I am writing in response to your request for health care related stories.  I am sure you will get many stories from patients and their bad experiences.  I am here to give you the perspective of a physician.  I hope you are able to objectively hear my concerns, and further, that you can utilize my experience to the greater good.  I do not write this with a political agenda, but as a South Dakota kid who really thought becoming a physician was about being a patient advocate.  Here is my story:

Nothing could have prepared me to become a physician better than growing up in South Dakota.  It was here I learned old-fashioned values about treating others with kindness, working hard and always doing my best.  It was with happiness and pride that I received a diploma from USD School of Medicine. After nearly 10 years taking care of patients, I continue with each patient interaction to advocate for patients to the best of my abilities.

From my experience in hospital medicine, I believe there is a prevailing principle on the side of a health care provider that is little understood by the public at large.  The principle is that patient autonomy drives patient care.  In other words, what a patient wants, they get. 

For physicians, this means relying on costly tests rather than on our basic history and physical exam skills.  Often, I will tell a patient there is nothing wrong and they insist upon a CT scan or lab tests.  Because they have information available on the Internet, they will demand admission to the hospital to solve a mystery when they really do have something treatable and obvious.  Physicians do not tell patients what they really think (i.e. that a patient has severe anxiety) for fear of complaints or law suits.  This has all contributed to the demise of our clinical skills and has only enhanced our reluctance to trust our own judgment.  In the end, costs escalate.

Patient autonomy also contributes to costly care in other ways.  In my experience, the most costly hospitalizations occur in the ICU when family members wish to pursue heroic measures to save a life when such measures are futile.  An example is an elderly nursing home patient with end-stage heart failure and lung disease whose family wants to keep the patient alive at all costs.  Sometimes, this even goes against the patient’s wishes.  Physicians and staff are left to deal with complex family issues while an unresponsive patient goes on for days, weeks or even months only to die in an ICU without the comfort of loved ones.  There is no peace.  There is no closure. And the family is left to experience the grief which comes when they realize how much their loved one has suffered in the face of medical futility. 

It is in these moments that I realize we have treated the family (who is the voice of the incapacitated patient) more than we ever treated the patient.   In these cases, the autonomy we so desire to preserve was put in a place of such importance that what we do for a particular patient no longer makes sense. 

Because we are scared to tell the family what we REALLY think, we keep going, afraid that the end result will be accusations of sub-standard care and eventually a law suit.  Again the result is more costly, less sensible care.  Most of all, there is pain and suffering beyond what anyone should have to endure.  And after many discussions with many patients regarding end-of –life care, the physical cost to heroically preserve a life in these instances is not worth the number of days it provides.  Most, in the end, would choose to be surrounded by friends and family in a peaceful setting away from the chaos of a hospital.      

On the other hand, patient autonomy is what allows our system to do lung transplants, kidney transplants and treat metastatic cancers successfully.  It also allows us to place importance on treating those who cannot advocate for themselves including those with mental health issues or physical disability.  In many countries, patients would be left to die from illnesses deemed too expensive to treat.  This is not the case in the United States, even if one does not have health care.  At my own facility, a patient from another country was aggressively treated for their illness with no means to pay.  This patient received excellent care even at great cost to our institution.  This would never have happened elsewhere.   

Physicians must increasingly function as a medium to get access to tests not as clinicians who use their judgment and determine that the test is needed. Do not misunderstand.  Patients have every right to be their own advocate.  However, there must be a balance between the clinical skill of the physician uses to determine the course of care and what the patient wants.  What we are never publicly allowed to discuss is how we many times we feel painted into a corner because our patients or worse, their families, do not trust our decisions

In addition, physicians have been increasingly marginalized by media and politicians because of a perceived monetary status.  Patients have the perception that we all play golf and make “the big bucks.”  Of course, because of patient confidentiality we have no recourse.  We cannot tell them that we are up nights, weekends and holidays with their loved ones trying to function in a hostile system and be their advocates.  We cannot tell them that we suffer verbal abuses and threats of physical harm at the hands of families and patients which go undocumented in the charts because we are afraid the family will read it and cause more trouble.  We cannot tell them that we are $150,000 in debt.  We cannot explain to them that we work 60 to 80 hours per week and wish we could make half as much so that we didn’t have to spend so much time away from our families.  We cannot tell them that our children think it is normal for their parents to leave them in a daycare or with another care provider for the same number of hours that we work and that they lovingly understand why mommy and daddy have to leave to “take care of the sick people.”  They have no sympathy and we don’t expect that they should.  We only expect that when we interact with them, that they show us the care and respect that we show them. 

