Friday, October 14, 2016

The Doctor-Patient Relationship: Power Struggles

In my previous post I discussed the need in the modern health care system to re-invigorate the relationship between patient and the health care system.  This seems like a intuitive exercise but when you start examining the process, as is the case in most of health care, the problem becomes much more complex than many in the public may realize.

When we, as patients, go to the Doctor's office we entrust our health and well being to these professionals.  Patients need (and should demand) that the only interest the physician has is the well being of you, the patient.  The goal is to achieve the right care at the right time.  Little do many patients know is that the most recent trend in health care management is to place a little voice inside the physician's head that says "do you really need to do that test?"..."is that referral really necessary?" 

Question:  Do I want my Doctor to make decisions based on their best judgement regardless of the cost or consideration of health care resources?

 It is true, many patients do not want unnecessary services.  We don't want to spend any more time in the health care system than we need to.  The problem with this subversive message being placed inside the physician's head is that increasingly physicians are being asked to consider scarcity of resources when they make medical decisions.  

An Ontario physician, Shawn Whatley, makes several important points, in a recent blog post, as he considered the conflict that exists when physicians try to balance "Relationship vs Stewardship"

"With unlimited money, doctors can pretend to put their patient’s interests first and try to please society at the same time.  But at some point, doctors must choose: Do they do what’s best for the patient in front of them, or do they do what’s best for the community as a whole?"

This conflict becomes even more disconcerting for patients when you consider proposals for how health care is being managed.  In recent negotiations between the Ontario Medical Association (OMA) and the Ontario government the concept of "co-management" becomes a key component of potential cost reductions in the Ontario Medical system.

"co-management" of the physician services budget. which would allow the government and doctors "to work together to jointly identify savings, update fee codes and account for technological change." -  Canadian Press

Call me paranoid but co-management sounds a lot like collusion, as the "true" voice of the patient is not represented in this scenario.  In this scenario, I am sure that the Ontario government and the OMA both claim the moral high ground of representing the interests of patients.  The problem is that both groups have an inherent conflict of interest.  The OMA at it's core has a mandate to represent the interest of Ontario physicians.  Many times what is good for physicians is good for patients but that is not true 100% of the time.  The same goes for government.  The goal of any elected government is to get re-elected.  Are decisions made in government based on political expediency, which can have a negative impact on patients.  Yes.  This begs the question; who is truly representing the interest of the patient.  In reality; no one.  You are on your own.  

I think the question that patients really want to know is how does this affect me?  Dr Brian Goldman is an Emergency Physician in Toronto, who also hosts a radio program on CBC radio.  The title of which I think is very appropriate...White Coat, Black Art.  I have learned to understand that medicine is in many ways a "black art."  Physicians have to use their considerable skill and training but in many instances are reduced to using "intuition" and "gut feel."  With limited resources in health care and the pressure to do more with less I think physicians do an admirable job of putting the patient first but in my role as a hospital administrator I hear all to often where we could have done much more for that patient.  In closing I want to share one anecdotal story that illustrates my point:

Reality Check

When my wife, Susan, was referred to an obstetrician when she was pregnant with my son, Russell, we "lucked" out and were seen by a specialist in complex and high risk pregnancies.  At the time, Susan's pregnancy was normal but she was in her late 30's and so the Dr took some extra precautions with her.  Susan had a heart murmur that had been discovered years earlier.  Simple mitral valve regurgitation (or so we thought.)  A very common cardiac anomaly.  During a routine prenatal checkup our Doc paused for a moment.  It was a "thoughtful" pause.  In his words, he wanted to order a cardiac echo..."just cuz". That sounded like a flippant response.  He was being careful and covering all of his bases.  Could he have rationalized not ordering the echo?  Susan had previously had a cardiac echo, several years earlier, and at the time she had no profound cardiac issues.  An argument could have been made this test was unnecessary and an example of "waste."  It was as a result of that cardiac echo that Susan was diagnosed with cardiomyopathy.  A cardiomyopathy which one of its symptoms is arrhythmia and can cause sudden cardiac death.  This diagnosis also resulted in a referral to pediatric cardiology to perform a fetal echo on our unborn son.  In time, this referral also resulted in a diagnosis of cardiomyopathy in our son.  If it had not been for that "thoughtful moment" from our obstetrician we may never have found out about the congenital heart conditions that both Susan and Russell had.  The result of missing this diagnosis would likely have been catastrophic for one if not both of them.

Getting back to my original question.  Do I want the voice of a cost conscious bureaucrat in my Doctor's head, questioning whether a test is necessary or not?  Absolutely not.  I want my Doctor to be using their best judgement and ordering the tests that are necessary and not having to worry about arbitrary metrics.

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