Sunday, July 29, 2012

The Penn State Mentality of Tomorrow's Doctors

There is a moment in everyone’s life, for oneself or a loved one, when one receives the “Diagnosis.”  In that moment, eyes meet across the desk and the shell-shocked individual looks up and asks, “Doctor, what should I do?”  In that instant, the patient is putting all of their trust in another human being who is trying nothing less than to save a life.

A good doctor has always been a person who has the ability to think autonomously and critically while holding themselves responsible for the accuracy of their decisions.  They develop their own inner authority and autonomous thinking through years of being scrutinized and challenged through training and exposure to an infinite variety of clinical scenarios – many of which remain unique (despite what the Internet would have us believe).   It is this collection of attributes that a patient relies on during that very critical human-to-human moment.

But in the world of unintended consequences of health care reform, we are systematically dismantling this kind of doctor.  We are systematically diffusing responsibility across care providers, undermining treatment authority, dismantling critical thinking and derailing physicians’ moral authority.

Enter the era of Dr. McQueary.

At water-cooler talks and cocktails across the land in the wake of the announced sanctions against Penn State, people are still asking how a young coach Mike McQueary, brought up in a corporate, big-money team-think approach of college football, could bear to witness the violation of a 10-year old boy in a shower by his colleague and not rush to the child’s aid.  Instead, at that moment he chose to walk away to ask his father and the head coach what he should do.  You see, there is no "I" in "team."

Who is such a person?

How did he become that way?

Would a patient in the throes of life-altering decisions want a doctor with such team-think mentality as their doctor?

This is the precisely the  right question to ask if we have the patience to do so. Is the creation of doctors like this our intention? Must we believe the narrative of necessity and progress that leads us to accept such a loss?  It is a familiar individual vs. collective, relationship vs. system debate.  Yet this time the debate is in an arena that has only the stakes of our mortality.   Is this worth thinking about?

Dare we ask what we are creating as we move to make doctors shift-workers, business minded. algorithm-driven, group-think, productivity-incentivized cogs in our new heavily-funded health care wheel.  Paying doctors for performance standards based on computer-driven check-boxes, guideline adherence and proscribed health care is of more importance than the individual.  Health care, then, devolves to nothing more than a nine-to-five series of clicks.

And Dr. Mike McQueary is born.



Lew said...

This will be but one of the many Kafkaesque scenarios that we will see played out over the next several years.

In a society that has already undervalued medical services, believing that health care is a state-given right, the physician of our country's future will be unrecognizable to folks like Hippocrates.

And although your Penn State Mentality is a nightmarish prediction of how our current policy will effect future physician behavior, I am more inclined to look at Terry Gilliam's dark-comedy, "Brazil", for glimpses into our "collective" future.


Anonymous said...

Please correct me if I am wrong:

Prior to the dramatic cuts to primary care, your internist would care for you in the hospital and as an outpatient. In essence, coordinating care with specialists consulted either in the hospital or as an outpatient.

Now, those cuts have moved the internists to outpatient medicine only and a whole new 'specialty' has been created known as hospitalists.

Of course, this creates tremendous difficulties with coordination of care since there is no longer one person responsible.

Enter the ACO which is tasked with recreating the original internist/patient model in a big bureaucratic world.

Basically, the government destroyed the original working system and is now supplanting it with something much more cumbersome.

The more things change the more they stay the same or better yet. How about the Coast Guard running over your boat then hauling you in after the crash--all the while you are thanking them for saving you.

Lisa said...

Okay, I have congenital long QT syndrome and then I was diagnosed with highly aggressive breast cancer. My cardiologist (who by the way, was vacationing in Europe) talked to my medical oncologist. Because ALL of the drugs they would be giving me prolong the QT interval. He warned to watch electrolytes and have an AED available at all times. An ICD was inadvisable because the cancer was on my left side. Because of the cardiac toxicity of the drugs he asked for close monitoring and frequent echos. Because of the dangers of radiation therapy to my heart he did his homework and asked for a newer technique. My oncologist, my two surgeons and the radiologist worked with him. I don't know that without this team effort I would still be alive. I have a hard time villanizing the "Medical Teamwork" approach.

Anonymous said...

Isn't the idealists' goal for EMR and large clinical studies the same; to identify what does or does not work the best for most people with a given condition? This is simply a starting point. Isn't it still the job of the physicain to then make the critical decisions of where does thier specific patient fit within these larger popultaions. What are their comorbidities, drug tolerances, surgery tolerance, what aspect of the patient's specific situation would cause the physician to follow the guidelines or modify therapy? Sub-analysis of the larger clinical studies always show that different subgroups have stronger or weaker associations to the main populations. Individual patients are no different and their physician should be no less of an advocate for them.

Keith said...

The problem I see is one of where responsibility lies in this new team model. We in the primary care field seemingly get the brunt of this supposed coordination of care, dealing with the psychosocial issues of disease while allowing specialist more time to perform well compensated procedural medicine. This makes primary care less financially rewarding and drives all our new medical graduates into high paying medical professions. To justify their high compensation, they must do more procedures and spend less time discussing and counseling their patients (NPs and primary care docs can take care of that).

My guess is that this becomes less rewarding for specialists over time who are now doing widget work instead of taking care of the whole patient. But this is what efficiency demands!It is assembly line work of the future. No wonder specialists, primary care docs, and patients all seem dis- illusioned by our current system.

In reply to anonymous:

The goverment had NOTHING to do with the creation of hospitalists; they were a sole creation of hospitals that wanted to 1) have better control of utiliztion of hospital resources and 2) provide off hours coverage of hospitalized patients and 3) allow primary care to become more efficient since spending time driving to the hospital is not efficient if you have all the patients you need coming to your office. We have to stop blaming the goverment for all of societal ills and it is up to our citizenry to become more involved in goverment policy and elections if things are ever to change. I would look in the mirror and blame yourself if you find fault in the system. An uneducated, disinterested population is what will lead to the slow death of our country and that their needs to be a clear balnce between goverment oversight and freedom to do as one wishes. The big bad goverment should not alway be the fall guy.

Anonymous said...

Lisa, it's great that you're receiving excellent care. That's the form of 'Medical Teamwork' that's most beneficial. However, I don't think that's the sort of teamwork Dr. Wes is painting. I believe the form he's describing is more institution serving. Say for instance the culture of a hospital (whether implicit or explicit) is productivity and efficiency measured via various forms of metrics. Physicians in such a system would be incentivized to be most productive. This could have the unintended consequence of a physician placing the institution's goals over caring for the patient. I'm not saying that hanging the incentive fruit over physicians heads will cause widespread harm to care, but it could lead to the rise of the Dr. McQueary.

Anonymous said...

Health care is a state-given duty or right. Providing accessible services is the job of government. The state of one's own well-being is not a right.

Providing education, housing standards,clean drinking water along with healthcare is want governments ensure. Especially when tax-payer money goes to 'subsidize' buildings and maintenance of hospitals, clinics, and other healthcare facilities, accreditation, education of medical professionals, and provision of expensive equipment, for which individuals have no access without the benefit of an tax-payer funded (in some way) hospital or clinic.

Cathy Lane RPh