Please know that in spite of the challenges, I am glad to be a physician.  I love my job and would not want to do anything else.  Nine times out of 10, I have wonderful, meaningful interactions with patients and their families.  I am constantly trying to make a difference.  What bothers me though is seeing the academics pontificate about how health care needs to be universal etc.  While I appreciate the contribution researchers make to furthering patient care, I can certainly tell you that those of us in private practice have a much different view as we see many more patients than any paper-writing academic sees in one year.  You would do well to speak with us as I suspect your perspective might change.  In other words, I cannot write about how to change health care, because I am too busy seeing patients.

My suggestions for change include the following

1.    Proactively help rebuild the physician/patient relationship to control costs.  When the patient and his/her physician are a team everything is better. 
2.    Allow physicians to bill for palliative care conferences and interventions in an effort to educate patients and families about the burdens of heroic care.
3.    Hold patients accountable when their autonomy supersedes the advice of their physician who may be telling them to lose weight, stop smoking or to take medications.
4.    Address issues such as morbid obesity, which continues to stress the system by producing more patients requiring chronic ventilator support, joint replacements, heart surgeries and physical disability.  I am sorry to say that patients need to understand that if they want the government to help them, they must play a part in controlling costs by making some sort of attempt to be healthy.
5.    Analyze your most expensive hospitalizations (e.g. those over $1,000,000) and see what it is you are spending our money on.  I would submit in this case that the issues of patient autonomy/fear of lawsuits contribute to on-going care when it won’t actually make a difference.
6.    Institute medical litigation reform.  I am sure you hear this from many physicians, but I hope I have painted a much different picture than you have heard before.  The threat of law suit and the possibility of losing everything we have worked for is a physician’s worst nightmare.  Most of us are good, kind-hearted individuals who are honestly trying to do our best.  The interplay between public perception of our financial solvency and our financial reality are very far apart.  Unfortunately, unless you take a stand for us, we will be unable to fight it. 
7.    Reward efficiency.  Reward efficient health care systems and use them as an example of good care (e.g. Any Sioux Falls hospital)
8.    Set standards.  In other words, set goals which patients receiving public assistance must achieve in order to continue receiving help from the system.
9.    Understand that when you go after Medicare fraud, you are actually looking into physician and hospital billing practices which are so complex that entire armies of people need to be hired to maintain it.  Additionally, the ever changing rules are so numerous that one cannot possibly know them all.  Please realize that if you really knew the amount of work involved in a level of care, you would likely see you are getting a deal.  As an example, I do not get to charge for a 2 hour family meeting about a comatose patient unless I am in the same room with that patient.  Many times this is physically impossible and I do not get a lick of credit for it.  But, I am willing to do it because it is what is best for my patient.
10.   Realize that many stories of patients being wronged by the system are not quite as horrific as you would like to believe.  This isn’t to mean that it cannot happen.  It is just to say that when listening to a story, it is important to realize that there are many factors which determine the outcome and physicians are NEVER allowed to tell our side of the story. 
 
In the end, I don’t believe the system is quite as broken as people would like to believe it is.  I believe there is already enough health care to go around but that it is ineffectively used because physicians are afraid to rely on their clinical abilities.  Also, I believe inappropriate care at the end of life which does not prolong it meaningfully, contributes greatly to the overall cost.  If we can restore the balance of trust between a patient and their physician, costs will go down because the care will be driven by the physician/patient team and not some perceived course the physician believes the patient wants. 

As I learned from an attending in medical school, “the patient will tell you exactly what is wrong, if only you’ll listen.”

Sioux Falls Physician

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