Monday, June 9, 2014

Physicians as Stewards of Health Resources

Doctors are people.  While I want all physicians to rise above and be totally selfless in helping those in need, I know that all people work within a broader milieu and are sensitive to incentives, economics and the metrics on which they are judged.  As part of the health care consolidation that is ongoing in our society, doctors are increasingly employees of large organizations rather than private professionals answering only to their patients.  That tendency in healthcare to organize more effectively is necessary as medicine is increasingly a team sport that requires many different professionals, using complex equipment often available only in sophisticated facilities, working together.  Large organizations can often combine these resources more effectively.  However organizations that are large can also lose the focus on the individual who is in need of care.  It can lead to systems in which health professionals are judged more on their effective use of organizational resources and their contribution to the well-being of the organization, rather than the well-being of the patient.  Ultimately, because physicians and all health professionals are people, judging them as stewards of health resources rather than as fierce advocates for their patients puts them at risk to be less focused on the values and needs of the specific individual they are helping in the moment. 

Two articles this week shed light on this issue.  In the Journal of the American Medical Association, an article entitled “Guidelines, Online Training Aim to Teach Physicians to Weigh Costs of Care, Become Better Stewards of Medical Resources.”  It intermingles two points, benefit to the patient and benefit to society, as if they were the same and those two related but critically different points can result in danger for patients.  Lowell E. Schnipper, MD, chair of the American Society of Clinical Oncology’s Value in Cancer Care Task Force speaks of the need to raise physician awareness of the financial effects of medical care on their patients.  That is critically important as the physician must know their patient, and must know the factors that will affect that patient’s care.  Financial considerations are an important part of anyone’s life and a doctor must be sensitive to those factors.  Schnipper however later states, “The dollar amount isn’t the driver; it’s the degree of benefit the patient and society get.”  That statement makes me nervous.  A doctor’s focus must be on the benefit the patient receives and not the benefit for society.  Doctors who are “stewards of medical resources” rather than stewards of their patients’ needs and values can harm the trust needed between a doctor and patient. 

Dr. Charlotte Yeh voices my own fears quite well in her article “Nothing is Broken: For an Injured Doctor, Quality Focused Care Misses the Mark” published in Health Affairs.  She tells her own story of being in an accident, then taken to the ER and ultimately admitted.  She felt alone, isolated, and ignored.  She did not feel cared for.  At one point, after being in the Emergency Room for 14 hours, a physician said to her, “There’s no medical reason to admit you but if you can’t walk, we’ll just have to.”  That callous statement made her feel embarrassed and guilty.  Yet the physician was following medical scientific protocols and trying to be a good steward of the expensive resource of a hospital admission.  Dr.Yeh laments the “uneven nature of my care, marked by an overreliance on testing and a narrow focus on limited quality metrics” and states that it “fostered an inattention to my overall well-being.”  She points out that patient-reported outcomes are critical and that the “North Star” guiding all care must be “providers using any means possible to know the patient, hear the patient, and respond to what matters to the patient.”

If I, as a patient, believe that my physician is more focused on a broader societal good, and not as much on my own benefit, then I will not have the trust I need in the physician.   Part of that trust is a physician understanding the financial impact of any care on me and my family.  There is a slippery slope however in focusing on societal and organizational goals rather than the patient and family goals.  It could lead to physicians thinking more about the society and deciding, for example, that it is not worth helping a healthy alert 80 year old get the care needed, as his or her life expectancy on a cost benefit analysis would not bring enough value.  If you practiced in a prison setting, a focus on being a steward of societal resources could cause you to decide that someone serving a life sentence should be allowed to die of disease because the price to society of both the cost of care and the cost of maintaining that person in a prison is too high.
 
I say all this as a person who works, and has worked for the past twenty-five years in some very large organizations.  I have built and managed many of the policies and programs of those organizations.  Yet I have always done so with the knowledge that any metric, any policy, and any organizational design will not fit 100% of all the people they are meant to impact.  I design these with the knowledge, and the proviso that smart people, using judgment, must be allowed to override the process in order to help a person in need.  I do this design work in the hope that caring health professionals will battle the design when they must to maintain the sacred patient trust that is part of being a Health Professional, and especially part of being a Physician.  I want the dynamic tension that comes from caring people, with different frameworks of healthcare, occasionally arguing for different approaches because that leads to better results for all.  Once, when I was Chief Medical Officer of an organization that covered 11 million lives, I was called because a 9 year old girl needed a type of therapy for a rare cancer that was not approved under the medical policy of the health plan for that particular cancer.  It was covered for other types of cancer however no one had foreseen the potential of using it for the particular rare cancer this young girl suffered from.  The mother of the patient had been fighting with the health plan for three weeks before it came to my desk.  I immediately approved payment for the treatment, called the mother directly and listened to her cry with relief.  Money was a factor and this family could not have afforded the treatment had it not been covered.  I was later taken to task by my organization for going against the medical policy.  I still wear that decision, and the price I paid organizationally, as a badge of honor. 

While doctors are people, and will work towards incentives as people, I still want the practice of medicine and all health professions to be callings; sacred missions to help people and not just jobs.  People are able to rise above their own incentives and their own concerns if they are trained and imbued with the responsibility that a calling entails and given the proper protection if they fight the system.  What is needed is more education to physicians about all aspects of a patient’s life impacted by illness, including finances.   What is needed is a culture in which doctors are encouraged to know their patients, and care more about their patients, and not necessarily the broader society.  Physicians must be given the tools and time to return to the caring role they traditionally have held.  A physician should be focused on listening to the patient, learning who they are and what their values are, and following a solemn oath to be true to the patient’s needs and values while practicing the best scientific care in partnership with that patient.  Only then will physicians be true stewards of the trust that their patients place in them.