There have been a number of developments in the past
week that I wanted to comment on, but I kept finding myself thinking about two
op-eds I read recently. Each, in its own
way, discusses the impact of culture in the health care system on our health care. In brief – our culture of medicine may actually
be adversely impacting our health.
The first was a piece by third year medical student
Ilana Yurkiewicz entitled Why Rude Doctors Make Bad Doctors. You should read the whole piece, but a couple
of her thoughts really hit home to me.
Ms. Yurkiewicz makes a point of saying that ill-mannered physicians are in
the minority, but, even so, their behavior adds up: she cites a study from the
UCLA School of Medicine that found 50% of medical students across the U.S.
experience some sort of mistreatment, such as being bullied. She points out another study
that found 17% of nurses and physicians could name a specific adverse patient
outcome that occurred as a result of disrespectful behavior.
Ms. Yurkiewicz warns that communication in health
care settings suffers as people worry about intimidation, fear of
confrontation, or retaliation, so potential errors or warning signs may not get
pointed out.
Here’s one of her important insights: “Many in medicine actively protect the
culture of disrespect because they hold a fundamentally flawed idea: that
harshness creates competence” (italics added).
As Ms. Yurkiewicz goes on to say, “bad
cultures lead to bad outcomes.”
In addition to ending the culture that tolerates
bullying by medical professionals, Ms. Yurkiewicz argues that the culture puts
too much of a premium on saving face, which “…creates doctors who value looking
like they know what they’re doing at all times more than actually doing what is
best.”
Strong stuff.
It is perhaps no coincidence that our archetype physician has gone from
the kind, gentle, all knowing Marcus Welby,
who was happy to make house calls, to the even more brilliant but pathologically
irascible and insensitive Dr.
House, who only sees patients in the hospital.
The second op-ed, which comes from a very different perspective,
was by We Are Giving Ourselves Cancer
We are silently irradiating
ourselves to death” ” (italics added).
In addition to the simple overuse of scans, Ms.
Redberg and Ms. Smith-Bindman mention the lack of standards about dosage, which
they say can be 50 times more at one hospital than another. Studies have confirmed the variability across
institutions and even within
the same institution.
The common thread I find in these two very different
pieces is the can-do, almost cowboy culture of “we can do it, so we will do it,
and don’t tell me any different.”
I find signs of this everywhere I look. A few days ago HHS released rules
allowing patients direct access to their lab results, which begs the question –
why weren’t they available before? If it
was that the results were deemed too complicated for patients to understand,
why wasn’t more effort made earlier to make them more consumer friendly?
Or take my personal favorite – colonoscopies. They bring in lots of cash
for GI docs, but the prep is universally reviled by
patients and the procedure isn’t much fun either. Turns out maybe they don’t need to be this
bad – the FDA has just approved
a pill-sized camera that patients simply swallow. Granted, this took some advances in
technology, but virtual
colonoscopies have been around for several years, so
why haven’t they become more the “gold standard”? And why can’t the prep be easier – or at
least less distasteful – for patients? A
consumer market, driven by patient preferences, would have addressed this long
ago.
Frankly, too much of what goes on in medicine looks
like it is more about protecting income or turf than about protecting patients.
There are fights going on between physicians and
their medical boards about how to demonstrate ongoing
competence. Board certification
has gone from lifetime to 10 years and is moving in some specialties to 2-5
years, but not all physicians want to have to prove they know what they are
doing – why not? In another battle, anesthesiologists
don’t want
nurse anesthetists horning in on their territory, although they admit they
don’t have proof that patient outcomes suffer (and, in fact, nurse anesthetists
can claim
the care is the same).
Heck, there has been a battle
going on for years about the release of Medicare Physician Payment data. Advocates for the release have pointed out
the potential for detecting fraud
and overutilization and improving
patient safety, while the AMA has raised physician
privacy issues. Really? Physician privacy concerns outweigh patient
safety or defrauding Medicare? It would
appear that the battle for the release has been won, but I’m not sure the war
is over.
The best example of all, though, may be medical
education. Perhaps someone could explain
to me, with a straight face, why we still have allopathic (M.D.) and
osteopathic (D.O.) branches of medicine, each with its own set of schools,
residency programs, hospitals, licensing and oversight – not to mention
chiropractic or alternative medicine.
It’s been over a hundred years after the Flexner Report
and we still haven’t figured out how to take the best from each approach in
terms of what works best for patients and how to best train people to deliver
that care?
As Ms. Yurkiewicz neatly concludes about our medical
education process, “…we also can’t ignore a system that takes loads of formerly
‘nice’ people and churns out jaded, bitter, and gruff ones.” Amen, although I like to believe that plenty
of physicians somehow still manage to stay “nice” despite the process.
I could go on and on, but perhaps the reader will
take my point.
Just when I start to get too discouraged, signs of
positive culture change do pop-up. CVS
just announced
they will no longer sell tobacco products, deciding they truly are in the
health care business and forgoing $2b in annual revenue as a result. They’ve already made a big bet in retail
clinics, as have several of their pharmacy
competitors.
Volumes have been written about retail clinics’ potential;
even hospitals
are getting into the game (we’ll have to see what kind of retail experience
they can deliver). A truly retail
perspective should be better at
putting patients first.
Still, even the much vaunted retail clinics haven’t severely
dented more traditional practices of medicine, due in large part to the usual
suspects – regulatory
and reimbursement barriers.
Its distant cousin telehealth faces much the same problems, and, as a
result, is having its most success in places where there aren’t many good
alternatives, such as in rural
areas. Those are
the underlying kinds of culture issues that are proving very hard to shake.
The culture problem really crystallized for me a
couple years ago when Dr. Michael Joyner of the Mayo Clinic raised
the question of whether physicians should treat lack
of exercise as a medical condition. That
signaled to me that we’ve officially tipped too far from thinking about health
to relying on medicine, and signified abdicating our own responsibility for
taking care of our own health to the medical professionals. They certainly should be part of our health
team – just not in charge of that team.
It’s our body, our health, and we should be in charge.
At the end of the day, it is us – the patients, the
supposed consumers – who allow the culture to exist. Every time we don’t ask physicians questions
or don’t demand better explanations, we allow it. Every time we get a pill or an extra test
instead of taking time to evaluate risks and risk factors, we allow it. Every time we accept overbooking, confusing
bills, inconvenient hours, or inadequate time with our health care
professionals, we allow it. And, of
course, every extra pound, every missed exercise, and every missed fruit and
vegetable serving, we allow it.
Maybe we need fewer doctors like House and more
patients with the attitude Howard
Beale had in Network,
where he famously declared “I’m mad
as hell and I’m not going to take this anymore!” We need more of that attitude to win the
health care culture wars.
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