Health-Reform Anxiety: One Doctor's Perspective

Anne Brewster, an internist and instructor in medicine at Harvard Medical School, used to work in primary care, but left the field because she says she "felt unable to care for patients the way I wanted to within the constraints of the current system." Now an an urgent-care provider in Boston, Dr. Brewster has been worrying about whether health reform will really empower doctors, or if new laws will further erode physicians' ability to care for patients:

Last week, I met with a recent college graduate at her request to discuss her interest in becoming a physician. She wanted to get the inside scoop from a practicing doctor before deciding to apply to medical school. She was enthusiastic, energetic, and idealistic, as I once was. I worked hard to recommend the profession-the concrete skills, the human relationships, the privilege of intimacy, the value of helping people-but I was tempted to scream “DON'T DO IT!”

The truth is, I am demoralized. Many physicians are. In the current climate, it is difficult to practice the “art” of medicine. We exist in a world of 15 minute appointments, insurance company regulations, endless paperwork, and the constant threat of lawsuits. As a nation, we spend more money, yet have worse health outcomes, than most of the developed world. The current system doesn’t work for patients or doctors. We need change desperately.

Clearly, we need to rein in health care spending and improve health outcomes. As it stands, however, many reform proposals focused on these goals leave physicians feeling even more squeezed in an already constraining system. It doesn’t have to be this way. Instead, health care reform efforts must work to align the goals of cost-containment, patient safety, quality of care, patient and physician satisfaction.

Reform should make my job more, not less, satisfying. Of course, doctors should be expected to offer the highest quality care in the most cost-effective manner, but policies must be built on a foundation of trust in physician motivation and competency. Most physicians have a sound knowledge base, and are driven by a genuine desire to take care of people and “do no harm.” Professional autonomy must be protected. Instead of imposing mandates and restrictions from above like an authoritarian parent, policy makers should work to provide physicians with the tools to meet these expectations.

Let’s take the Electronic Medical Record (EMR) as an example. This is fundamentally an excellent idea, allowing for increased access to health information for both physicians and doctors, decreased medical errors, and potentially increased efficiency and cost-savings. E-prescribing should benefit everyone. When I order a new medication electronically, the computer scans the patient record and alerts me to any allergies or drug interactions. This clearly increases patient safety, saves time, and allows me to take better care of my patients.

But documenting electronically often takes more time than writing in a paper chart.

Patient portals that allow for email communication with one’s doctor, while clearly beneficial to patients, can often feel burdensome to doctors-just one more thing to check in an already unbearably busy schedule, and extra time for which we are not compensated. This is a shame. Communication with patients is a privilege, and essential to quality care. Allowing for electronic communication is a positive change, but we must protect and compensate for this time to make room for this improvement.

Furthermore, the EMR can challenge physician autonomy. In my hospital, I am required to order radiology studies electronically. I am prompted to select from a limited list of complaints and diagnoses, and the computer tells me whether or not the study is indicated based on this information. I actually get a score. If I want to continue despite the machines recommendations to the contrary, I have to justifying my decision. I don’t like answering to a computer. Patients cannot always fit into predetermined protocols. While the goal of eliminating unnecessary studies, and therefore saving money and decreasing patient risk, is one we would all agree with, physicians lose time and professional independence within this system.

The EMR should be a useful tool rather than a frustration. Perhaps, when ordering a radiology study, physicians could be directed to an optional link to the accepted indications or suggested alternatives. If I was uncertain, I would be thankful for this information. Even better, my workplace would offer regular seminars to review the most up-to-date standards of care, as a part of my already scheduled hours and as a work-place perk, instead of as an additional requirement. Thinking more broadly, providing more time for patient-doctor interactions and implementing medical malpractice reform would undoubtedly decrease unnecessary radiology studies, as many are ordered as a substitute for time or for “defensive” reasons. Instead of more restrictions, we need improved workplace conditions.

These same principles apply to other reform measures. Physicians may agree with the end goal, but many of us worry about the methods and unintended consequences. Comparative Effectiveness Research (CER) sounds sensible. Of course we need more studies to define best practices. But I find myself afraid that the results will be used by policy makers, hospital administrators, and lawyers to further limit my autonomy by setting hard and fast rules about what is “right”. Clinical situations are always nuanced, never black and white. Perhaps it is semantic, but I want to feel that CER will empower rather than constrain me.

Similarly, some payment reform proposals make doctors anxious. It is not that we are wedded to Fee-For-Service. Most doctors agree with the need for payment reform and support proposals that value quality over quantity, and, for most of us, our primary motivation is not money. But Pay-For-Performance models make me wonder if I will be held accountable for measures ultimately out of my control and perhaps clinically irrelevant. Global payment models, as in Massachusetts, leave me feeling panicked by the thought of even more restrictions in the context of pre-existing time constraints and the threat of litigation. We cannot talk about payment caps without simultaneously addressing these challenges to patient care. Change must be multi-faceted.

Society needs change, but we also need doctors. Physician satisfaction must be an explicitly stated goal as reform measures are constructed and put forth. In the final analysis, what we want as doctors-to be able to take good care of our patients in a professional culture of trust and autonomy-is not at odds with the larger goals of our country. We are on the same team. I want to love my job, to encourage young people to choose medicine as a career, to shout “YES, DO IT!”.