A new and developing force in medicine will add a new set of dramatic changes: the force of consumerism. No longer will you, as a patient, be willing to be “patient.” Instead, you will expect your caregiver to be responsive, prompt, effective, efficient, and — notably- polite and professional. Not dissimilar to what you expect and usually get from your other “vendors” like lawyers, accountants, plumbers, whoever. With these people, you change to someone else if you are displeased.
Until now, you just sort of accept medical caregivers to be what it is, even if it frustrates you. But the time is rapidly approaching when you will expect an adequate period of time with your caregiver, that the caregiver will know you as a person and indeed know you as a person that is part of a family, a community, and a society. You will not tolerate any longer being treated as a “number,” a “case,” or as a “problem.” If you don’t receive the care as described, you will seek out care elsewhere.
An example of this is a friend, Rebecca, a physician’s wife, who developed breast cancer. She was seen immediately by a topnotch surgeon who did her biopsy and then lumpectomy in a very timely manner with plenty of discussion and “hand holding,” She then went to a highly regarded medical oncologist with the expectation that she would receive her drug therapy and radiation therapy at that individual’s hospital. She knew that the oncologist was well trained and very competent. However, the physician seemed pleasant enough but not engaging and not really focused on my friend as a person.
It seemed as though she went through a “checklist” of information in a “rote-like” manner. Rebecca felt like she was just “one more” breast cancer patient rather than an individual with a particular problem. She felt that perhaps the physician was just having a tough day or that she, the patient, was being seen at the end of a long line of other patients that day. But no matter, this was the physician who was to be her primary caregiver concerning an issue of utmost importance to her. The result: My friend went elsewhere for her medical oncology and radiation therapy care. The basic message, of course, is that patients now want and expect not only competency but also personal and professional care and will both pay for it and demand it. A bit of empathy doesn’t hurt either.
Compare that story to this one. A couple, Bob and Ruth, went to a small Caribbean island for a two-week vacation. On the last day of their vacation, the husband had a heart attack. Bob was taken to the island’s small 25-bed hospital. He and Ruth, who works at a major hospital in a patient care/advocacy profession, were immediately concerned that the level of care would not be up to the standards that they would have expected in their large U.S. city. However, what they found, to their obvious pleasure, was a highly skilled physician who was also highly interactive with the two of them. He did the appropriate diagnostic tests to demonstrate that it was a heart attack and then began the proper medical therapy. Concurrently he arranged for Bob’s air transport to a major Florida hospital.
Meanwhile, others at this small hospital helped Ruth cope with her concerns and deal with some practical issues of getting checked out of the hotel, returning the rental car, arranging medical evacuation flight and all the other details that needed to be done. In short, they looked after her as well as her husband. Ruth cannot speak highly enough of the care that her husband received.
Both of these patients were “connected” to the healthcare professions. So, if you think compassionate, attentive care always comes to such individuals, think again. Years ago, doctors offered their colleagues and families “professional courtesy.” No more. That will not change, but whether the doctor or family member is a patient or not, they will expect compassionate, attentive care just like everyone else. They may be the ones to push the system the hardest and, at the same time, “look in the mirror” at their own practice patterns and initiate change. Change will occur but never as soon as desired.
Both of these stories also illustrate the issue of complex, chronic disease. These diseases do not go away; they can often be cured, but the possibility of a subsequent problem [heart failure] or recurrence [cancer] is real. Many chronic illnesses will be with the patient for life. They require many different practitioners with differing skills to help care for them, which all need coordination.
But in America today, care for these complex, chronic illnesses, which consume more than 70% of all medical care expenditures, are definitely not addressed in a coordinated manner except in a few centers and practices. This means that the care is not up to the quality levels it could be given our knowledge base and our excellent practitioners, and it also means that the costs are much too high. We need to find a way to change our delivery system so that it delivers coordinated, compassionate, and safe care to individuals with these complex, chronic diseases.
Here is a “problem” which everyone needs to understand. If you are on Medicare, Medicare sets the payment for the doctor. He or she cannot bill you more than what Medicare allows. So, if you say to your doctor, “Look, I’d like to spend some more time to fully have you understand my situation or so that I can better understand your advice,” the doctor can say “OK” but Medicare will not pay any more for that extra time and the physician, by law, cannot bill you for the extra time spent. If you were doing a new will and wanted to spend more time understanding what the lawyer was recommending, the lawyer would say “OK,” but both of you would know that you would be billed for the added time. With Medicare, you don’t have that option.
Consider Renee. A few years ago, she asked me for the name of a physician who would give her the time needed for her situation as an older single lady with multiple chronic problems not being fully addressed by her all too many doctors. I suggested Gary Milles, MD MPH, who has a “concierge” practice. He charges a flat fee of $1850 per year and, in return, is available by cell phone 24/7, text, and email. He has only about 490 patients, unlike his original practice with 2700. So, he can offer same or next-day appointments lasting as long as needed.
Each year he does a very comprehensive evaluation lasting two hours, including multiple blood tests, a vision, hearing, and pulmonary analysis at no added charge. Importantly, if a specialist is needed, he will call that doctor directly, explain why he is referring you, and ask for a prompt appointment. That means you will be seen much sooner than if you called that doctor’s office and the doctor will understand why you are there when you come for your appointment. This all makes a big difference in care.
“You aced it when you referred me to Dr. Gary Milles! He has been terrific for me. First, he found out why I’ve had very high BP for four years, e.g., 250/160. Then, instead of all those blood pressure pills, he stopped them and put me on something less powerful and with less side effects and stopped some supplements recommended by a different doctor, adjusted my diet, and gave me some suggestions on stress management. As a result, blood pressure is now OK. So far, so good….we had to make only one adjustment after several months!
“But now I need to see a pulmonologist. The one he recommended did not work out. Great background and experience, but when I had my first visit, things started out poorly (very impatient and rude with me) and quickly spiraled downhill. He definitely is not for me. I will ask for another option.” Dr Milles was thankful that she reported the poor caring and sent her to another pulmonologist who had the appropriate medical but also personal skills. The first pulmonologist will not be getting referrals in the future.
This change to “patient first” is occurring slowly, beginning with primary care physicians, using the direct primary care or concierge models, regaining the time needed to give adequate, expert attention, and, when necessary, coordinating multiple specialists. This means much better quality of care, coordination when needed, all tied into genuine compassion and caring. In that way, it will be a return to my physician grandfather’s time when treatment options were limited. Empathy and caring will be uppermost while still preserving the incredible advances modern science has brought forth. It will mean better care, less patient frustration, less doctor frustration and burnout, and a huge reduction in total costs as an added, very important bonus.
It is a contract between the doctor and patient; no insurer is involved. But of course, if the patient does not feel well treated, the contract is voided, and they will move on to someone else.