated under law) in the counseling session to allow him to be reimbursed for that service?

Caring as a Goal

I don't know how to fulfill the goal of allowing all to have caring physicians in their hours of need but I do believe that it takes more than legislation. In the words of Dr. Rousseau, "It seems that we physicians have strayed from the biopsychosocial model of patient care as well as the humane and personal touch that is so essential to healing and instead have chosen to hide in clinical foxholes where CT scans, laboratory data, and mundane and tangential information is discussed, far far from the bedside, and far far from the essence of the patient. " As we debate how to reform health care, lets think about how to reinforce the ability to find and treat the essence of the patient and not just the disease that they have.