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Monday, July 21, 2014

"There is no more wasteful entity in medicine than a rushed doctor."

From the New York Times:
Busy Doctors, Wasteful Spending

OF all the ways to limit health care costs, perhaps none is as popular as cutting payments to doctors. In recent years payment cuts have resulted in a sharp downturn in revenue for many hospitals and private practices. What this has meant for most physicians is that in order to maintain their income, they’ve had to see more patients. When you reduce the volume of air per breath, the only way to maintain ventilation is to breathe faster...
Indeed. "Productivity treadmill" and all that. He cites the Mayo and Cleveland Clinic models, in which physicians are ostensibly insulated from the Suits and all their MBA Worry Beads.

Read all of it. What do you think?

apropos, from Health Affairs (subscription firewalled):
‘Nothing Is Broken’: For An Injured Doctor, Quality-Focused Care Misses The Mark
Charlotte Yeh

It was just after 6 o’clock in the evening on Wednesday, December 7, 2011—Pearl Harbor Day—when I left my organization’s Washington, D.C., office to meet a colleague for dinner. It was dark and rainy, and I had one more intersection to cross to get to the restaurant. I was about a third of the way across the intersection when I heard a loud “thump” and felt a sharp pain squarely in my backside. A dialogue unfolded in my head: “Wow! I wonder what that was…. I think it was me. No, I don’t think it was me. Wait…I think I just got hit by a car! But there’s no way!” Before I could even make sense of the situation, I had flown through the air and landed on the street...

As a medical professional who became an accident victim and then a trauma patient, I was a participant-observer in emergency care, with a big-picture window into how well our health care system does or doesn’t work...

In my case, I was struck by the uneven nature of my care, marked by an overreliance on testing and a narrow focus on limited quality metrics such as pain management or catheter care processes. Looking back, I believe that this approach fostered an inattention to my overall well-being. Instead of feeling like a connected patient at the center of care, I felt processed and disengaged. This is disconcerting, especially at a time when patient-centered care—that is, care delivered with me, not to me or for me—is becoming the new normal.

The Oath of Hippocrates, the medical profession’s ethical creed, reads: “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” This vow compels physicians to heed both the “science” and the “art” of medicine. The science often lies in defining the treatment regimens. The art lies in understanding what matters personally to the patient.

Even in an ideal world, this would be a high bar to clear. Despite some national consensus on quality metrics, we have continued struggling to measure “the good of the patient.” Still, quality metrics cannot alone advance the good of the patient. Focusing on clinical measures in particular is not enough as long as other measures that focus on patient-desired outcomes are ignored. If we don’t understand what patients’ expectations are, we can’t engage patients effectively in their care.

Through my experience as a patient, I observed a bias in what the metrics track: toward the clinical and away from the personal. To help restore this balance and reassert the “art” of care, I see three areas that the medical community should address...

The unintended consequence of our current approach is that the clinical measure can become more important than the patient. I am afraid that as a result, we may be training a new generation of practitioners to equate high-quality care with conducting a test. Instead of having the test be used to discover new information about the patient, it is being used to define if one even is a patient.

Personalizing care
After I’d spent four days in the hospital, it dawned on me that not once had anybody come by to ask how I was doing, what I needed, what I wanted, or whether I had any concerns. I then understood something that my own patients had been telling me all the time: They don’t feel engaged in their own care. There is nothing personal about it...

Patient-reported outcomes currently in development, such as asking for the patient perspective (“what do you want,” “what are your fears,” “what matters to you”) and equalizing the patient-provider dialogue, create shared partnership in the outcomes and might have made a difference in my care. Going forward, quality metrics should give more weight to patient-reported outcomes, if we want to truly assess care more effectively. As my experience suggests, we’re not quite there yet.

The 'North Star' of Care
If I resolved anything on my care journey, it is that the “North Star” guiding all care must be providers using “any means possible,” to know the patient, hear the patient, and respond to what matters to the patient. It should make no difference where you practice; any provider can do this. Emergency departments can’t hide behind the excuses of “we’re too busy” or “it’s too chaotic” to avoid connecting with every patient.

It is time to frame a new paradigm of care, a consumer-driven approach that concentrates attention on the art of medicine. This might begin with a reinvigorated focus on patient-centered care and mastering the skills of listening, empathy, and patient partnership...
Yes, but the "productivity treadmill" could not be more antithetical  to "listening, empathy, and patient partnership."

Dr, Yeh's article is a lengthy and thoughtful piece, poignantly so. I have cited only some small excerpts. Highly recommended.

I groused a bit about our obsession with "quality metrics" back in April.

Process measures like Meaningful Use, CQMs, PQRS, etc, as I've noted before, are tangential proxies for effectiveness in health care. It's assumed that if you are doing and reporting on X, Y, Z, A, B, C, D, E, and F, improved outcomes will eventually follow.

How about if we lay on a concerted effort to measure actual outcomes directly?
Yeah, like maybe to include actually listening to the patient at greater length and depth?

More to come...

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