Monday, March 29, 2010


Here’s a comment by Donald Kaye of Santa Fe, NM, on my March 25 piece, “Gadgets”:

I read a comment by you saying that trust was necessary in a patient/doctor relationship. Have you figured out how to develop that trust in the usual ten minutes that most primary care docs give (sell) to a patient?

I'm sure there are exceptions but the only doctors I have met who aren't in a hurry are on a government or foundation salary. That includes military and VA doctors and all of those who work for Mayo or Cleveland Clinic and some faculty docs at universities.

That tells me something about fee for service.

Donald’s gone to the heart of the matter. Any benefit that might emerge from the examining room depends on the relationship between the patient and practitioner. (I say “practitioner” because more and more, it’s not a physician, but a physician’s assistant or nurse practitioner.) And what kind of relationship can you nurture in ten minutes? Did I say ten minutes? Blimey, the national average is now seven minutes.

There’s more at play here than fee-for-service, though. Thirty years ago I hired on as a salaried doc in the general medical clinic of a prepaid system. It soon became evident, though, that we were working under a quota: even though management denied it, I was to see four patients per hour, period. It struck me as scandalous! How much can one learn about a stranger in fifeen minutes? I gave it a decent try, but had to check out after just a few weeks. The incentive for me to rush patients came from the company, which suffered the same conflict of interest that medical insurance carriers do: the more money it takes in and the less care it dispenses, the greater its profit.

These ridiculously short visits result from greed not on the part of physicians, but the entities that pull their financial strings. The docs I know yearn for more time with each patient, but they seem caught in the Boiling Frog Syndrome. I hope you’re familiar with BFS since it’s widely applicable these days. Put a frog in a pot of water, apply high heat, and the frog will jump out. But apply low heat, and the frog will accommodate to each rising degree until it calmly lets itself boil.

Private insurance carriers, Medicare, and Medicaid have incrementally decreased their payments to doctors for as long as I can remember. For their part, doctors, not generally known for political activism, responded by seeing more patients in shorter visits. Even though they sped up their turnstile, their incomes still plummeted. (When one of my kids considered going to medical school, she pencilled out the possibilities: “...let’s see, medical education costs…hmmm, my student loan… and I’ll earn, hmmm…wait a minute…am I crazy, or what?” In sum, she’s not in medical school.) Today, at last, some docs are beginning to feel the heat and reach for the edge of the pot. When Medicare reimbursements were recently cut a further 21%, my e-mailbox filled with medical howls.

The Mayo Clinic is indeed a healthier model, and thank goodness for that. Valuing patient individuality and a healing environment, people routinely leave there feeling better, no matter what was done medically. The VA and military medical services are just that—services—so profit is not a consideration.

Donald asked whether I’d figured out a way to develop trust between practitioner and patient in ten minutes. Maybe Buddha can, but I can’t. That’s one reason I drone ad nauseam that authentic healthcare reform can’t happen in an exclusively economic discussion. If we’re actually to alter healthcare to make it worthy of its name, we need a decentralized national conversation about its most basic elements.

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