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Maggie Kozel, MD, on how perverse incentives and modern life are destroying a sacred relationship. And how to get it back.
I went through medical school on a Navy scholarship. So within weeks of graduating from Georgetown University School of Medicine in 1980, I traded in my short white coat for a set of lieutenant shoulder bars and pointed my regulation shoes toward Bethesda Naval Hospital - the mother ship of universal, single-payer healthcare. I spent the next eight years insulated from, and blissfully ignorant of, the seismic forces overtaking U.S. civilian healthcare.
In my formative years as a Navy pediatrician, I had to continually call upon my specialized training to manage everything from distressed newborns to new diabetics. I appreciated the skills and knowledge of our nurses and other health professionals, who enriched our well child practice by providing parents with education on nutrition, safety, expected developmental milestones, discipline, and the countless other issues that empower parents and keep children healthy. It was an effective division of labor that made sense to parents. One of the best gifts my training and experience in childhood illness allowed me to offer parents was reassurance - telling the parent of a feverish child that they were handling the illness well, or that the child's cough was harmless and would run its course. Although I certainly had my share of disgruntled or frustrated parents, for the most part I enjoyed trusting relationships and felt respected for my expertise. The trust and respect was mutual.
Flash forward to 1988, the year I left the Navy. With a two-year-old daughter and another on the way, my husband and I decided to settle down, and I left active duty. I assumed that the biggest change in my move to civilian practice would be that I would no longer have to wear my white polyester uniform. But as my civilian patients became more aware of the pound of flesh that health benefits were requiring of them, tethering them to specific jobs and costing more and more out-of-pocket they morphed into consumers, seeing the doctor became a quest for getting their "money's worth." In the American psyche, that usually translates into "only the best will do."
The "best" in the view of many parents was a board-certified pediatrician, so many parents came to expect routine child-rearing advice from me - the person at the most expensive tip of the healthcare pyramid. Entire doctor visits would be frittered away on naps vs. no naps, or whether to start strained peas before applesauce - things which never even came up during my residency training or that would be handled by experienced nurses in my Navy practice. In addition, the normal travails of childhood, from spitting up to teething to not sleeping through the night, were increasingly viewed as pathologies that require medical action - often a prescription medication. Minor illness that threatened parents' work schedules or other commitments demanded immediate intervention, not an explanation of the natural course of the illness or advice on what to watch for. Best practices, like not prescribing antibiotics for a cold were now likely to be regarded as the doctor being difficult or controlling, and my best gifts of all -reassurance and advice on watchful waiting - were, as often as not, seen as me being dismissive or uncaring.
"So you mean you're not going to do anything? I just paid a $20 copay for nothing?"
My advice on lifestyle issues, like constipation or obesity, was likely to fall on unwelcome or deaf ears.
"You basically mean there's nothing we can do?"
Our culture of "expertise" has eroded parents' confidence in their own judgment, and our societal trend towards sensationalism, where silent dangers lurk in every corner, erodes their confidence in their doctor's judgment. Tummy aches on school mornings demand a pediatric gastroenterologist, and headaches are being evaluated carefully only if a CT scan is involved.
For our part, primary-care physicians are under immense pressure to see ever greater numbers of patients, and to do it all ourselves, since insurance companies are not going to pay for a nutritional discussion with a nurse. A healthcare model centered on physician productivity rather than quality has robbed us of our greatest tool - time to talk with our patients. And it generally takes a lot more time to talk a patient out of an unnecessary intervention than into one. Yet just when our patients need us the most to help them navigate the complex world of medicine, we are intently watching the clock.
One thing is clear to me after a 20-year career of taking care of children: parents and pediatricians want the same thing - a healthy child. Yet the financial stresses and incentives that health insurance puts on all parties, combined with employment pressures and a cultural bent toward the quick fix, have cast doctors and patients into roles that, while not of our own making, seem to put us at odds.
The pendulum is slowly swinging back, as parents and pediatricians alike come to understand the dangers and ineffectiveness of overmedicalization of childhood. My wish for parents is that they understand the profound value of the doctor-patient relationship, as well as the meaningful kinds of relationships they can have with other healthcare providers. From a doctor's perspective, that relationship is what keeps us in the game despite the long hours and personal sacrifices. It arms us against all the insults insurance companies throw at us and keeps us from banging our heads against the wall when hamstrung by paperwork. It is what reminds us why we went into medicine.
But perhaps most important of all, this relationship is at the very heart of health and the healing process. We cannot tolerate a healthcare system that sabotages that relationship by limiting the ways healthcare can be delivered while incentivizing rapid patient turnover, tests, and procedures. We must not be forever tempted by the appearance of quick fixes. As we approach healthcare reform, we must raise the doctor-patient partnership up. We, the patients and the doctors, must continue to see value in the relationship, and work to maintain it. We must listen to each other, respect each other, and trust that we are indeed working toward a shared goal.
Maggie Kozel is a retired pediatrician and author of the medical memoir, "The Color of Atmosphere: One Doctor's Journey In and Out of Medicine." Her blogs on health care reform have appeared regularly on the Huffington Post as well as in the New York Times Well blog and on KevinMD.com. She currently teaches high school science in Providence, R.I.
This article originally appeared in the October 2011 issue of Physicians Practice.