This insecurity is the biggest challenge in my practice: getting people to change their behavior. Somehow I have to somehow get people to pay attention to their health when they'd rather ignore it, to be taking medications when they'd rather not, to be exercising when they don't want to, to lose weight when they love cheeseburgers, and to be checking their blood sugars when they'd rather not know how high they are. After trying lots of things over the past 20+ years, the one thing I find almost never works is what is usually done: lecturing the patient.
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Improving Health Care
My hope is that somehow we are able to return to care that is patient-centered. People want their narrative to be a good one, and doctors need to be able to enter that narrative and become a positive influence. Our goal needs to push people out of the medical realm and back to living the rest of their narratives with as little contact with the healthcare system as possible. That's what patient-centered care really is.
If you look up the word "compliance" in a thesaurus, the first synonym (at least in my thesaurus) is "obedience to." This implies that non-compliant patients are, at least to some degree, equivalent to disobedient patients. This is borne out by the reaction many patients seem to expect of me when they "confess" they haven't taken prescribed medications: they look guilty — like they are expecting to be scolded.
The real question I am asking here is not if this care is good or bad (the answer to that is, yes, it is good and bad), but whether it is patient-centered.
This should be a silly question, like asking if car-repair is car-centered. But it is clear that much of the high cost of care in our country is due to the huge number of unnecessary procedures, medications, hospitalizations, and services given to/done on people. Unnecessary care is, almost always, not patient-centered.
The vast majority of people truly want a doctor they respect and actually like. This may come as a shock to many of my jaded colleagues who routinely face the ire of people stuck in waiting room purgatory, ignored or disbelieved by doctors, and treated as objects instead of people. They think that people are angry because they don't like doctors. They view the people on their schedule as, at best, the hungry masses they must placate and, at worst, as their adversaries they must conquer. Then they wonder why their patients are so unhappy?
The past three years has taught me otherwise. People want to like their doctors. We just haven't given them any reason to do so.
Rather than dwelling on the malfunction of the system, however, I want to turn my eyes toward what most people don't see: what real patient-centered care could and should be. It's not that I am suddenly wiser than my colleagues in the sick-care system. Despite 18 years in practice, I was not able to see what true patient-centered care looked like until I left the system.
It's been two years since I first started my new practice. I have successfully avoided driving my business into the ground because I am a dumb-ass doctor. Don't get me wrong: I am not a dumb-ass when it comes to being a doctor. I am pretty comfortable on that, but the future will hold many opportunities to change that verdict. No, I am talking about being a dumb-ass running the business because I am a doctor.
My previous two posts lamented the incredibly bad the documentation I get from a local hospital is. In truth, the documentation I get from everyone is terrible. Seldom does it tell me what I actually want to know, and if there is useful information it is buried in an avalanche of yada yada. The main reason for this is that documentation is driven by our ridiculous payment system, which requires us to follow arcane rules to generate notes that justify the obscure codes we submit for money from the payors. This is the reason for much of the gibberish. These rules, combined with computers' ability to quickly and efficiently generate drivel (see also The Entire Internet) are the hot house and Miracle Gro for meaningless words. Sprinkle the rules on a computerized medical record and stand back! Useless words and codes will spew out at you like milk from the mouth of an overfed baby.
I examined him, leading him to his bedroom so he could lay down and I could examine his abdomen. He required significant help even with the 20 steps it took to get to the bed. He let out a big sigh when he lay back on the bed. The diagnosis came quickly, as his liver was very large and had an irregular, lumpy feel.
I had little doubt: he had cancer in his liver, probably spread from his colon.
We went back to the den, where we initially had talked. "I am going to be square with you. I think you have a very, very serious problem. I think you have cancer in your liver. I'm sorry to have to say this the first time meeting you, but you seem to be the kind of person who would want the truth, even if it is hard."
Why do patients feel like they are treated like cows, not humans? Why does our system produce more sick people getting more procedures? Why are things so different for the patients in my new practice? It all comes down to one thing: the basic financial transaction of the healthcare system. From it flow all of the bad things doctors and patients experience. From my rejection of it flow all of the wonderful changes to the care I can now give. There is no meaningful reform that can happen without changing this basic transaction.