My last post discussed the wide gulf between healthcare and the rest of the world in the area of customer service. To sum up what took over 1000 words to express: customer service in healthcare totally sucks because the system promotes that suckiness and does nothing to penalize docs who make people wait, ignore what they say, rush through visits, and over-charge for their care. We get what we pay for.
But shouldn’t we judge the system for what it was build for: the quality of the care we give? Sure, the service is overwhelmed with serious suckitude, but that can be forgiven if we give good quality care for people, right?
Even if that was the case, there is no excuse for the lousy service people get from our system. The lack of respect we, as medical “professionals” show to our patients undermines the trust our profession requires. Why should people believe we care about their health when we don’t care about them as people? Why should they respect us when we routinely disrespect them? No, the incredibly poor service we have all come to expect from hospitals and doctors is, and never should be overlooked or forgiven.
Still, I already wrote a post about that. Go back and read it if you missed it. This post isn’t going anywhere. Now I want to cover the actual care we give, and how it too has moved away from the needs of the people it is supposedly for. The people question how much providers care (verb) mainly based on the (lousy) service they get. The care (noun) we give is all about the quality of the product purchased by whoever pays for that (be they third-party or the patients themselves). The real question I am asking here is not if this care is good or bad (the answer to that is, yes, it is good and bad), but whether it is patient-centered.
I was talking with a few friends not long ago. Our conversation somehow got to the issue of authority, and what exactly respect for authority looks like. One of them, trying to make a point, turned to me and asked: “So you surely deal with people who don’t listen to what you have to say. What do you do when your patients don’t take the medications you prescribe?”
I totally wrecked his point, which made me glad because I didn’t agree with it anyhow.
Since I am in the midst of a series of posts on patient-centeredness in healthcare, I need to take a quick (1,200’ish word) detour to an important related question: what happens when the patient doesn’t cooperate? What does patient-centered care look like with non-compliant patients?
If you look up the word “compliance” in a thesaurus, the first synonym (at least in my thesaurus) is “obedience to.” This implies that non-compliant patients are, at least to some degree, equivalent to disobedient patients. This is borne out by the reaction many patients seem to expect of me when they “confess” they haven’t taken prescribed medications: they look guilty — like they are expecting to be scolded. I guess scolding is what they’ve had in the past. Certainly hearing my colleagues complain about “those non-compliant patients,” I am not shocked that they scold their patients. It’s as if the patient is not taking their medication with the express intent of irritating their doctor.
But this is a very doctor-centered view of things, not patient-centered. It assumes the doctor is the one who should be in control, and the patient’s job is to “obey” what they’ve been told. It is a “prescriptive” type of healthcare, telling people what they should do. Doctors, after all, give “orders” for things, and the Rx on our prescriptions translates to “take thou.” We are the captains of the HMS healthcare, aren’t we?
American healthcare has a customer service problem. No, customer service in the US is terrible when it comes to healthcare. No, the customer service in the US healthcare system is horrendous. No, healthcare has the worst customer service of any industry in the US.
There. That seems about right.
What makes me utter such a bold statement? Experience. I regularly hear the following from people when they come to my practice:
“You are the first doctor who has listened to me.”
“This office makes me feel comfortable.”
“I didn’t have to wait!”
“Where’s all the paperwork?”
“Your office staff is so helpful. They really care about my needs.”
“This is the first time I’ve been happy to come to the doctor.”
“It’s amazing to have a doctor who cares about how much things cost.”
2015 was a hard year for my father. He’s a remarkably healthy 89 year-old, with no diabetes, no hypertension, and (most importantly) he’s got a sharper mind than I do on most days. Perhaps that’s a low bar to cross, but it’s pretty good for him. I think this is from all the crossword puzzles he’s done over the years.
Dad’s troubles started around the middle of the year when he started having low back pain. This pain progressed from mild pain to being so severe that he required a wheelchair to get around the house. This is the man who, a year after breaking a hip, was impossible to keep off of a stepladder to fix something on his roof. It was a big change. After trials of conservative treatment, he was eventually diagnosed with a compression fracture of his lumbar spine (presumably from steroids he took for an inflammatory problem).
