OP-ED

Is the Patient the One With the Disease?

Screen Shot 2014-08-21 at 11.45.17 AM“The patient is the one with the disease.”  This medical aphorism, often quoted as rule number four from Samuel Shem’s 1978 novel, The House of God, has probably been around as long as medicine itself.  Its point is that doctors need to learn to accept their own vulnerability and fallibility before they can devote themselves fully to the care of their patients.  And so long as medicine was built on the relationship between two parties, patients and doctors, the rule worked reasonably well.

More recently, however, the party is being transformed into a crowd.  A third player is increasingly encroaching on the doctor-patient relationship, and more and more doctors are beginning to suspect that it may be the vector of much of contemporary healthcare’s pathology.  Who is the third party?  Its precise identity is often difficult to pin down, but its seat in the doctor’s office and at the patient’s bedside is often occupied by a hospital, a health insurer, or a government agency.

This third party usually does not see individual patients.  Instead it sees aggregates, such as rates of mortality, disease incidence, and the utilization rates of particular tests, procedures, and pharmaceuticals.  It tends to be particularly interested in parameters such as efficiency, safety, cost, and revenue.  Because it is largely blind to individuals, however, its risk of developing certain disorders is dramatically increased.  And when it falls ill, both patients and doctors suffer.

Before patients and doctors can respond effectively to such pathologies, they must first recognize that they exist.  One of the first steps in recognizing a disorder is applying a name to it, and one physician who has taken up this challenge is Adam Ratner, MD, one of the founders of the San Antonio-based non-profit, The Patient Institute.  Ratner, who has been struggling to clarify the nature of these pathologies for many years, believes that healthcare is in the midst of an unrecognized epidemic.

Ratner’s compendium of healthcare disorders runs into the dozens, but exploring just a few of them illustrates the value of the general concept.  He calls one of the most prevalent disorders hypermetricosis, the belief that the act of measuring makes things better.  The symptoms are everywhere: doctors and other health professionals are being required to spend more and more time obtaining and reporting data, such as vaccination, smoking cessation, and diabetes control rates.

The problem, however, is that such measures do not define good medicine.  A good doctor is defined by more than just a set of statistics.  A good doctor is also caring, curious, dedicated, and a good listener.  When hypermetricosis takes hold, more and more time and resources are focused on the measurable, at the expense of everything else.  “In extreme cases,” Ratner says, “the condition can degenerate into malignant hypermetricosis, in which the human side gets lost completely.”

Another such disorder is hypermechanosis.  Many third parties envy the kinds of productivity and quality gains that have been achieved in other industries through the application of various forms of statistical process control.  For example, six sigma focuses on reducing variation, usually treated as error.  If only we could run medical practices the same way Toyota manufactures automobiles, Southwest flies airplanes, and Disney treats its theme park visitors, proponents argue, we could revolutionize healthcare.

But every patient with colon cancer, congestive heart failure, and low back pain is not the same, and this makes it problematic to treat reducing variation as the top priority.  Patients and doctors are not identical to one another to the same extent as brake rotors, take offs, and roller coaster rides.  As a result, the effort to equate quality improvement with reduction in variability may often do more harm than good.  Says Ratner, “We must never treat human beings as widgets.”

A third disorder is hyperbureaucrosis, which in some cases can progress to malignant hyperbureaucrosis.  It tends to arise from a sense that the healthcare system is broken.  In fact, the afflicted argue, the so-called system may not be a system at all.  So they seek to systematize it, moving authority away from those on the ground, patients and doctors.  By centralizing authority, they aim to bring healthcare under the authority of those who see it from a much higher vantage point.

The problem, however, is that making medicine more systematic may in many cases undermine the care of individual patients.  Too often it forces doctors and other health professionals to spend so much time memorizing, complying with, and proving that they comply with third-party regulations that they have little time and energy left to care for patients.  “In some cases,” Ratner says, “those suffering from this disorder end up equating quality with compliance, as opposed to good patient care.”

A final disorder really represents a class of maladies, collected together under the general rubric of malalignment disorders.  Among the groups whose goals and incentives may be malaligned are patients, doctors, hospitals, and payers.  For example, most patients want to get better, or to avoid falling ill in the first place.  But hospitals and health systems often want to increase their market share and profitability.

Problems arise, for example, when increasing market share and profitability take precedence over the needs of individual patients, or when physicians are incentivized to adopt practice patterns that benefit their employers but not their patients.  “In the final analysis,” Ratner says, “good health care should be defined by the needs of each patient.  And the people most likely to be focused on patients are the ones who know each patient best – individual health professionals.”

