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Holding Patients Hostage: Medicare, Stockholm Syndrome, and Choice

For 6 days, captors held employees hostage in a bank vault in Stockholm, Sweden, August 1973. Police finally rescued the victims and caught the criminals, but some employees defended their captors for days afterwards.

The Stockholm Syndrome describes the positive feelings that victims sometimes develop toward captors by mistaking a lack of obvious abuse for kindness.

Even after long waits, survivors of major illness are glad to be alive and thankful for their care in Canada.

Fear mongering about financial ruin and system change makes patients cling to a system that holds them captive to long waits with no easy options.

Debate centers on whether our system harms patients. It does. But, issues get dismissed as isolated, or labeled as ‘solved’ with wait-time strategies and benchmarking.

Patient harm is the wrong debate.

Holding Patients Hostage

We need to focus on what patients aren’t getting. The public doesn’t really know what they are missing. It’s up to providers to say so. When patients finally get an MRI, they’re impressed. Who wouldn’t be…for ‘free’!

People need to know we have an economy-car version of healthcare at a mid-sized price. For the same or less money, better systems can:

Treat patients like valued customers
Give patients choice about who they see and when
Provide home or office visits
Provide same/next day imaging AND results
Offer specialist consultation within days
Arrange elective surgery within the week with biopsy results in days
Offer electronic access to records
And much more…

Increased Utilization

At this point, quants (quantitative analysts) say, “But that would just drive up utilization.” Utilization equals the number of services provided. More service means more money: always bad in a publically funded system.

But, increased utilization is good if more patients get necessary care.

Quants see spikes in utilization as unnecessary care (even in the face of population growth). They assume providers offer unnecessary care when allowed, fingering providers as liars and thieves. They assume the same of patients; ergo, patients don’t deserve more care.

But, we know patients need more care; they die on wait lists currently. We also know patients would like better service; they want more value for money and prompt care options at home, not abroad.

Food Industry Analogy

Just imagine if we socialized the food industry. Groceries cost thousands per year, and many citizens are malnourished and poor. Socialized food would help. We could set prices and offer only essential items, without junk food, for free in government stores. We could make it illegal to purchase food elsewhere.

Others have tried this: state-run food industry results in no choice, long line-ups, and terrible customer service. Sound familiar?

We Need Change

Medicare was built to prevent financial ruin from acute, major health needs, before modern treatment options existed. Now, most care issues are chronic, multiple, and create arguments over the definition of ‘need’. Medicare began like collision and theft automobile insurance, but it now covers all mechanical issues: a warranty, not insurance.

We are held hostage, unable to change. We defend our captor mistaking lack of obvious abuse as kindness. We must debate whether people should be free to choose more than the bare minimum of care.

(photo credit: tripadvisor.com)

Narrow-Minded Medicine Gives Government Control & Leaves Patients’ Interests Out

Clinicians and bureaucrats wrestle for control with talk of quality and accountability. Both sides crave concrete definitions. Accountability zealots want control of provider’s performance as if chaos would reign without policing.

Healthcare delivery gets shaped using concrete metrics like HbA1c levels, blood pressure readings, or surgical complication rates.

People start to see medicine as nothing-but fixing high blood pressure, or normalizing sugar levels, or replacing hips.

But, if medicine is nothing-but controlling blood pressure or HbA1c, then it’s a product to be managed like any other.

If medicine is nothing-but matching patients with evidence, then quants can match populations with resources without input from physicians or nurses.

If we reduce medicine to technical outcomes, bureaucrats regulate with impunity.

Medicine is more than applied physiology.

Medicine applies science, but it is much more than applied science.

“[Medicine] is the totality of this unique combination which constitutes the clinical moment and the clinical encounter, without which authentic medicine does not exist. No simplistic neo-Cartesian reduction of medicine to sciences of mind, arithmetically added to science of the body and tied together with a ribbon of moral science, is adequate to explain this synthesis. Nor is this merely biology. Neither plants nor animals – granted they become ill as well as humans – can enter into a relationship with the healer in which the patient participates as subject and object simultaneously.” A Philosophical Basis of Medical Practice, Pellegrino and Thomasma.

Sure, we must improve clinical metrics. But, meaningful outcomes for patients are often qualitative, subjective, or impossible to measure. How do we measure surgical judgment beyond complication rates? How do we measure communication skills? Reasoning ability? Aptitude at interpreting non-verbal cues?

We need to learn how to articulate what medicine is. And, it must be hard. It needs to be tough and complicated to capture everything we do for patients. Narrow-minded medicine makes patients secondary.

We need a definition of medicine that starts with the clinical encounter and puts patients’ interests at the centre.

EMR – Bigger Is Not Better

Docs spend more time with electronic health records than with patients. Many blame electronics. True, bad systems eat hours of nurse and physician time, but the biggest waste is fat charts.

If bigger is better for patient charts, then medical students make the best charts; staff physicians the worst.

Every year, trainees get better at sharpening details. Expertise leads to focus on critical information: everything that does not add value gets left out. Charts get shorter…until providers start padding charts for other reasons.

Modern patient charts aren’t just about patients.

Charts get longer to:

1. Protect against Lawsuit:

A long chart makes it tough to prove providers weren’t thorough. You can prove you thought about all sorts of things by listing all the negative responses you found even though the negatives don’t help the patient.

2. Protect against audit from your regulatory college:

The overseers/authorities/police believe they know what makes a great chart. They support #1 above and enforce it, and they (groups of lawyers and lay-people mostly) define ‘best practice’.

3. Protect against billing audit:

Long charts look like lots of work was done.

Value Added?

Would an informed patient willingly pay for long notes that were created to protect providers?

Do long lists of ‘pertinent negatives’ add anything for patients? Sure, they ‘prove’ providers considered a differential diagnosis, but considering a differential diagnosis is core medical practice; why should they prove they did it?

The whole medical decision-making heuristic rests on a differential diagnosis approach; why prove it over and over on every single chart?

As a provider, if you just wrote the diagnosis, does that mean you suddenly became anti-differential diagnosis? Even if you recorded pages of negative findings and came up with the wrong diagnosis, does that help the patient any more than just writing the wrong diagnosis in the first place? All it proves is that you were thoughtfully wrong.

Two types of Complaints

A. You know what’s going on:

This chart needs positive historical points and physical findings, diagnosis, and treatment. That’s it. Nothing else adds value for the patient.

B. You have no clue what’s going on:

This chart needs more. You should write a book: everything you thought about and why it doesn’t fit. In fact, long charts define clinical uncertainty, not clinical excellence.

If patient charts should be about patients, we need to:

1. Change expectations:

Focus only on what adds value for patients.

2. Change charts:

The whole process could be done with macros and tick-boxes. Only critical findings (positives, diagnosis, treatment plan) need manual entry.

When physicians and nurses go back to review a chart, they NEVER need all the information in it. NO ONE DOES, except non-providers! Clinicians look at old charts to find 1-2 critical pieces of information that have meaning for their patient.

How short would your chart be if you weren’t worried about lawsuits and audits? What needs to be in the chart if only patient benefit mattered?