If you want to discourage a worker, subject them to policies and procedures that don’t make sense. This principle was first described by Frederick Herzberg, an American psychologist who developed one of the most widely studied theories of workplace motivation. Unfortunately, Herzberg’s principle is being widely applied today in medicine. Changes in healthcare payment systems, the use of information technology, and the doctor-patient relationship have left many doctors deeply discouraged.
Consider three specific examples. A physician who could provide care for a pediatric patient over the phone asks the mom to drive three hours each way to the office, because he can get paid for an office visit. A physician taking a patient’s history points and clicks a computer form to record information, but recognizes that many parts of the patient’s story will be lost because they don’t fit the template. A physician trying to learn more about a patient’s prior hospital admission can’t find the information she needs because the record is an example of “note bloat,” overflowing with big chunks of information that were cut and pasted from day to day, but containing little of real use.
It is easy for many healthcare leaders to forget that doctors go into medicine not because they enjoy entering data into complex electronic health records and ensuring that their employer gets paid for everything they do, but because they want to make good diagnoses, prescribe appropriate treatments, and help patients.
I recently spoke with Dr. Paul Weygandt, an orthopedic surgeon who is now vice president of physician services at a medical communications firm. Early in our conversation, Weygandt expresses a sentiment shared by many contemporary doctors when he describes the way his father, also an orthopedic surgeon, practiced medicine decades ago. In short, his father never filled out any insurance forms, meaning that he could not be directly paid by insurance companies.
With a substantial chunk of income at stake, why wouldn’t the elder Weygandt take steps to ensure that insurance companies could pay him? Simply put, he believed that by allowing an insurance company to come between him and his patients, he would be turning over medical decision making to a stranger. In some cases, he never received any of the reimbursement insurers provided his patients, but he regarded this as a price worth paying to provide the type of care he believed in.
The younger Weygandt believes that contemporary medicine has allowed too many intermediaries—financing, technology, and the way practices are structured—to come between patients and doctors. Too much time is focused on generating revenue rather than quality. Too many technological systems are built in ways that make sense to computer engineers but not to doctors. And too much time is spent pointing and clicking rather than capturing the essence of a patient’s story.
What can be done? Weygandt argues that doctors need to play a more active role in all aspects of healthcare’s future, not just implementing but also designing it. Too often, such decisions are currently being made by people who do not take care of patients, and in many cases, have never cared for patients.
“Every innovation should be tested not just to see if it increases revenue or cuts costs,” he says, “but also to ensure that it enhances the doctor-patient relationship.”
Everyone involved in contemporary healthcare—patients, doctors, nurses, hospital administrators, payers, and politicians—needs to recognize the importance of preserving and promoting medical professionalism. Good medical care is an art as well as a science, and the professionalism of doctors is at its core. “Doctors should be encouraged to think first not of their own incomes but the needs of their patients, and that means designing systems that keep the patient front and center.”
New technology can do a better job of helping doctors practice better medicine. For example, as doctors interview their patients, their notes could be projected on a screen that patients can read, so errors can be corrected in real time. And medical practices could take better advantage of the fact that patients have cell phones, making it possible to communicate (with images) at a distance. “In short,” he says, “technology should serve doctors, rather than doctors serving technology.”
But change isn’t easy. Weygandt describes the case of a doctor who began sharing his cell phone number with all his patients, so that he could handle their needs in a more timely and convenient fashion. However, he soon realized that no one was calling him. It turned out that patients would not phone, even about serious problems, because they “didn’t want to bother the doctor.” With time, however, they learned to call him, and now many potentially serious problems are nipped in the bud.
Would doctors make sacrifices to practice better medicine? Dr. Weygandt answers this question with a resounding yes. For example, he and colleagues have collected survey data suggesting that 88 percent of doctors would invest more time, see fewer patients, and make less money for a period of six to nine months in exchange for the opportunity to become involved in helping to develop better clinical information systems. In the end, he says, “Doctors really want nothing more than to take great care of their patients.”
As Frederick Herzberg would put it, “If we want doctors to do better work, we need to give them better work to do.” Medicine practiced well—in such a way that it really makes a difference in the lives of patients, families, and communities—is a great deal more fulfilling than medicine practiced poorly. If doctors are to enjoy the opportunity to make such a difference, they must cease to be the tools of their tools, and instead become their designers.