What does all this mean to patients?  Ratner believes the answer can be nicely encapsulated in a few words of advice.  “The next time you see a doctor spending more time looking at a computer screen than the patient, charting care according to an algorithm rather than the specific clinical situation, following orders rather than writing them in the chart, or devoting more attention to the needs of the hospital or health system than to those of the patient, ask your doctor one simple question.”

“Could you be suffering the effects of hypermetricosis, mechanosis, bureaucrosis, or some variant of a medical malalignment disorder?”  In other words, is the third party the one with the disease?  If the answer is yes, then a conversation is in order.  Such a conversation should begin with the realization that measuring, mechanizing, bureaucratizing, and realigning incentives are never the top priorities.  “If we want truly good medicine,” Ratner says, “we need to recognize that sometimes it is the hospital and the health system – not the patient – that is suffering from the most serious disorder.”

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Don Levit
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What I find interesting is that this third party is so hard to define because it is a combination of special interests which cooperate and compete with each other at the same time
There are also conscious and unconscious matters in play
One unconscious matter is our fear of our own mortality
If we can come to some type of acceptance of this inevitable fact we can better piece together this strange secret undefined third party
Then we can more of our own free will make better choices
Don Levit

Karen Sibert MD
Guest

This is a welcome description of the intrusiveness (and uncontrolled metastasis) of the outside forces that come between patient and physician. I especially enjoyed the definition of the new syndromes–hypermetricosis in particular, a new disease carried by an insidous vector: the EHR.

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Phil Pffei
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Phil Pffei

Phil – says as in ‘One Nation’ by Ben Carson-turn the system upside down, …at birth give child a birth certificate, give child electronic medical record(EMR) and establish Health Savings Account(HAS) if done you have established the Patient – Physician relationship – Which requires the parent, guardian or the individual to authorize the releases of their information. Going forward in life that individual has the right to access the information, where ever he/she our and the hospital, providers should honor that request and provide electronically to those caring for that individual at that moment

Charles Kenney
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Charles Kenney

Vy thoughtful and interesting post. For me, this quote from the article gets at one of the most disturbing threats in health care —

“Problems arise… when increasing market share and profitability take precedence over the needs of individual patients, or when physicians are incentivized to adopt practice patterns that benefit their employers but not their patients.”

Amen.

allan
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allan

Amen is right and that is the problem with HMO’s and other types of care that mimic the HMO. To maintain loyalty to the patient rather than the institution physicians have to be independent. HMO’s use both subtle and not so subtle techniques to keep physicians in line and protect their profits.

allan
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allan

Amen is right. That is exactly the problem seen with HMO’s and similar types of groups. The HMO has subtle and not so subtle ways to keep the patient in line so that the patient can be left out in the cold to benefit the physician’s employer.

Granpappy Yokum
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Granpappy Yokum

“physicians are incentivized to adopt practice patterns that benefit their employers but not their patients”

And when their employer is also an insurer, like K . . . oh, never mind.

allan
Guest
allan

Excellent!

I look at the healthcare system along with the recently passed ACA as a system that exists for everyone servicing the industry, and lastly the patient. At the top of the ladder are the politicians that are aligned with large healthcare systems. The problems could likely be solved by a few urologists to reattach something that our politicians are missing. A few neurosurgical transplant physicians might be needed as well.

[Note:] Third party began during the wage and price controls of WW2 about 20 years earlier than Medicare.

Perry
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Perry

“The problems could likely be solved by a few urologists to reattach something that our politicians are missing. A few neurosurgical transplant physicians might be needed as well.”

And some proctologists to remove heads from you-know-where.

Perry
Guest
Perry

It’s a condition called Cerebrus Ani.

MD as HELL
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MD as HELL

Rectocephalic reflux syndrome…sh*t for brains.

Vik Khanna
Guest

Allan, you are right about the WWII birth of workplace medical benefits. But it was really Medicare that codified so much market dysfunction, and gave the FFS the propellant that it needed. And, eventually, Medicare’s policies came to be the de facto policies in the private sector, as health plans followed the government’s lead on coverage and reimbursement whenever they could. Rarely was it the reverse.

Rob
Guest

Agree. This is a very well-written and witty post. Nice.

Vik Khanna
Guest

A great post, with tons of very amusing, interesting, and quotable material. I quibble only with the notion that the third-party intermediary is “recent.” I mark the introduction of Medicare and Medicaid as the start of the modern era of healthcare financing in the US, so there’s not much “recent” about something that 50 years old. I’m 57, and I am pretty sure my kid (10) believes that nothing about me is recent. One place this post comes up short (or maybe it is subsumed in malalignment) is the medical care industry’s deceptive marketing to patients of screenings, overutilization (definitely… Read more »