Chapter 83 Potential Conflict between Patient Care and Systems-Based Practice Competencies
You walk into the examination room, introduce yourself to Mrs. Smith and her family, and sit down to begin reviewing the pertinent medical details of Mrs. Smith’s condition. This is a familiar encounter in our health-care system that occurs thousands of times per day. In the purest sense, this is straightforward. You are there to serve Mrs. Smith’s needs for care, providing appropriate information and arranging for further testing and treatment as required. The patient’s expectation is that you will do everything possible and appropriate to treat her without concern for cost. When you are sick, it’s no time to start cutting corners, correct? And besides, she’s well insured. The cost of her care won’t come out of her bank account.
Fortunately for physicians, our role in these encounters is usually pretty clear. But in the real world of health care in the United States, where we have the ability to provide (and charge) much more than we can afford as a society, this is not as straightforward as it may seem. One of our competencies as physicians is to practice systems-based medicine that would have us concerned not only with Mrs. Smith, and all the other patients we will see today, but with the ability of our system to provide care to everyone.
There is nothing more important in health care and health policy than the patient-provider relationship. Hence the dilemma of the individual’s need versus the community’s need requires conscientious communication and concomitant interpersonal skill. Communicate effectively with your patients, advocate for them with insurers and employers, and be a knowledgeable spokesperson for the vulnerability of the “doctor-patient” relationship in our evolving health system.
In your role as provider, you also take on an important role as teacher: you must be able and willing to explain why you are not ordering tests or providing services patients may feel they should have. Those decisions must be based on sound evidence as to appropriate and cost-effective practice. We should be equally forthright with patients regarding care we know they should receive but for which they are denied access because of the limitations of their insurance contract or their lack of health insurance.
One of our most important roles as physicians is to help define and defend the boundaries of appropriate care. Though for most patients we provide and they get what they want, we currently “ration” care in both overt and subtle ways. The United States has the world’s most expensive health care system, spending 50% more per capita than the next highest industrial society, yet we fall well behind on many standards of population-based health statistics. Almost one in six of our citizens is uninsured, and countless others are in need of health services but lack citizenship and insurance. Complicating this dynamic is the fact that the U.S. government is paying for about 45% of the $1.6 trillion spent on health care in the United States per year in spite of a national debt (current as of this writing) of $8.5 trillion.
As physicians we must embrace our role in the public debate about how to reduce the cost of health care and provide coverage for everyone. To do that effectively, we need to be willing to discipline ourselves to manage the health-care dollar through an effective, open, and honest balance of patient needs and societal needs. The lack of clarity on that balance, the lack of consensus on an appropriate basic set of health benefits for all, and the badly misaligned economic model of our current system challenge us greatly. But if we as physicians do not step forward to take on this challenge, all the while protecting the integrity of our relationships with our patients, I shudder to think who will and what the results might be.