Monday, April 11, 2016
Patient-centered care, part 1
Three (and a half) years ago, when I left my old practice, I was near burnout. I was exhausted, not because of the amount of time I was spending—it was actually about the same, if not less than I had worked before—but because of an ever-increasing gulf between me and my patients. I have always tried to give care that focused on the person with me in the exam room, but did so against a growing current constantly pushing me away from my patients, a current emanating from the system that was built to serve them.
My early adoption of computerized records (1997) was not because of my fondness for technology, but because I felt it was the quickest and most efficient way to organize and retrieve the information necessary for good care. I was obsessed with improving work-flow in the office, as any efficiency would buy me a little more time to focus on clinical care. As this obsession grew, the gulf between me and the other physicians in the practice, who didn't share my focus on patients, grew inextricably and irrevocably wide. The end result was a “divorce” from my partners. I was ushered out with a nice plaque, some cake, a buy-out check, and a firm “pat” on the back as I walked out the door.
Three years does a lot to crystallize one's view of the past and why things really happened. I didn't really understand the cause of the divorce while it was happening; how it could happen that within a very short time I went from a sure future as senior partner to an outsider. I went from architect of medical records and caretaker of my patients to having no access to those records of my care.
Now, as my journey has taken me and my old practice down very different roads, I see clearly the dividing point between us: patient-centerdness. Over the three years since opening my doors as a direct primary care doctor, my obsession with patient-centerdness has, if anything, grown. The same certainly cannot be said about my old practice, as it has followed the rest of the healthcare system's lemming march away from patients and toward the cliff of ICD-10, meaningful use, and whatever other requirements the payors demand.
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.
Why? What I've explained in the past bears repeating. A successful primary care business is fueled by 3 things: having as many sick patients as possible, doing as many procedures on those sick patients as possible, and spending as little time with each of them as possible. These 3 things are not only the antithesis of what my patients wanted, but they stand directly in the way of any attempt I made to center my focus on their needs. The only way to be a patient-centered doc in the current system in our country is to be lousy at the business of medicine. The soil on which my old self tried to grow good patient-centered care was clearly too hostile to produce anything that promoted health over sickness, reduced cost, or encouraged time spent with people. A good idea of what truly patient-centered care looks like simply cannot grow within of such a system. It dies under the intense heat of ICD, CPT, ACOs, and EMRs. I had to leave that world to understand that.
Now I am in an entirely different world. To catch those up who don't know, my current practice is entirely different than my old one. I don't accept any payments from insurance or other third-party payors. Patients pay a low monthly fee, between $30 and $60 per month with no copays for office visits. Other treatments, procedures, or diagnostic tests are given at the lowest possible cost.
I am now nearly up to 700 patients, and (despite having a doctor running the business) am seeing steady growth of the business in numbers and in the care we are able to give people. We are able to accomplish 4 things that the current system cannot touch:
1. My patients are much happier.
2. My nurses and I are much happier.
3. The care we give is much better.
4. We are saving the system (and our patients) a lot of money.
Nobody who comes to my practice would argue any of these points. The only downside at this point, and the reason this kind of practice has yet to catch on, is that my income is still about half of what I earned in my old practice. That needs to change for this model to truly disrupt our system, and if I want to retire before I am 80.
The lessons I have learned about patient-centered care are in the following areas:
• Patient-centered service
• Patient-centered communication
• Patient-centered medical care
• Patient-centered medical records
• Cost-conscious and responsible care
I've used up my words for this post (shocking as that may sound), so I'll go after each of these in upcoming articles. My goal is to give people a vision of what truly good care can look like. A number of years ago I came up with a pithy summary of the state of the health care system: People don't clamor for better care nearly enough because they don't know how bad the quality of their care is; and the reason they don't know how bad their care is in quality is because they don't know how good it could be.
I feel it is the responsibility of all folks innovating in healthcare to raise the expectations of people for whom the care the should be designed. To quote C.S. Lewis (out of context): ”[We are] like an ignorant child who wants to go on making mud pies in a slum because he cannot imagine what is meant by the offer of a holiday at the sea.” We need to expect more from our system, but the only way we can expect more is to see what the holiday at the sea would look like.
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Suneel Dhand, MD, ACP Member
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