Tuesday, December 15, 2009

Who's in Charge, Anyway??

Physicians no longer feel in charge for many things that occur during their daily clinical work. During our training years we are carefully monitored and have mentors who we can look to for advice, guidance and in some cases, even wisdom...For those in 'private practice' in a solo or small group practice 'autonomy' becomes a real issue, and blending this with the reality of patient care, risk, and medical politics becomes a narrow balance beam for most of us.

Health reform measures are a reflection of a conundrum. Will we be reformed from within, or without??   It is a mess.  Even the informed, educated and well read can make little sense or aggregate the impact of the legislation presently being debated in congress. Driven solely by financial analysis the legislators pretend to develop a 'quality driven, consumer oriented health care policy', a real oxymoron in itself.

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Kenneth Fisher, MD in his blog, Health Care Reform in America, states,

Dr Fisher and I are classmates and graudated from George Washington UniversitySchool of Medicine

"Indeed it takes more training to take care of seriously ill patients than to fly a jet liner. Yet it is inconceivable that a jet pilot when facing a problem, instead of using his experience and judgment, would have the passengers vote on what to do. However, unlike the pilot, in today’s medical practice it is common for physicians to place the task of medical judgment on the patient/family frequently resulting in irrational care. This often leads to patient suffering and the wasting of valuable resources.

This exaggerated sense of patient autonomy along with the fear of legal action has augmented medical consumerism. This problem has been enhanced by drug and device advertisements directly to the public and by the medical profession’s undue reliance on the legal system to decide what are, in effect, medical questions. Instead of our various medical societies forming referral mechanisms to help decide difficult issues, hospitals and doctors have abdicated this responsibility to the courts with the result being an ever-present fear of legal action.

It should be noted that till this day our medical societies have not answered this challenge. Again, in May, 1994 (New England Journal of Medicine) while discussing the Baby K court case, an encephalic baby with no chance of recovery, George J. Annas had a similar message. He commented that for medicine to avoid becoming a consumer commodity and thus unbearably expensive requiring control by payers, physicians will have to set standards and follow them. Again organized medicine did not and has not responded

A few weeks ago (November 2009) a talented second year resident told me that, in his opinion, American medicine is no longer about treating patients’ problems. It has become a hospitality industry focused on customer satisfaction regardless of the appropriateness of the medical plan.

For health care reform to be successful we have to insist that our medical societies set up procedures so that patients are treated as individuals, each with unique needs. At the same time mechanisms must be established so that we uniformly practice high quality medicine with evidence-based use of resources. We must have expanded peer review so that difficult situations and overuse can be quickly resolved using medical experts.

Dr Fisher's Interview on National Public Radio

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