Who Works for Who in Healthcare?
I have a lot of respect for the military and those who serve. Among more obvious reasons, I appreciate that the hierarchical organization is well-defined, and it's well understood where its members stand. For instance, a soldier knows his rank. It's there right on the uniform. Orders are taken from those above and given to those below. More importantly, it's clear that he works for the United States government, which serves the American citizen. I guess most people, whether it be in the government or the private sector, know well who they work for. That is, except for my occupation: the medical field. Medical professionals and patients alike have lost this important sense of who is working for who.
Example 1: A Lack of Bed Side Manner
A patient was in to see me about her knee pain this past week. She has a torn meniscus and requires surgery to fix the problem. As such, she went to see an orthopedic surgeon. At the consultation, the surgeon was rushed, didn't make eye contact, and didn't fully answer her questions. She left the appointment disenchanted and has been hobbling around on the bum knee now for a couple months.
When I asked about the knee, she relayed the story and lamented that she is not sure that she trusts this doctor to handle her knee with a high level of caring. I asked her what she wanted in a surgeon, and she told me, in detail, what most of us would require in her situation. After all, she's dealing with something so intimate and impacting, a surgery on the leg - her prime source of mobility. Reflexively, I told her that I would find a surgeon who combined a high degree of compassion and technical excellence. She looked at me bewildered. "You can do that?" she asked. She even expressed concern that the surgeon would be offended that she chose someone else.
Example 2: Jumping to Conclusions
A large portion of my patients are insured by a certain health maintenance organization (HMO). The HMO reviewed data regarding the incidence of chlamydia among women in their late teens and early twenties. They made the decision that all of their female members in this age group should be screened for chlamydia. Financial incentives were given for compliance.
On the surface, it's not a bad idea considering that chlamydia infection can be silent and lead to infertility or abdominal infection if left untreated. The rub here is that there is really only one way to get chlamydia: sex. As I took this "forest view" and began to sort out the individual trees, I had many conversations with young women regarding their sexual behaviors. Some were adamant that they had never been sexually active. Should the test be ordered anyway, giving the message, "I don't trust you." Or, should the HMO be snubbed for these particular cases?
The Problem in Healthcare
In the medical field, we have lost that important hierarchy of who works for who. I guess if I have to cast blame, it would be on the presence of health insurance. We have developed a system where doctor sees patient, patient receives treatment, and doctor is compensated by a third party. To make things even muddier, the insurance company is most often paid their premium not by the patient, but by the patient's employer. This dilutes value and lacks oversight. Patients care little how much their insurance company is charged, while the insurance companies play the financial game of paying out as little as possible, as they work to hold control over healthcare providers.
It makes me long for the day where doctor saw patient and patient paid doctor. In this system, there was never any question about who worked for who and who was being served. If patients controlled market forces, demands for better and more judicious care would follow at light speed. I will admit, however, that the lack of "cost anxiety" creates a more comfortable experience and things are kept to a different standard than, for instance, visiting the mechanic or getting the furnace repaired.
Where Do We Go from Here?
A warped sense of hierarchy has evolved in healthcare. Health insurance is a powerful industry that is not going away anytime soon. The emergence and growth of health savings accounts (HSA's) is a push in the right direction. Politicians are pulling and tugging at the notion of a single-payer (government) system which may or may not improve things in these particular regards.
We in the field would do better to constantly remember that our paychecks ultimately come from the patients whom we serve. Sometimes, these same patients need an empowering reminder too. "I work for you" with a genuine smile is often all it takes to return my patients to their honored place as the rightful boss of their own healthcare. And to you, dear reader, never forget that those who provide your healthcare are in fact working for you.