Given the severity of his pain, he ended up going to a back specialist to get a procedure to fix the compression fractures and, presumably, reduce his pain. Unfortunately, his pain increased and changed after the procedure. It got so bad, in fact, that he ended up being hospitalized in November for pain control.
The hospitalization was confusing for both him and me. It wasn’t clear if his pain was from a problem in his back, as it had moved to his leg. Yet while in the hospital he didn’t get any radiological study to determine the source. Plus, he’s quite resistant to the effects of narcotic pain medications. I really don’t like to intervene on behalf of family members unless it’s absolutely necessary, but I finally ended up talking to the hospitalist who was quite nice, but not much help. Dad was being discharged to rehab the next day and I still wasn’t clear on what was wrong after a week in the hospital.
I’ve heard this from a lot of folks. I’ve heard it from my accountant (of course), other doctors, consultants, and even some of my patients. I’ve had some patients who are especially complex offer to pay me more because of the difficulty of their care. I think they feel guilty and worry I’m upset that they are being “too demanding” for what they are paying. I don’t ever take extra money.
When I recently told an elderly patient’s family that I was willing to do house calls if/when the woman needed it, their question was: “how much extra does it cost?” No extra charge, actually. They were delighted at how “old fashioned” I am. Yep, Dr. Smartphone is certainly old fashioned.
He’s a middle-aged man with diabetes. This kind of thing is a “red flag” on certain patients. He’s one of those patients.
“When does it happen?” I ask.
“Just when I do things. If I rest for a few minutes, I feel better.”
Now the red flag is waving vigorously. It sounds like it could be exertional angina. In a diabetic, the symptoms of ischemia (the heart not getting enough blood) are atypical. It’s the pattern of symptoms that is the most important, and to have exertional shortness of breath which goes away with rest is a pattern I don’t like to hear.
What he needs is a stress test – more specifically in his case, a nuclear stress test (because his baseline EKG is abnormal). But there’s a problem: he has no insurance. A nuclear stress test will cost thousands of dollars.
I can refer him to the hospital, but I know the financial situation he and his wife face. They have no money because of a chronic pain problem he has. He hasn’t worked in several years, but hasn’t ever been able to get disability either (“I tried, but was denied three times”). Without insurance he’s not able to get his problem fixed, so he’s disabled. But he can’t get disability, so he can’t get insurance to get his problem fixed and no longer be disabled.
But the problem on hand is this: he needs a test he can’t afford.
There are many folks out there in this same situation. It may not just be the people with no insurance, and it may not even be people who don’t have money. In fact, my own family is facing this same problem. Multiple family members (myself included) need dental work done. Some need it done badly, yet we don’t yet have the money to pay for it. So we wait for the money to show up while the problems gets worse.
Thanks for contacting me about my most recent blog post. I’m sorry to scare your administration about HIPAA information, but I am equally concerned about that and will always do my best to respect the privacy of my patients. At your request I hid even more of that information.
I know it’s kind of embarrassing to have that kind of thing made public, and I am overall grateful that you did not take it personally that I put the “transition of care” documents for all to see. My goal was not to embarrass or ridicule, it was to point out what our healthcare system is driving us all toward: replacing patient care with documentation. You are being encouraged by the system to produce those ridiculous documents, as they are part of the deal you accepted when you became “ACO General” in the first place.
My 87 year-old father broke his hip this past weekend. He was in Michigan for a party for his 101 year-old sister, and fell as he tried to put away her wheelchair. The good news is that he’s otherwise pretty healthy, so he should do fine.
Still, getting old sucks.
During the whole situation around his injury, surgery, and upcoming recovery, one thing became very clear: technology can really make things much easier:
I communicated with all of my siblings about what was going on and gave my “doctor’s perspective” to them via email.
I updated friends and other family members via Facebook.
I have used social media to communicate cousins about what is going to happen after he’s discharged from the hospital and coordinate our plans.
