Secrets of Medical Decision Making (eBook)

Physician's Perspective

The term ‘Medical Box‘ is my invention to show the boxed-in thinking imposed on physicians; the boundaries they need to overcome in order to do what's in the patient's best interest. I believe it is important for the patient to be aware of them too. Here are what I call the four corners of the Medical Box:

• Fear of litigation.
• Financial and time pressure.
• Guidelines of Health Care authorities.
• The current Medical Model—disease oriented thinking.

I think most physicians wish to do good and to be genuinely helpful. This wish is impeded by the Medical Box.

Litigation has a potential of disrupting medical practice and increasing malpractice insurance premiums. Being labeled as high risk physician limits one's employability. According to the Association of American Medical Colleges, an average physician who graduated from medical school in 2004 had $115,000 of educational debts! This debt has been steadily increasing. After spending a minimum of eleven years of intense learning, one tends to want to have some degree of comfort, to be able to repay one's debts, and have a feeling of some financial security in order to support a family. All of that is threatened by a lawsuit. Medical mistakes do happen and it is fair to hold the doctor accountable for them. However, the success of a lawsuit does not always depend on the degree or even presence of a mistake on the doctor's part, but rather, on the gravity of the outcome or on chance alone. One of my obstetrical colleagues was successfully sued after her patient's unborn baby died. Though by the standards of medical practice there was no error, it is hard for the jury not to feel overwhelmed by such a tragedy. Consequently, she was deemed guilty, resulting in stigmatization, raised malpractice insurance premium, and a mark on the record that will be questioned whenever she may want to look for another job, or apply for another malpractice insurance.

This record is permanent. It is not surprising that fear of being sued is one of the major forces driving medical decision making in the US today. I attempt to illustrate some of the implications of this in the vignettes of the subsequent chapters where actual patients are described. I am not the only one to believe that the success of a lawsuit does not depend on the presence of an error. Linda Crawford, who is on the faculty of Harvard Law School, where she teaches trial advocacy and has been consulting people on research and evidence-based effectiveness for malpractice depositions, states that five out of six lawsuits involve good medicine, half the time there isn't even a bad outcome (Tracy, 2003). She further states: “Let's talk about brain-damaged children. All of us now go into labor and delivery presuming we will have a perfect outcome. The parents believe it. The family believes it. The community believes it, and frankly the providers believe it; yet, it is still true that we have not made any significant gains since 1965. Five percent of children are born with significant disabilities. There is a gap between what everybody is expecting and the reality. I am all for good relationships with your patients; I think it has a great deal to do with the quality of our professional lives. However, I also look at the specialties and the individual surgeons who are sued, and it often has to do with the expectations of your patients going into whatever the event is.” These expectations are not easily changed and are often the result of a well publicized boasting of the medical system about the great advances we've achieved.

Money and time are intimately related in our society and the medical system is no exception. Beginning in medical school, we (medical students) were repeatedly told that medicine is business. I do not share this opinion but it is now held by the vast majority of physicians. More than that, in medical school we were specifically taught that it is not important for us to care about the patients, what is important is to know how to create an impression of caring. We were then taught how to do that, how to fake a caring attitude. A doctor has to say “aha”, “ tell me more”, to make a pause after a patient says something he finds significant; one needs to make brief remarks indicating compassion and understanding so as not to make an impression of being uncaring. All this is so that the business part of medicine can go more smoothly.

Third party payers also drive some of the important changes in this realm. Health insurance attempts to cover health care needs and make some money off of this process. They have to find some quantifiable way of reimbursing physicians. This quantification (which is difficult to avoid) is one of the problems. My residency training was in a suburban university hospital. From time to time, in addition to the usual lectures by the faculty, we were lectured by the community physicians who were supposed to teach us how to “survive in the real world”. We were taught that “talking to the patient doesn't pay”, that in order to survive financially we needed to decrease the amount of talk to the minimum and instead to do as many office procedures as possible. Insurance won't pay for educating a patient, but they pay for throat cultures, wart removals, hearing, vision, blood and urine tests etc. An excerpt from a recent article for the physicians in the Family Practice Management Journal (Martz, 2003) illustrates this point:

“As practices’ expenses continue to grow at a faster pace than revenues, physicians are under greater pressure to do more with less. While working harder and seeing increasing numbers of patients each day is an option, finding methods to work smarter is becoming an attractive alternative. One viable strategy for your practice is to increase charges per unit of time. Performing more procedures is a simple and successful way to achieve this goal.

As you are probably aware, not all procedures are created equal. Some procedures (e.g., flexible sigmoidoscopy) are reimbursed very poorly considering the time they require. Other procedures (e.g., skin biopsy and excisions, colposcopy/biopsy and exercise treadmill testing), though reimbursed more handsomely, may require significant amounts of physician and nursing time, significant up-front costs to the practice and extensive training. However, there is another category of procedures well worth your time and effort - joint and soft-tissue injections.”

I don't think that many patients want to see a physician who is thinking of performing more procedures as a means of increasing his revenue. We want our physician to be impartial keeping in mind only what's in our best interest. The interest in joint and soft tissue injections is so strong that it drives practices that were proven to have no more effect than a placebo. I still see patients who ask me to inject their knees with Synvisc—an expensive product used to treat osteoarthritis and subsequently shown to be no better than injections of salt water (Pedtgrella et al, 2002). Their previous doctor did it and insurance paid for it, so they want more. Things may soon get to the point that when you come to your doctor for a sore throat, he'll offer you a knee injection.

Another necessary way of increasing the revenue is to address one or two problems at a time and to keep bringing patient back for frequent revisits. Insurance will pay for addressing one problem on separate visits, but will question and decrease payment for trying to address multiple problems in one visit. Health insurance usually monitors physicians—this is called physician profiling. Payments are decreased to the physicians who charge more than the average. This causes a disincentive to try to solve more than one problem and a preference for younger and healthier patients with fewer problems. There is also a threat of an audit—when a health insurance such as Medicare may review charts. If during an audit, chart documentation does not reflect the charges, a practice can be fined millions of dollars. This brings several consequences. One is that physicians will ‘downcode‘ (charge insurance less) just to avoid the possibility of an audit, another is the need for careful documentation for insurance purposes (which is not the same as the patient's); the third is less reimbursement. All three cause the physician to accelerate his pace in order to continue making the same amount of money. Naturally, quality suffers. Dealing with insurance leads to an additional loss of time because of other bureaucratic processes involved. Billing, coding, credentialing, and auditing are the tasks that take the time and money. For example, a physician has to hire a biller or a billing service. Different insurance companies use different drug formularies—list of medications that are preferentially covered. The physician has to be able to keep up with all that and have the time to do quite a bit for the patient—what the guidelines demand, and what the patient wants, which are usually two different things.

Most medications and treatments carry some consequences, as does the option of foregoing them. That and the fact that physicians have been required to have the informed consent of a patient, creates tension. On the one hand, the physician has to educate the patient in order to obtain a true informed consent; on the other hand, he has no time/money for...