You and Your Doctor Part 2: Solutions

By Mohan Peter

Mohan Peter MD is the Principal at SMS Leadership Coaching specializing in physician coaching and leadership development. He obtained his International Coach Federation Certificate (ICF) from Georgetown University in Washington, D.C. He is an Executive Partner and Leadership Coach at the Mason Business School at the College of William and Mary in Williamsburg, VA. Dr. Peter trained and worked as a cardiac surgeon in United States and abroad including the Cleveland Clinic in Cleveland, OH, the Mayo Clinic in Rochester, MN and Dartmouth Medical School in Hanover, NH. Email: mohanpeter44@yahoo.com.

If you talk with most health care providers today, the ACA (Affordable Care Act) is the all-consuming event in their lives. As we mentioned, this act affects almost everything in the health care arena and we can look at this at the Institutional level, affecting the health care business and at the Individual physician level.

Two eminent physician leaders in the country have chimed in as to how they see this playing out in the years ahead. Writing on LinkedIn, Dr. Toby Cosgrove, CEO of the Cleveland Clinic, and a former colleague, sees the future as follows: He sees a country in which, over the coming years, approximately thirty million people who are currently uninsured, will join the ranks of the insured and increase the demands on physicians and health care facilities to provide added services. At the same time, he anticipates diminishing physician reimbursement per patient as part of ACA. Simultaneously hospitals will not be reimbursed for preventable readmissions thereby putting additional strain on the system. Cosgrove sees hospital systems employing physicians as salaried employees with NO added incentive to physician reimbursement with regard to increased volume of procedures or for ordering increased number of lab tests to help control costs. He sees hospital consolidation as a means for efficiency in implementing electronic medical records, technology and super computers as part of the system.

Cosgrove has walked the walk even as he talks the talk. Under his leadership, the Cleveland Clinic System has evolved into a world class health care center and his views deserve careful consideration.

Dr. Eric Topol has also written extensively about the future of health care. In his book, “The Creative Destruction of Medicine” he sees the future somewhat differently. From his point of view, the future of medicine will be impacted primarily by technology. He sees algorithms replacing some of the work done by doctors today. He cites the example of EyeNETRA in which one’s refraction can be tested over the smart phone with an app that is down loaded and the cost of the whole process just a couple of dollars and a few minutes. Emailing the refraction to the optician can procure the requisite eye glasses, saving time and money. Similarly, smart phone pictures of skin lesions can help dermatologists to identify the lesion without an office visit. There currently are available subcutaneous implantable needle devices that can provide continuous reading of blood sugar, for diabetic patients over a smart phone app on real time basis just as there are similar devices that can provide the readings necessary to control blood thinners.  He sees all these technologies freeing up physicians from having to spend time on these “routine” calls from patients and be able to focus and spend time with patients on more meaningful visits.

Another area that Topol sees change occurring is in the area of individualized medicine, which is quite different from the social medicine that we practice today. With expanding knowledge and understanding of genetics, we are entering an era of individualizing medical treatments, so that they are most efficacious for the given individual. Many of the chemotherapeutic agents and antibiotics are beneficial to only select subsets and identifying those through genetic technology helps to individualize the administration of the drugs to those that benefit most from it. Some of this, and other decision-making can be done by super computers, probably just as or more efficiently than physicians. These machines can handle some of the processing that is done by physicians today. I mean, just look at IBM’s Watson for an example of what can be done!

All these lead Topol to think that a physician shortage is not a given – but moreover, the role of physicians may change from its current form to that of “humanistic compassion” and “communicative judgment”.

Predicting the future is fraught with danger, but I believe that the role of doctors in delivering health care is bound for change. At the individual physician level, some of the potential changes are outlined below.

Doctors now assume the responsibility for making the diagnosis and treating their patients.  When you think about it, this is an awesome burden—to be responsible for another human being. Multiply that by the number of patients that an individual physician cares for, and it is no wonder that they tend to develop sagging shoulders and drooping eyelids.  How can we change this?

What happens if some of these responsibilities are shared?

Many health care institutions are now developing the concept of shared caring, or teams. This helps to share responsibility and the interaction among health care professionals helps to create new ideas. The secret to success in these groups may very well be in the group assigning responsibility to individuals best suited to carry them out. A nurse practitioner, a pharmacist or a fellow physician can all share responsibility in the area where they are most competent. Thus, a pharmacist becomes a valuable resource for the team in finding the best suitable drug for the given patient and situation. This frees up the physician from addressing the issue him or herself, and the shared knowledge provides him or her with the best information, resulting in the patient receiving the best possible care.

Being at the top is lonely. By tradition, if nothing else, physicians have chosen or placed at the top of the health care provider pyramid. Sadly, at this level free and frank exchange of ideas and thoughts occur much too infrequently. True, physicians do call on colleagues for consultation, but this is mostly for expertise in areas such as cardiology, rheumatology, etc. Consultations with colleagues in the same field are, surprisingly, minimal. Very often “my patient” is my patient is the prevailing mode in care giving. Facilitating this free exchange of ideas between physicians in the same specialty is often stymied by pride, ignorance and cultural norms. Behavioral change in this existing culture is an area where change can be most effective in creating a partnership atmosphere for patient care.

Almost from the very beginning of their schooling, physicians are trained to be mistake free, because their mistakes can kill or maim. Such a culture results in the physicians over a period of time developing a defensive attitude against committing mistakes and in many cases refusing to own up to them when they do occur. And the overhanging threat of litigation only compounds this problem.  Changing practice in this regard can be beneficial both for the physicians and those they treat. Acknowledging and accepting mistakes helps minimize their occurrence in future.

What to do?

A recent Medscape Survey linked physician burnout to several factors and suggests some of the following as possible changes that would be helpful.

First, find time for yourself. This has to be a priority to be able to rejuvenate and re-energize oneself. Without that a general malaise sets in and life becomes a drag.  Adjusting your mind set to control feelings and thoughts can have powerful beneficial effect over the lives of individuals. Finding time to engage in activities other than those related to work is important for growth and even effective functioning. And as other demands occur such as parenting or caring for elderly parents, you cannot give the same undivided attention to medicine you did as a young physician. Accepting and acting on this reality is difficult for most physicians.

Most professionals realize, and accept, the need for coaches to enhance themselves. Executives, athletes, and performers all employ coaches to improve their craft. Medicine as a profession is lagging behind in this area. It may be partly because of a culture that is not used to asking for help and doing so is almost admitting loss of control. William Osler, father of medicine, lauded the value of detachment for physicians. He found this quality useful for physicians to get not too attached to the problems of the patients, so that it helps them maintain sufficient detachment for sound judgment. But as we see, the role of the physician is changing and it is moving away from just problem solving to being a partner with your patient in creating an environment where the two together create growth and wellbeing.   In other words, Emotional Intelligence becomes a significant part in the physician-patient relationship. For many doctors this is a paradigm shift. Learning to master these skills may very well determine the success or struggle within the profession. Reinventing modern physician to address the changing needs of today’s patient may very well be the most significant  thing happening in medicine today.

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