Friday, August 19, 2011

On Closure

The chief complaint, the history and physical, the differential diagnosis, the proper testing, the treatment.

From Day 1, these are the pieces of medicine that are hammered in to young doctors' heads: the best way to treat this or that, the best drug, widget or gizmo, the latest advance. We learn which approach is better than the other, which treatment to apply when more conventional approaches can't be taken. Each of these steps are drilled over and over again in the hopes of crafting a strategy for each clinical scenario a doctor is likely to encounter. Yet while each of these steps that are learned are important in their own right, few of these steps are critical to doctors' sustainability in their profession.

Because after the treatment strategy or therapy is applied, there's another vital part of the medical care that is often under-appreciated for doctors and policy makers: the closure.

"Closure" is the time in medicine where we either revel in our success or squirm in our failure. It's where we must face the music - good or bad - with our patients. More often than not, it's the time for doctors that brings meaning to our efforts and the hours we work.

Closure can occur at different times for different doctors. For specialists (increasingly called "proceduralists" these days), closure usually occurs in the post-operative or post-procedure period. For primary care doctors, "closure" occurs during the follow-up visit after a prolonged hosptitalization or difficult illness. For both types of doctors, it's the chance to see the good they did or bad they did first-hand. It a time to validate their understanding of the patient's ailment and the caliber of their treatment plan. Importantly, it's not the end of the patient's ongoing care but rather, it's the conclusion to a particular chapter of their care. For doctors, it's the critical time we grow as professionals.

Yet sadly, these moments of closure are becoming rarer for both the patient and the doctor.

With doctors racing between facilities on productivity compensation plans who must perform more cases in less time and in more locations to offset declining payment rates, it's become harder both logistically and financially to justify excessive post-operative time with patients after their procedures. The money required to feed the our massive system of administrators, collectors, quality score counters, overheads and salaries demands a constant ever-growing source of funds, so doctors must keep moving.

To that end, specialist physicians have seen post-operative care routinely clumped together with the pre-procedure and intra-operative care as one big "encounter" that pays health systems only once. Increasingly to add "value" to health care dollars, policy makers are shifting the "risk" of caring for patients to the providers of that care. Insurers and policy makers like to call this shifting from "procedural-based" payments to "outcome-based" payments. In theory this sounds nice, but it's robbing the doctors of the closure time so critical in the valuation of their profession in favor of treating a greater quantity of healthier, lower-risk patients to assure reliable payments to the system.

For primary care doctors who now only see patients in their offices, the opporunity to see the product of a continuous care strategy has been surrendered to the hospitalist movement robbing them of closure time. And even the hospitalists who "diagnose and say 'adios'" from the confines of the hospital, the opportunity see the late consequences of their care in a non-critical environment has been lost to production quotas as well. No fractious group "medical home" care in the world can replace this loss of closure inflicted upon primary care and shift-working hospitalist physicians or the patients for whom they care.

Our health policy analysts have assured us these "closure" visits can be accomplished by ancillary care providers. Technically, they are correct. But there is no question that the loss of these post-procedure visits by the treating physician or operating surgeon robs them of a critically important opportunity for continuous self-improvement as they reflect on the quality and cailber of their work first-hand. Further, doctors lose an opportuntity after the haze of amnestic medications have subsided to educate and re-connect. Doctors need this time with their patients just like patients like this time with their doctors - maybe even more. It's what makes it worthwhile to get up and do it all again.

Despite the current push, I still try to see my patients after a procedure whenever possible. Sure, we don't get paid for this, but I still relish a patient's gentle smile or a quiet "thank you." More importantly, when things aren't perfect, I need the opportunity to reassure and console. If things really don't go well, I find there are huge benefits derived when I can explain and empathize with the patient's situation.

Still, I feel the tug. "It's not efficient," they tell me.


But it's this closure that sustains me and I suspect sustains many in our profession. And honestly? If doctors' closure time continues to be parsed and devalued further, they'll look for validation of their work elsewhere.

Then what kind of closure will we have?



Keith said...


I am in total agreement. This idea of not folowing your patient through the continum of care during an acute episode of illness is the wrong approach for physician and patient alike. Specialists who give up post op care in the hospital or follow up in the office to some mid level lose out on alot of valuable information and feedback from their patients. Likewise, in primary care, I find the hospitalist/primary care tradeoff to be one of the more dangerous points in a patients care continum, further complicated by medical records packed with superfulous information included more to satisfy the billing parameters rather than facilitaing better communication. It is much more satisfying to see my patients throughout their hospitilization than to try to disect what happened to them in a 15 minute visit.

The idea of proceduralists or hospitalists only fragments care even more, and recent studies indicate that, at least on the hospitalist side, it doesn't save any money; it only pushes it from the hospitals side of the ledger to the outpatient setting. This is probably why hospitals love hospitalist so much!

Our central problem with health care is that we measure efficiency in terms of dollars and cents rather than putting value and quality in the equation. So we get a system that works to maximise revenue, but not better patient outcomes. Only whenthe two are aligned will things change.

Tim Hulsey, MD said...

I'm sure you've heard the complaint that doctors don't see the "whole patient." I believe we really do see the whole patient, because, as Keith said, continuity of care is important. Even if I, as a plastic surgeon, didn't take care of every problem a patient had, I still had to understand its effect on my treatment. I still had to perform a history and physical examination to see if there were unrecognized problems that could put the patient in jeopardy during my treatment. In the ER, I always ausculted the heart lungs, and abdomen and felt the belly, checked pulses, even though the ER physician and general surgeon had already done it. That's just part of being a "doctor." That sets you apart from a technician, which role "proceduralists" are being forced to take.
Medical practice, as someone said recently "is a continuous open-book examination." Closure is when you put all the treatment together and process its lessons.
Of course, the more we and our art are fragmented and part of what we do given to those less well trained, the easier we are to control. Ultimately, we will practice the Panel of Experts' medicine. Perhaps there will be a physician on the panel, but who knows. There are so many "experts" that know so much more than those of us who treat patients daily who will help us see the Bigger Picture."