Grand Rounds is up over at Doc Gurley’s site, and I’ve been engrossed in it for the last hour. Duncan Cross has written an article about what patients can do to advance healthcare reform. The article stemmed from another one that he wrote, which was critical of the notion that patients – rather than doctors – would have to be the ones who compromise the most in order for healthcare reform to move forward. I read both articles, and all of the comments, and am struck by how radically different the view of healthcare is, depending on the perspective from which one is looking at it.
My father is seriously ill. Over the years since his diagnosis, my family’s life has become inextricably interwoven with the healthcare system. My father is an intelligent, educated, highly compliant patient. He and my mother meticulously moniter his medications, dialysis, diet, and liquid intake. They communicate with his doctors, carefully read EOBs before they file them, and double check any new prescriptions to make sure there are no contraindications or allergies (over the years they have found several errors, which highlights the importance of taking more than a passing interest in ones own healthcare). From my family’s perspective, I would agree that everything Duncan Cross wrote is excellent advice.
Two of my best friends are healthcare providers. One is an emergency room nurse, and the other is a PA, working in a government-funded clinic here in Colorado, where the majority of her patients have no health insurance. When I discuss healthcare reform with them, they have a very different perspective. While they both see patients who are compliant and taking an active interest in their own healthcare, they also see plenty of patients who are not (and who are not likely to change). They see red tape and billing issues that take up time they would rather be spending with patients. They see patients who demand antibiotics for a viral infection, and simply seek out another provider if their request is denied.
The thing about healthcare that separates it from most other commodities is that virtually all of us will have to use it at some point in our lives. Doctors treat informed patients like Duncan Cross and my dad, and they also treat patients who take no interest in – or responsibility for – their own health. Duncan’s original post, where he decried the notion that the change must come from the patients (as opposed to coming from the providers) was very astute. But I think part of the problem lies in the fact that there isn’t consistency among medical providers. When doctors don’t give in to patients who demand antibiotics for colds, there is always another doctor down the road who will. And for every doctor who refuses to perform a high cost test right out of the gates, there is another doctor who will. Patients are bombarded with pharmaceutical advertising, which means that they often show up at the doctor’s office with a preconceived idea of what is wrong and what drug will fix it.
It’s awfully hard to dramatically change the perspective of 300 million people when it comes to the role we each take in our own healthcare. Education, family background, health history, stress level, employment situation… there are a lot of factors that come into play, and it’s tough to bring about widespread chang across such a diverse group. I think change is possible, but I don’t see it being a quick or easy shift.
The medical profession, on the other hand, is a much more homogeneous group. They all have medical degrees. They all maintain medical licenses, which means they stay current on continuing education and updated medical board exams. They know that antibiotics don’t cure a cold, and they know that high cost testing isn’t necessarily the best option when confronted with a diaognostic situation. But our reimbursement system for the medical profession doesn’t reward doctors who spend time with their patients. Instead it rewards doctors who see the most patients in the least amount of time (writing a prescription for an antibiotic is a good way to move patients along). Expecting change to come from patients isn’t fair. But it’s also not fair to expect change to come from the medical profession as a whole until we make some changes to how doctors are reimbursed for the services they provide.