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Taking Care of Our Healthcare System: The Physician-Patient Encounter

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Medicine is an art and it is a consequential relationship

Healthcare is largely communication, behavior and understanding.  Physicians do most of their learning working with patients and learn to share that learning to help future patients.  Healthcare learning and help happens within the patient – physician helping relationship.  People helping people is always a wonderful thing to see, but it is also difficult and fraught with some of life’s most vexing and ironic contradictions. Human life and dignity are some of life’s most precious things; yet their value, in monetary terms, is often questioned. The value of a person’s health is often underrated–even by the person themselves. For this reason, it is often difficult to understand and manage healthcare policy priorities for society in general, in terms of public spending and health policy, and for healthcare leaders, in terms of prioritizing and evaluating the components that go into building and managing the primary care process.

The relationship between healthcare services available, healthcare needs, and healthcare outcomes is not always obvious. Nowhere is this more evident than in the conversation between a physician and the person who comes to them for help. To be sure, the physician – patient encounter must remain the locus of control to ensure healthcare quality in a way that balances patient interests, outcomes and healthcare system sustainability and affordability goals. Measuring healthcare quality and patient satisfaction continues to elude most healthcare leaders and systems. Society, however, demands it. Medicine is an art and its goals, preserving and promoting a healthy life, can usually be seen as humane and priceless. Sustaining that art in the professional and public spheres is another proposition. The many variables that have to come together to make the art of medicine function in an optimal way must always be measured by the experience of the provider and the service recipient. At least in the actual healthcare encounter moment, there is a unique opportunity to define and support the quality of the craft and its product.

Creating an environment that can sustain the art of medicine is one of the few universal needs of people in any society. Of course, this easily seen and agreed to truth is always mediated by business concerns and economic considerations. How can we preserve the art of medicine and at the same time design and sustain systems that can take care of all comers as well as balancing the budget of institutions (including governments and corporations) responsible for minding the business of caring?

Medicine is about people and physicians are people too

Most people don’t want to be sick, and to be truthful, they also don’t want to pay for being sick at the expense of what they see as competing personal and family budget essentials. Much of the literature on healthcare problems and on ways of “fixing the healthcare mess” revolves around paying the healthcare bill as the initial catalyst for caring about health. It is the main reason we come to the table as individuals concerned about our family, as leaders addressing budgets or as providers concerned about our role in practicing the healthcare caring profession with real people in real places. If we are going to look at changing how people feel and think about healthcare, we better look at supporting the role of physicians as professionals meeting the expectations of patients within the institutions where they practice; and we better look at the role of publics who pay the bills to sustain those institutions.

Community healthcare outcomes are the consequence of thousands of healthcare decisions at many levels. Chronic health conditions are the largest portion of illness and disease, as the drivers of costs and as ideal mediation points for behavioral health interventions. Chronic health conditions are most often a consequence of specific lifestyle related health activities or the lack there certain activities. In the first and final instance these health problems, and their resulting costs, are caused by health behaviors and can best be moderated by changes in those behaviors. The nexus for that hopeful work is the physician – patient therapeutic and educational encounter.

Most of the serious chronic illness challenges that physicians confront on a daily basis begin and are worsened in private homes behind closed doors. The quality of the practice and the professional potential, of the individuals who embark on the education and then the profession of medicine, are both constantly mediated by the type of patients that health practitioners will see, and the environment in which they will perform the “art” of their practice. Patient mix and environmental demands can present a significant burden to physician motivation, decision making, and professional efficacy and growth. Changing the demands and burdens on physicians that are caused by both patients and payers, administrators and educators, would go a long way towards getting us back to an enjoyable and dignified relationship between persons in need and physicians that can help.

The physician – patient encounter continues to be the central nexus in our healthcare system and it is that encounter that may prove to be most fruitful when we are considering to build a more client centered system that will yield more healthy and sustainable healthy lifestyles. If we intend to keep our treatment systems humane, then we better find ways to support physician decision making and advocacy on behalf of their professional autonomy, their commitment to their professional integrity and to their own well being, and, of course, to the well being of their patients.

The physician – patient encounter can be an important nexus for improving the healthcare learning and treatment experience of healthcare consumers. But it isn’t easy and physicians will not be able to go it alone. Healthcare behavior is perhaps both the most important driver of healthcare costs and of desired healthcare outcomes. It is at once a potential liability and a moderator for escalating costs. And healthcare behavior involves all of us doing our share–both the behavior “actor” as well as all of us who seek to improve and promote healthy lifestyles, health literacy, and just all around good neighborly advice and community quality of life. The RWJ Foundation’s current push for changing local healthcare by promoting and helping to build healthier environments that sustain healthier lifestyles is a start. Physicians need to play a central role in both the continuing evolution and needed conceptualization of such an effort, and the implementation in all the settings where the physician – patient encounter will provide opportunities to teach and support patients in their pursuit of a healthier life.

There are hundreds of physician “types” and roles today, each are shaped by their specialization, their personal motivators for being in the healing and helping business in the first place, and the organizational and business systems in which they practice their craft. As these “supporting” systems change, so do physicians as they are real people with people needs. Our ability to change as sick people needing help is also important. It’s all about change, if the healthcare system changes so can you.

