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Medicine’s Great Resignation – Can History Show Us a Better Way Forward? (Part 2)

In the 2nd of a multi-part series, Demetrio J. Aguila III MD examines the doctor-patient relationship, oaths, how we ended up where we are, and how history can help us find a better path.

In my first article, which you can read here, I asked questions about burnout, shift-work, small-town medicine, and other concerns, laying the groundwork for an exploration of history to help us find solutions to these questions. 

 

Now, let’s delve into the philosophical underpinnings that led to many of these questions in the first place, as we search for the ever-elusive “perfect solution.”

Medicine today is caught between two divergent philosophies – let’s examine these philosophies a little more closely.

On the one hand, many medical practices and hospitals today see the practice of medicine as an exchange of goods and services, not that different from getting an oil change or going out to dinner.  

  1. The customer (patient) shows up with a particular need.
  2. The need is identified and met by the service provider (physician.)  
  3. The service provider then offers options for meeting the need.  
  4. The customer chooses the option that is most appealing.
  5. A bill is presented.
  6. The bill is paid.

The details vary, but the general outline is typical and reproducible.  The goal of the medical practice in this scenario, then, is to decrease the cost involved in identifying and meeting the need of the customer, while increasing the revenue, either by widening the profit margin, or by increasing the volume of customers seen – again, not that different than an auto mechanic shop or a restaurant.  The goal of the customer (patient) is to get the best product at the lowest price – a value proposition that we can all understand.  

 

In this approach, how do we address the needs of the patient/customer (reduce cost / increase quality = augment value) as well as the needs of the physician (increase profit margin / reduce risk / improve outcomes) in this scenario? 

Aren’t these mutually exclusive priorities? 

As a result, a dichotomy of philosophy has developed over the last few decades to solve the dilemma – centralized (so-called socialized) medicine vs decentralized (so-called fee-for-service) medicine. 

While it may seem that the binary perspective is simple to understand, we will see that there is subtlety that results in more questions.

 

It has been suggested that a centralized approach that employs LEAN principles, in which the organization’s most specialized person in the process (the physician) spends all of his time doing what only the physician can do, and then the organization hires other personnel to do the rest, so as to maximize productivity, would meet these goals. 

The physician becomes the bottleneck, the rate-limiting-step in the process, delegating all non-physician tasks to non-physicians. 

On the surface, this seems to be a reasonable solution, especially as the volume of non-physician tasks has increased over the years.

 

The physician becomes the bottleneck, the rate-limiting-step in the process, delegating all non-physician tasks to non-physicians. Click To Tweet

 

Theoretically, if a practice hired enough ancillary staff to take care of all the non-physician tasks, the physician would do nothing except see and treat patients.  Carried to its logical conclusion, all the documentation would be done by a documentation specialist who listens to and sees everything that the physician does and documents that accordingly, without the need for the physician to dictate, transcribe, type, or even acknowledge that any of it is being done. 

The physician would be solely responsible for the end product, much as the chef at a restaurant is simply responsible for providing a good meal, but relegates the tracking of supplies and costs to someone else. 

In effect, the physician becomes a highly-specialized, highly-efficient widget-maker, whose sole task is to produce the widgets that he is hired to produce. 

With enough ancillary personnel, theoretically, this would be possible.  

 

In effect, the physician becomes a highly-specialized, highly-efficient widget-maker, whose sole task is to produce the widgets that he is hired to produce. Click To Tweet

 

We see this scenario play out every day. 

In the private sector, group practices are set up with the physician as the chief widget-maker, and everyone else hired to keep that physician busy with physician-only stuff. 

In order to pay for the personnel to keep that physician busy, the physician must “do more.” 

More volume means more gross revenue, and more gross revenue means more money to pay the people who are keeping the physician busy, as well as more money to pay the physician for the work. 

In this scenario, the physician is not only the chief widget-maker – he is the ONLY money-maker.  

 

More volume means more gross revenue, and more gross revenue means more money to pay the people who are keeping the physician busy, as well as more money to pay the physician for the work. Click To Tweet

 

There are numerous pitfalls in this approach. 

One of the dangers is that it can become a profit-driven machine, in which the physician is driven as hard as possible to generate the revenue needed to keep the machine running. 

Volume can be driven simply for the sake of revenue, independent of whether or not the patients need to be seen or need to undergo a particular treatment.  Overtreatment is an inherent danger in this scenario. 

This model rewards those who are willing to provide care, regardless of whether or not it is warranted.  The more care that the physician provides, the more that the physician is rewarded.  This model would constitute one of the two divergent philosophies mentioned earlier.

 

In the second philosophy, many have objected to the profit-driven incentives, and have advocated a centralized model that does not depend on physician volume to support the practice. 

If the physician gets paid the same amount of money, regardless of volume, and the personnel get paid the same amount of money, regardless of volume, then there is less temptation to drive up volume simply to drive up revenue, thus avoiding overtreatment. 

We see this model in use within the Veterans Affairs medical system. 

Physician pay is not tied to volume, and non-physicians are hired to take care of non-physician tasks.  In this model, the physician is incentivized to show up for work, as are the rest of the team. 

The team gets paid the same amount, whether they treat 1 patient that day or 41 patients that day. 

Overtreatment is disincentivized, and physicians pursue courses of treatment that are independent of the patient’s ability to pay.

 

This approach, however, is not without its own shortcomings. 

An inherent danger in this model is that while it doesn’t incentivize productivity and volume for its own sake, independent of whether or not it is medically necessary, it also fails to incentivize high quality care, and also fails to incentivize supplying enough care to meet the existing demand. 

Since the incentive to see a large number of patients is the same as the incentive to see a small number of patients, there is a temptation to “take it easy” and provide a supply of care that is not connected to how much demand may exist for that care. 

 

If the physician gets paid the same amount of money, regardless of volume, and the personnel get paid the same amount of money, regardless of volume, then there is less temptation to drive up volume simply to drive up revenue, thus avoiding over-treatment. 

 

As a matter of fact, there is a tendency to introduce additional administrative barriers to limit access in order to mitigate the perceived demand for the end-user / physician.  If enough hoops are introduced to finally reach the physician, then the physician doesn’t see the need to treat a large number of patients because those who “qualify” or meet the criteria for an appointment are a much smaller number than those who are actually seeking care. 

This model rewards those who can develop mechanisms to stand in the way of care being provided, even though the resources might be available to provide the care. 

“If I get paid the same to do the same amount of work, then why should I work harder,” or put another way, “if working harder means that everyone else will push more work onto me so that they have to do less, then why should I continue to work hard?”

 

Both of these approaches illustrate a systems-based shortcoming that neither has attempted to address. 

They fail to recognize that the healthcare delivery “system” isn’t broken – it’s actually perfectly designed to achieve the results that it achieves.  The problem lies in the fact that the incentives are not properly aligned with the stated objectives.  In both models, the incentives are intended to achieve one outcome, while instead resulting in a different one.

In our next segment, we’ll examine what assumptions led to these two imperfect solutions, and how addressing those assumptions may suggest a “third path” worth consideration – a path rooted in the long-lost history of medicine.

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