Health Care Reform and Clinical Culture
It is a tired and cynical cadre of physicians who will implement health care reforms. Yet few published perspectives include the view from the factory floor. The usual platitudes about changing financial incentives, increasing efficiency, and delivering high-quality care sound naïve to clinicians who deal with the imperfections of human nature and the messy effects of illness on patients.
Doctors are already, by training, sophisticated decision-making machines, capable of achieving extreme efficiency through the use of heuristics and experience.
The main problems that clinicians face in achieving efficiency and reducing costs are, first, a perceived need for certainty in diagnosis and treatment — a need driven by secular expectations and malpractice concerns; second, gross inefficiency created by obligatory documentation to satisfy billing requirements that have little value for clinical care; and third, restrictions on the use of clinical judgment that could avoid excessive testing. None of these problems, whose solutions would save money and time, have been incorporated into the national discussion about reform.
One change that would augment the role of clinical judgment would be for the health care system to resist the temptation to require adoption of often-elusive “best practices.” There has been an assumption by analysts that published clinical trials provide a sound guide for therapy, but all reputable studies report odds, hazard ratios, and effect sizes, almost all of which are small or modest. Absolutes are discordant with the realities of sickness and health.
There may be guidelines and measurable outcomes for mundane problems, but for the vast majority of daily doctor’s visits and hospital decisions, incremental or recursive approaches to diagnosis and treatment are more effective and efficient.
A second reform should be to limit malpractice awards so as to reduce physicians’ fear of lawsuits. Regardless of the arguments of defenders of open-ended malpractice payments, this insidious concern is a major driver of overtesting and overconsulting.
A third key reform would be to eliminate the time sink of the comprehensive exam and its lengthy documentation required by Medicare — a requirement that is likely to be adopted or exaggerated in any new codified system. Immaterial information is already cluttering the electronic medical record.
My survey of neurology notes, which I presume would be among the most thoughtful in medicine, shows that less than one fifth of the average note is taken up with analysis and discussion of the patient’s problem; the remainder is part of the “waste” in modern medical care.
Fourth, payment codes should be reduced to “simple” and “complex” — or at least the numerous billing levels and codes should be conflated, and payment should be based on diagnosis and time expended. Physicians should also be paid for their expertise.
Health care reform can redress slowly accrued and detrimental cultural changes, particularly the loss of reliance on clinical judgment. It would be a missed opportunity if practicing physicians (as contrasted to their representative bodies and societies) were excluded from the center of the conversation. The efficient use of the professional workforce will be more powerful than rules.
Allan H. Ropper, M.D.
Brigham and Women’s Hospital
This article (10.1056/NEJMopv0907607) was published on August 26, 2009, at NEJM.org