Monday, January 11, 2016

Physicians on the Assembly Line

The role of the physician in our evolving medical system is the subject of many studies, articles and angst on the part of the physician community.   In an article this week in the New York Times, about the efforts by a group of physicians in Oregon to unionize, the physicians involved discuss how their creative assessment and problem solving skills are brought to bear in even the most mundane cases.  Dr. Rajeev Alexander, one of the physicians involved is quoted as saying, “Real life is all about the narrative.  It’s sitting down and talking about bowel movements with a 79 year old woman for 45 minutes.  It’s not that interesting but that’s where it happens.”  Dr. Alexander may start out believing the source of this elderly woman’s constipation is related to dehydration, often the most common cause when elderly people have to be brought to the hospital due to bowel problems, however he is following the best medical approach by spending time to first determine that the problem is not something less common, and then trying to also determine factors that may contribute to the dehydration.  He brings a cognitive approach rather than a strictly reflexive approach.  However his approach from a pure resource management point of view may not be seen as efficient, hence the disagreements that led to the physician group forming a union. 

The system clearly needs to be more efficient.  We must be both customized and thoughtful for each patient, and also recognize that much of medicine is the same from patient to patient.  We must build more efficiency into the system.  Is the best way to do this by taking the traditional leadership role of physicians in patient care and making them into unionized workers?  In that same article, Dr. Brittany Ellison, another member of the physician group says, “We’re trained to be leaders but they treat us like assembly line workers.  You need that time with the patient where his wife is ratting on him.”  Is the best way to accomplish this by making the role of the physician be more of a follower – of algorithms, of management incentives, and of organizational goals, than a leader for their individual patient?  Should they be judged on population effect, efficiency and data capture rather than their work of caring for the individual?

While I have an MBA from Northwestern University and twenty-five years of experience working on the business side of the health care industry, I do not believe the answer lies in money, bonus programs or physician incentives.  I have found, that while physicians are people and want to make money and earn incentives, they are driven more by their own sense of commitment to their patients and their own sense of professionalism.  Dr. Robert Wachter, chief of the division of family medicine at the University of California, San Francisco in that same article states, “If at the end of the year, 10 percent of your salary is at risk based on whether you have consistently clean hands, what patients say about you, readmission rates, that can be OK. The counterargument is that you could screw things up by tying everything to financial incentives.  You stomp on their intrinsic motivation.”

Appealing to that intrinsic motivation is critical for the individual patient interactions that make up that data.  The goal when I or the professionals who work with me at Accolade, help people through the health care system is to find ways to bring out the best in people by finding ways to use the internal motivation of both doctor and patient.  We help people find the right clinicians for the problems they have and help them communicate with their doctors, nurses, and other health professionals in such a way so as to bring out the best in their clinician. 

Maybe we have to rethink the role of the doctor.  Perhaps we need to reserve the use of the doctor as a true leader and always team them with another professional who can spend more time filling in the blanks for them.  We have experiments going on around the country which are as varied as having nurse practitioners be the front lines for most patient interactions, to having scribes be with doctors to free them from the data capture duties that they have.  At Accolade we have pioneered a new profession of Health Assistant to assist patient and doctor with the life context issues, emotions and clinical decisions that patients must make (which specialty to see for my problem, what questions should I ask the doctor, how can I balance my life responsibilities with my compliance needs).  A Health Assistant who is part of a team led by a creative problem-solving physician could make the physician more efficient and allow for more access to the system.   Whatever the solutions that are developed, it should not be to make the physician into an assembly line worker.