It has been approximately 10 years since well-intended people suggested that medicine change to become more like a business. Presumably, they did so with the intention that health care would improve for both patients and those working in health care. After a decade of medicine in a business mode, we can now assess what changes have occurred with this new paradigm. I don’t intend on talking about all of them, only those that I feel are the most significant.
I believe one of the unintended changes occurred in the cornerstone of medicine: the doctor-patient relationship. Our language has changed. I am no longer a doctor who takes care of patients. Instead, I am now a provider who sees customers. The word “relationship” suggests an ongoing exchange between two individuals who have possibly come to know each other and respect each other. The patients bring their concerns to their doctor. The doctor in turn listens to their symptoms, gathers additional information using laboratory studies and X-rays, etc., and explains what he or she believes is wrong. Treatment options are given to the patients, who make the final decision. The interaction is important, because potentially life-threatening problems are being dealt with.
For most of us, relationships in a business environment involve asking a clerk where an item is, thanking them for their assistance and hearing the checkout person say, “Have a nice day.” Typical for a trip to the store, but not a relationship that is anywhere close to what occurs between a doctor and a patient.
The second change comes about due to the language that has changed a patient into a customer. It stems from the oft-quoted phrase, “The customer is always right.” Doctors realize that their patients truly have the final decision. Also, well-informed patients are one of the goals of medicine. The problem is that patients often have obtained information and advice from multiple sources, including the internet, family members and friends. When they then interact with the health care system, they many times already have decided what is wrong and what they need. At times, they are correct, but sometimes they are not. When the “customer is always right,” and the patient is the customer, the doctor potentially becomes an adversary rather than an advocate. Two common examples are patients who are determined that they require antibiotics to get better and patients who feel they need opiates to effectively manage their pain.
The physician now has the dilemma either of giving antibiotics or Vicodin when he or she honestly doesn’t believe it is in the patient’s best interest or else refusing to provide the requested prescription. If the requested prescription is not provided, the patient possibly sees the doctor as an adversary and looks for another physician who will provide what is wanted.
In business, customers go where they believe they are getting what they want for the best price. However, in health care, financial transparency has not been achieved. Despite efforts to determine what something is going to cost, patients often don’t find out the cost until the bill arrives in their mailbox. And that bill often has more sheets of paper than a novel.
In the business of health care, the insurance industry has become the middleman. (Interestingly, insurance is referred to as an industry.) Money from people’s paychecks or pockets is sent to Medicare or insurance companies. In turn, they pay the health care industry all or a portion of the bill. But since they are paying the bill, the insurance industry seems to believe it has a right to play a role in deciding what care, treatment, surgery, medication, etc., it will pay for. This may affect the care that patients are going to receive or perhaps not receive. We now have a system where the customer is always right, but the insurance carrier writes the check.
Customer satisfaction is another cornerstone of business. As medicine becomes more businesslike, patient satisfaction is measured with customer surveys. The plan appears to be that hospitals, clinics and doctors will be paid based on their survey scores. Low scores translate into low payments. For this to be genuinely effective, the surveys must accurately assess the quality of care provided.
One example of where this may not work is the patient who is drug-seeking. When a prescription for Vicodin is not given, the patient may complete a negative survey for that doctor. Unfortunately, there are many possible scenarios where physicians could in fact provide good care and give good advice but receive a negative survey result. Patients know if they liked the doctor they saw and if they received what they wanted, but it is much more difficult for the patients to assess the quality of the care they received. Surveys run the risk of being little more than a popularity contest.
The vast majority of physicians I have encountered are both good doctors and good people. They went through a long and arduous training process for the simple reason that they wanted to help people. Some of these changes have created an atmosphere where physicians are becoming disillusioned and disappointed. I’m not all that convinced that medicine as a business has been all that good for anyone.
Dr. Dave Watkin, of Alexandria, Minn., is a retired physician.