Blog | Monday, June 3, 2019

Removing the heart from health care: an experiment

I delight in learning my patients' stories and giving them exactly what they need when I take care of them in the hospital. Who they are and what is the best approach to their problem is the primary mystery to be solved, my Sherlock Holmes moment. This is why, if somebody asks me, I will tell them that doctoring is the best job in the world. The opportunity to connect fully with another human being and use my heart and hands and brain to help them is a profound gift and a sacred trust. When I'm not so overwhelmed that I can't function, that is.

Lately at work, with the recent flu epidemic and the collateral illness that a hard winter has brought on, my job as a hospitalist at my local rural hospital has become rushed and nearly overwhelming. I cut corners in ways that I hope will not compromise patient care. At times I dream of retiring, forgetting that I'm a doctor, letting the skills I've been collecting over these 30 years drift away like objects at a garage sale. But I don't really want to. I really want to keep doing the job that involves actually having the time to listen, examine, think and interact. I just don't want my job to suck.

I can tolerate bad days; that will always be the way of it. Epidemics happen. There are confluences of illness that result in surges of sick people who need help all at the same time. Once in a while everyone just has to suck it up and deal with the fact that time and care must be rationed. At those times I will get neither sleep nor food in adequate quantities. It is my job, though, as a mistress of my own destiny, to make sure that this doesn't happen often and not as a result of systemic problems that could be prevented by adequate forethought.

Recently there have been changes that will lead to me, as a hospitalist, being responsible for more patients. Since I'm already often at my limit of competent care, there will need to be some kind of increased staffing for my program. My brain is aging, as is my body, and I don't think my capacity for work can just increase. I now need regular sleep and food and time to think in order to do this rather difficult job of being a doctor. The job needs to continue to be something I can love. The hospital, my employer, has not given assurance of adequate help. Also my salary, though generous compared to that of a teacher or an accountant, is low when compared to other doctors doing what I do. Because of this and the upcoming changes and perhaps the phase of the moon, my partners have all given their 3 month notice and we will have trouble recruiting replacements to adequately staff my program. Dreading what I predict to be a situation that will have me trying to function beyond my abilities, I have also given my notice. And I am sad about it.

Why, we are all wondering, will the hospital not step up to make the program sustainable? I suspect it is because they are succumbing to the inexorable movement in the U.S. toward corporate health care. In the last 10 years hospitals have gradually become an important spigot on the huge tank of health care dollars, controlling the flow of money by employing physicians and opening clinics. As such, doctors have changed from being the bosses of hospitals to its employees. Hospitals spend over half their revenues on paying their staff. When we became hospitals' paid staff, we became a line item in a budget, a cost to be kept in control. If we want more time per patient to do the job the way we think is right, that means they may have to hire more of us, thus increasing their financial obligations. So long as the patients don't notice any problem and stay happy, controlling expenses attributed to physicians by minimizing staffing will be a successful strategy for them.

There are ways that the system can be tweaked to make it possible for doctors to handle more patients. Simplifying the way we order tests and document our encounters can give us more time for the important work of talking to nurses and examining and listening to patients. So far, however, even the best computer systems absorb what seems to be increasing amounts of time. Other strategies involve giving the patient the impression that they have been listened to, respected and that we have a coherent interpretation and plan for them. There are algorithms (AIDET) that don't take much time but increase patient satisfaction. This particular one dictates a way to speak to patients that covers a checklist of important talking points. As an algorithm it is not entirely bad unless it is used to replace genuinely good care, which I think it often is. Eventually artificial intelligence will help us take the confusing data that can be generated by our patients and use it to make evidence based decisions about diagnosis and management. This will probably improve out patients' health outcomes, a good thing.

It appears that we have been involved in an experiment, driven at its core by economics and the flow of money, in removing the heart from medicine. Because of the way we pay for health care and the vast number of businesses that depend on health care, it has gotten terribly expensive, pricing itself nearly out of reach of regular people. This is a problem to be solved. In working on this sticky problem there have been many technological advances and updates in systems that may improve efficiency. I love some of these. Doing bedside ultrasound, for instance, has made me a much better doctor and the concept of a computerized medical record is wonderful, with its ability to store and communicate information about our patients to the people who need to know. But we have also modernized the art and heart of delivering medical care just about right out of the picture. Nurses used to give patients massages with lotion before they went to bed (I kid you not) and doctors spent hours at the bedside of dying patients. Now we all just don't have the time.

A few years ago I read a book by Victoria Sweet, MD, a physician and historian who spent 20 years as a doctor at the last alms-house hospital in San Francisco (God's Hotel). This was a place where people ended up when their health was gone and they had no other resources. They stayed a long time. Many would eventually die there, some would move on. She spent as long as it took to take care of each patient and there was no rush. There is a movement known as “slow medicine,” which first took shape in Italy because of the “slow food” movement. It is based around doing what we do, but more slowly, paying attention to a person's story, context and values and not hurrying the process. Dr. Sweet wrote a book about that, too, titled, not too surprisingly, Slow Medicine. Sometimes in my job, when everything is going OK and there aren't too many patients with problems that are simultaneously blowing up, I can do slow medicine at my little hospital. I've been lucky.

How, though, with the amount of money it takes to pay a doctor, can we afford slow medicine? I think slowing us all down would have an avalanche of positive effects that would result in profound cost savings. There would be fewer tests and radiological procedures when we actually spent the time to figure out what was probably wrong and invited the patient to come right back if the problem didn't resolve with our well thought-out advice. There would be fewer referrals to specialists as we spent the time to take a good history, do our research and reach out to our colleagues for advice. There would be more demand for primary care physicians but the job would be much more rewarding and therefore attractive. Medical students would want to become primary care physicians because it wouldn't be a meaningless full-out grind. Internal medicine and family practice would be so much more gratifying than the organ centered specialties that now seduce some of our finest graduates. Drug costs would be lower since patients would be given consideration and advice rather than a pill. Savings such as these, unfortunately, would accrue to patients and payers, but not to hospitals. This makes it very unlikely that my hospital will find these to be compelling reasons to pay more so that I can work more slowly.

I am sad that I've gotten caught up in this experiment and I'm eager to find other ways to do what I do best. It's probably not quite time to retire. Being a doctor is awesome.

Janice Boughton, MD, FACP, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.