The Crestone Eagle • May, 2020

A Doctor’s Discourse: Modern medical practice & the doctor/patient relationship

by Earl W. Sutherland,

MD, PhD

Medicine’s most fundamental relationship is that between physician and patient. To ensure this relationship we must advocate for two principles: 1. Physicians need to spend adequate time with patients who need extra, for example, when there is diagnostic uncertainty, those with failing treatment plans, and those at the end of life; 2. The need to identify and support the work of a coordinating physician for patients who are seeing multiple specialists, to ensure that everyone is talking with one another and, if there are disagreements, to clarify the diagnostic and treatment plan and help the patient make decisions about next steps.

Our health care system often struggles to provide reasonable and affordable access to care, suitable approaches to payment, opportunities for innovation, and comprehensive care for patients with complex health issues or multiple coexisting conditions. Health care costs continue to rise despite continued downward pressure in the reimbursement models for hospitals and physicians, and health care administrators must ensure that their organizations perform well financially in an increasingly competitive environment. Patient and families worry about health care costs as well, fearing medical bills and the possibility of personal medical bankruptcy.

Financial considerations are necessary, but this focus too often overshadows the human side of medicine. A key attribute of physicians is the commitment to caring for others—the desire to decrease suffering and make a difference in the lives of patients, often at their time of greatest need. Practicing physicians despair that the focus on costs has reduced them to cogs in the health care business machine, with daily reminders of ever growing productivity expectations on top of crushing regulatory and clerical burdens. Physicians in general have continued to accommodate these added demands. But in the absence of strong administrative support, investment, and innovation, the results are predictable: loss of joy in work, erosion of professionalism, and ultimately burnout.

Physician and administrator leadership working together can achieve much, focusing jointly on patients’ needs, bringing together all members of the care team. Several key steps follow:

1. Aligning physician engagement, administrative support and the culture of the practice to effect change

Essentially, every practice has a mission statement stressing the primacy of patient care. Reminding everyone in the organization of that mission may inspire and support patient-focused changes.

2. Prioritizing identification of opportunities for innovation

The work of refocusing on humans rather than finances needs to happen within individual practices, specialty groups, and hospitals.

3. Involving all the members of a team and rethinking the purpose of their work and the skills they bring to the practice.

All the members should be supported to work at their highest level of certification, and efforts to redesign should bring iterative improvements and commitment to continue to invest in better solutions.

4. Identifying the key barriers to success

Technology should be organized as a tool rather than being a barrier and many tasks off-loaded from physicians allowing them more time with their patients. (The electronic medical record has often been cited as a major contributor to burnout.)

5. Mobilizing specialty groups to change reimbursement to properly reward additional patient service.

Start at the local level, but ultimately changes need to happen at the payer level, which will be more difficult, but possible. (Primary care physicians may appear undercompensated compared to those who perform procedures.)

Leading change efforts may be difficult, but changes that clearly benefit patients are more likely to succeed than changes that are designed to enhance financial performance. The right thing to do will be the easy thing to do. This can only happen with long-term thinking, societal will, and grit. The medical profession should be at the center of the effort to fix health care, yet it has gradually been backed into a passive position, as external factors have eroded the centrality of the patient-physician relationship.

   Maintaining a focus on patients’ needs and the benefits of collaboration may seem dated or nostalgic, but caring for the sick still demands personal interactions, supported by trust, evidence, experience, and technology. The patient-physician relationship is essential to healing and it brings meaning and purpose to our profession and our lives.

The thoughts Dr. Noseworthy so well presents to members of the health care professions seems very apt for the rest of us. We should not stop urging our health care system to do better. When we see our provider we should try to be accompanied: two heads are better than one. Encourage your provider to provide more accessibility to the questions you may have outside of appointments—some practices schedule their providers’ time dedicated to answering e-mails, texts, and phone calls. A long list of further actions comes to mind. And what about expenses? It seems like really big thoughts and actions are needed here. We’re all in this together (or at least 99% of us).

December 5, 2019, from the New England Journal of Medicine: J. Noseworthy, “The future of care—Preserving the patient-physician relationship” Vol. 381 (23) p 2265-69

Noseworthy, a neurologist and clinician-investigator, has been the head of the Mayo Clinic for the last ten years. This essay is full of finely crafted statements that the author freely admit to have often plagiarized, omitting quotation marks.