Shirah Vollmer MD

The Musings of Dr. Vollmer

Changing Face of Medical Care

Posted by Dr. Vollmer on June 12, 2013

 

There is change mentioned at every lecture I attend, every lunch time discussion, every committee meeting. I hear these discussions in primary care and in psychiatry, but I think it is likely that every corner of health care is struck by the feeling that we have reached a pivot point. Today’s angle was delivered from an esteemed Duke primary care physician, director of the Family Medicine Residency, and a former student. Family Medicine, he says, will no longer focus on why patient A does not take his blood pressure medication, but the physician will look at a bigger picture of how can he/she implement a system which facilitates compliance. We changed the name from compliance to adherence and back to compliance, but that is another story. This system is going to involve using technology, nursing and administrative staffs, wellness groups and community outreach. It sounds like Kaiser to me. In fact, it is the Kaiser model. Have lesser trained folks work on the patient interface, while the physician does what he is trained to do; decide what the problem is and how to treat it. After that, the can gets kicked down the road, and the health care team deals with the details of implementation. Theoretically, this makes a lot of sense. Practically, Kaiser, as the model, does a good job, mostly. My issue, as my readers have heard before, is that the reward system for the physician has changed drastically. It used to be that the implementation of the details, understanding why patient A does not want to take his medication, his resistance, if you will, to making his life better, was where the deep relationship developed, and hence the career satisfaction. Now, unless a physician “goes concierge,’ as my colleagues like to say, that connection is lost, leading to a more technical job of diagnosis and treatment recommendations. More technical means that patients, on average, will get good care, but the physician will only be using his left brain. The integration of the right brain, the understanding of how human emotion interfaces with disease management, will no longer be in the physician’s scope. As a policy maker, this makes sense. As a physician, well, the world is changing.

4 Responses to “Changing Face of Medical Care”

  1. Shelly said

    I’m happy to hear that this forum is interfacing with psychiatrists in trying to understand what motivates the patients to do (or not do) what they do, comply or not adhere to wellness plans. In some cases, what sounds so easy to physicians is not easy to patients. I’ve had physicians say to me, “We’re all busy. You think you’re busier than me? Even I have time to exercise, why shouldn’t you?” This physician doesn’t know the circumstances of my life and instead of trying to lecture me, had he tried to understand more, I would have taken what he had said more seriously. When physicians give prescriptions for medications, they should always check if the patient can afford them! I know people who simply don’t fill the prescription because they can’t afford the price to fill them! Yes, patients have many reasons for non-compliance, but it is the physicians’ job to know why not.

    • One could argue that someone should explore the reasons for non-compliance, but it does not have to be the physician. To this, I would say, that many folks get better because they value the doctor patient relationship and without this relationship there is less motivation to care for oneself. As your tale suggests, a doctor that responds in a critical way does not inspire the patient to take better care of himself. This art of persuasion was where I saw myself fit into medical training. Now that there is less of a need to train doctors how to talk to patients so that patients feel empowered to help themselves, there is less of a need for my teaching program. One might say that I could teach the associated personnel about how to help patients, but they are not developing the personal relationship and so again, my teaching about working with people, in order to help them, help themselves, is not as valuable.

  2. Jon said

    It all boils down to a matter of priorities. What is trying to be improved – efficiency, cost, care of each person, the best care that money can buy (and for whom), satisfaction of the participants? The answer will very as each criterion is considered, and in a nonlinear way. The choices and outcomes will be in flux. This Brave New World is becoming ever more complicated and intricate.

    • Hi Jon, I am not sure that this Brave New World is more complicated and intricate. I think, as you say, it will be more efficient, which sadly, means less personal. The point of this post is to say that the loss of personalized medicine is perhaps a bigger loss for the physician than the patient. Thanks.

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