Medical costs are skyrocketing and a survey published last month in JAMA has us doctors pointing fingers in every direction but at ourselves. The more than 2500 physicians surveyed rested most of the blame on malpractice lawyers, insurance companies, healthcare conglomerates, and drug/device companies. Patients came next. Trailing the lot were the doctors themselves.
Doctors’ enthusiasm for cost-containment strategies that affected their compensation—eliminating fee-for-service reimbursement, “bundling” payments for the total care of patients, penalizing physicians when patients were re-admitted to the hospital—was notably lukewarm. However, nearly all were in support of eliminating waste and fraud, promoting continuity of care, minimizing corporate influence in medicine, and having better data about the relative quality of various medical interventions.
The accompanying editorial by Ezekiel Emanuel and Andrew Steinmatz calls the current national debate about healthcare an “all hands on deck” moment in medical history. They wonder whether doctors will assume responsibility and step in to captain the ship, or stand aside, and let others navigate the future of healthcare while they swab the deck.
Only one-third of doctors in the survey felt that they themselves had a major responsibility for reducing costs. The news media jumped on this as doctors simply blaming others. But looking at it from a more human perspective may explain this seemingly callous response.
We doctors train in the scientific method and subscribe to evidence-based medicine. We calculate risk profiles and cite placebo-controlled studies. But we are not nearly as rational as we like to tell ourselves, or our patients. Past experiences, gut instincts, and emotional contradictions factor in just as much hard data, especially when we try to figure out how to steer the listing ocean liner that is our health care system today.
For the average practicing physician, the major goal of any given day is simply to stay afloat. The typical 15-minute office visit is rarely enough time to fully address the clinical needs of patients with multiple chronic illnesses, and the onerous documentation demands of electronic medical records ensure that doctors spend most of that visit interacting with the computer rather than with the patient.
Many of these documentation requirements are, of course, important.. As a primary care internist, I wholeheartedly support the idea that we should be asking our patients about domestic violence, depression, and pain levels, that we should be on the lookout for barriers to communication, that we should be documenting efforts in patient education, that we should be rigorous about age-appropriate screening tests, that we should print and review the medication list at every visit.
But there are so many requirements—and the list keeps growing—that there’s hardly time in that 15-minute visit to talk to the patient about their actual medical conditions, let alone do a thorough physical exam.
Every advance in health care delivery, even if it’s positive, seems to cram another task into the already overburdened office visit. So when it is suggested that we, for example, should also check the relative costs of each medication or procedure we order, we experience it as simply one more onus piled on. Many doctors feel—with some justification— that cost-containment solutions will simply worsen the day-to-day grind and leave even less time for patients.
It’s not that doctors don’t know we play a substantial role in the cost of medical care. After all, we are the ones ordering the MRIs, writing the prescriptions, implanting the artificial hips. Cost comes up on a regular basis with my patients, as I explain why I’m prescribing a generic medication over a brand name, or ordering a CT scan rather than an MRI. But here is where emotions and perceptions carry more weight than numbers. The idea that doctors should take charge of fixing the problem makes many feel like they are under siege, even though we know that we need to be part of the solution. The sense of embattlement is so potent that doctors will reflexively react against these suggestions, even if the data suggest that they are rational approaches.
About three-quarters of doctors surveyed did in fact support having cost-effectiveness data available in real time, and using that data to limit expensive but less effective treatments, so doctors aren’t quite as stubborn as they’re often portrayed. What the survey sheds light on is that the process of health cost reform—no matter how laudable—often has little connection to the daily experience of practicing clinicians. Bringing doctors into the true muscle of controlling costs requires recognition of the experiential component of medicine today. Framing how reform might improve this for doctors and for patients on a daily level, is critical.
If doctors feel that the grind of medicine is just going to get worse, then they won’t have any stake in making major changes. The same is true for patients. You can present all the data you want—objective, evidenced-based numbers showing that reform X will solve the cost problem—but it doesn’t have a chance when stacked up against deep-seated emotion and experience.