Understanding healthcare system change and knowing how to change to take advantage of the benefits the changing healthcare system offers

The healthcare system is changing and so is the role of the individual who touches and communicates with the person needing healthcare services. The physician – patient encounter is both preceded and surrounded by often conflicting narratives, streams of information, and variables that cause inordinate distraction and preoccupation with things outside of “What is your health problem today and what can I do about it?” Social media and the internet can both help of hinder this important learning and therapeutic relationship. The fulfilled salutary potential in this patient efficacy and health literacy regard remains to be defined and addressed. Physicians can not be all things to all people. We must be creative in evolving the practice environment to bring in roles and technologies that can help both physicians and patients in their predominantly communicative encounter.

In my three decades as a educated health professional and health consumer, and five years in health program implementation, ten years as a health and human services policy advisor, five years as a community health system administrator, I have had the pleasure of looking at the healthcare process from the perspective of just about every imaginable stakeholder. This is even more true in my past ten years, in the public relations and administration areas of behavioral health, in a large policy oversight service payer organization. I have also worked with physicians from every conceivable angle imaginable.

We have seen the role of the physician evolve through and beyond two major national efforts at healthcare reform (during the early 90s with Clinton’s HSA failure, and now with ACA). One could argue that the idyllic role of the “Norman Rockwell” physician continues to be the frame of reference for today’s modern healthcare practitioner and our demands on him/her. Given the evolution of healthcare as a commodity, today’s physician is too often an employee. S/He is certainly an individual equally preoccupied with the challenges of providing effective interventions, as S/He is faced with the plethora of obstacles and challenges surrounding the costly and increasingly evaluated physician – patient encounter today.

Some of these challenges include:

  • The uncertainty and negativity that pervades healthcare today, including preoccupation with costs, competition between the various payers and the patient “recruiting networks,” and the tension between deciding what is needed and what is affordable.
  • The management of pharmaceutical products and information, including how to use those products in the treatment process; and the role of a never ending product cycle that promises to address ever changing patient needs and symptoms.
  • The increasing pace of change in the payer and reimbursement system and the simultaneous challenge of a changing healthcare environment with evolving variables that constantly change the provider’s calculus regarding professional, personal and business risks.
  • The increasing dissemination of health information from multiple sources and the so called “empowerment” of the consumer which can erode (deservedly or not, necessary or not) physician – patient trust and control.

For these and other reasons, practicing medicine today is increasingly less of a one on one, personal experience once driven by laudable helping objectives and noble goals of doing good. Patients enter the physician – patient encounter today with personal and public media marketed fears, agendas, and competing messages in their head.

Physicians, of necessity because of today’s complex primary care process, too often enter that encounter with distractions and pressures from pharmaceutical business, the vicissitudes of insurance reimbursement, and daily business or professional pressures as physicians are also employees, partners or business owners. Today, when you are walking into the physician – patient encounter you could be dealing with a business man, an employee, or a business partner. Each of these roles can significantly mediate the behavior of both attending physician and consuming patient.

We are all in this together. At the end of the day, physicians are real people who also get sick and who ultimately will benefit from you being well. Whether that means less patients in the waiting room and patients that actually followup on the their various recommendations for better health, the important thing is that we go to our doctor’s office with an open mind and a belief that we can help our doctors help us–because we will behave in accordance with their professional advice. This brings up some general ideas regarding the patient’s responsibilities in the physician – patient encounter:

Healthcare change is happening to all of us. Improving our healthcare experience and outcomes will require all of our collective responsibilities in keeping up with the information that will allow us to address how healthcare change affects our specific healthcare needs and how we can improve our communication with our healthcare provider and how we use that communication to live healthier lives.
Just as we expect for physicians to be our advocates we must also be respectful and understanding of their needs as caring professionals performing difficult work that benefits us.
When we make purchasing or political decisions that will impact healthcare policy (whether macro social policy or institutions policies that impact our healthcare), we must always consider that our vote or our healthcare purchase includes the commitment to understanding our responsibility to be informed consumers that can help vet information regarding our needs and to hold both providers and policy makers accountable to protecting our interests and needs.
In the end, we must think of healthcare as a personal behavior issue that begins with how we live our lives and how we take care of ourselves and our loved ones.

Healthcare will always be personal but it will also weigh heavily on our politics and out budgets

After the failure of the early 90s healthcare reform (HSA) and the difficulties with today’s ACA (so called “Obamacare”), what remains is a never ending tension between “Who will pay for this?” and “How can we help people stay healthy so that they don’t incur healthcare costs beyond their economic capacity?” The current RWJ Foundation efforts to invest in transforming the healthcare experience at the community level is a good attempt at favoring the balance towards addressing the second question. Ideally, if we find appropriate answers at the local healthy living level, it will be easier to answer the first question because “Who will pay?” will be addressing a much more manageable bill.

Ask not who will help me pay for my health bill in the first instance, but always ask how will my current lifestyle affect my overall health?


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