All in all, tech has really made things much easier.
This reality is in stark contrast to the recent headline I read on Medscape: “Doctors are Talking: EHRs Destroy the Patient Encounter.” The article talks about the use of scribes (a clerical person in the exam room, not a pal of the Pharisee) to compensate for the inefficiencies of the computer in the exam room. Physician reaction is predictable: most see electronic records as an intrusion of “big brother” into the exam room.
To me, the suggestion to use a scribe (increasing overhead by one FTE) to make the system profitable is ample evidence of EMR being anti-efficient.
Despite this, I continue to beat the drum for the use of technology as a positive force for health care improvement. In fact, I think that an increased use of tech is needed to truly make care better. Why do I do so, in face of the mounting frustrations of physicians with computerized records? Am I wrong, or are they?
Neither. The problem with electronic records is not with the tech itself, it is with the purpose of the medical record. Records are not for patient care or communication, they are the goods doctors give to the payors in exchange for money. They are the end-product of patient care, the product we sell. Doctors aren’t paid to give care, they are paid to document it. Electronic records simply make it so doctors can produce more documents in less time, complying with ever-increasingly complex rules for documentation.
I’m back. I’m recovering right now from trauma related to the Affordable Care Act. I’m OK, but probably a few months until fully recovered.
Some would think that since I no longer accept money from insurance companies, the Affordable Care Act would have less of an effect on me. Those folks may be right in how it directly impacts my practice (since I don’t know the actual impact on other doctors, it’s not easy to compare), but there has been a significant impact. I’ve got plenty of ACA stories.
But that’s not what I am going to discuss in this post.
My personal adventures with this law are far more interesting from the other side of the insurance card: the health care consumer (AKA patient). It has been quite a ride — one that has not yet reached its destination.
CHAPTER 1: December 9, 2013
Being the adventurous guy I am, I thought I’d give the Healthcare.gov website a whirl. Expecting the worst, I set aside a lot of time for the experience. It was actually quite a bit easier than advertised. My family is as follows:
Me – Age 51, healthy
Wife – Around my age, but actual age disclosed only for legal reasons.
Child 1: Son, 21 years. College grad but living at home for now.
Child 2: Daughter, 20 years. In college
Child 3: Son, 18 years at time of application. In college. Birthday later in December.
Child 4: Daughter, 14 years.
I submitted the information about whether any of us smoke (no), any of us are pregnant (no), and how much money we earn (not much, as I am starting a new business). I immediately got the following eligibility notice.
The janitor approached my office manager with a very worried expression. “Uh, Brenda…” he said, hesitantly.
“Yes?” she replied, wondering what janitorial emergency was looming in her near future.
“Uh…well…I was cleaning Dr. Lamberts’ office yesterday and I noticed on his computer….” He cleared his throat nervously, “Uh…his computer had something on it.”
“Something on his computer? You mean on top of the computer, or on the screen?” she asked, growing more curious.
“On the screen. It said something about an ‘illegal operation.’ I was worried that he had done something illegal and thought you should know,” he finished rapidly, seeming grateful that this huge weight lifted.
Relieved, Brenda laughed out loud, reassuring him that this “illegal operation” was not the kind of thing that would warrant police intervention.
Unfortunately for me, these “illegal operation” errors weren’t without consequence. It turned out that our system had something wrong at its core, eventually causing our entire computer network to crash, giving us no access to patient records for several days.
The reality of computer errors is that the deeper the error is — the closer it is to the core of the operating system — the wider the consequences when it causes trouble. That’s when the “blue screen of death” or (on a mac) the “beach ball of death” show up on our screens. That’s when the “illegal operation” progresses to a “fatal error.”
The Fatal Error in Health Care
Yeah, this makes me nervous too.
We have such an error in our health care system. It’s absolutely central to nearly all care that is given, at the very heart of the operating system. It’s a problem that increased access to care won’t fix, that repealing the SGR, or forestalling ICD-10 won’t help.
It’s a problem with something that is starts at the very beginning of health care itself.