Crucial doctor-patient relationships showing distressing signs of fraying

dochands-300x200Although health policy experts and doctors themselves may sing the praises of primary care providers — medical generalists who are supposed to be the first and important caregivers for most patients — recent studies suggest that yet another idealized aspect of the U.S. health care system has cost- and access-driven problems.

Patients, to start with, are driving a concerning trend in which they in increasing numbers are declining to tap the services of family doctors and other so-called PCPs.

Doctors in this field, as well as others, say that patients may be turning to online consultations, urgent care centers in drug stores and shopping malls, or more costly visits to highly credentialed specialists due to the spiking pressure on frontline MDs to maximize revenues by minimizing their “face time.”  Physicians describe how “bean counting” executives in health systems may require them to see more than a dozen patients a day, while also handling all the bureaucracy, consultation, research this requires — or face sizable pay cuts for their “inefficiency.”

The short and harried doctor time also may be contributing to significant issues like overuse and improper prescribing of antibiotics, practices that damage in a major way the protective value of crucial, infection-fighting treatments.

As NPR reported — and as I have long emphasized — it can be invaluable for patients to spend time to research, talk to trusted friends, family, and experts, and choose with care a respected, excellent doctor to be your primary provider of medical services and counsel. As  Dr. Ishani Ganguli, Harvard assistant professor of medicine and physician in general internal medicine and primary care at Brigham and Women’s Hospital, told the news broadcasters about such medical providers:

“Primary care has all kinds of benefits, both for patients but also for populations.” Research shows that people are healthier when they see a primary care doctor, rather than a specialist, for their routine care. Where there are more primary care providers per capita, death rates drop for cancer, heart disease and stroke, among other illnesses  and life spans lengthen … there’s no substitute for building a trusting relationship with a discerning provider — someone who knows your medical history, and might be more likely to screen you for depression when a sore throat doesn’t seem to be your only problem, or schedule you for bloodwork, a PAP smear, or vaccines that you need.”

But Ganguli and colleagues, after studying nationwide data on more than 20 million insured adults nationwide, found that “visits to primary care providers made by adults under the age of 65 had dropped by nearly 25% from 2008 to 2016. What’s more, adults who went at least a year without a single visit to a primary care provider increased from about 38% to 46% in that period.”

Practitioners, the researchers found, face two big challenges in getting patients to rely on their important care: cost and competition, NPR reported, quoting in part Dr. Kimberly Rask, chief data officer at Alliant Health Solutions, who wrote an editorial accompanying the study:

“The average out-of-pocket cost for a visit to the doctor related to a health problem rose from about $30 to nearly $40 during the study period. And the share of primary care visits subject to a deductible jumped, too: Less than 10% in 2008, versus more than 25% in 2016. ‘There is a lot of data showing that when you raise health care costs, people will receive less care,’ Rask says. ‘But it doesn’t mean that they only stop unnecessary care. They will reduce both necessary and unnecessary care.’”

NPR doesn’t drill down on this data point, but other studies have: An issue for the health care system lies in patients’ use of specialists — at higher cost and with some concern — to be their primary caregiver. Studies have shown young people are reluctant to give up their pediatricians when they advance into adulthood, while some cardiologists carve off a slice of different group of patients by serving as their main doctor for all their health care needs. Big hospitals, of course, have sought to exercise an iron grip on their competitive markets by throwing up satellite facilities or urgent care or surgical centers to battle the burgeoning growth of such enterprises in drug store chains. Add in the increased presence for patients of telemedicine or phone-in services, and suddenly it may not be so key in their minds to see a primary doctor.

Physicians may need to heal themselves and their own practices, too. That’s because they’re feeling nothing less than desperation and anger over the economic grind (maybe of their own creation) that leads them to see more patients and spend less time with them, on average around 18 minutes per visit. That’s not much time when patients may come in once or twice a year and doctors also may try to squeeze in recommended screenings about substance abuse or mental health. For primary doctors, who long for the deep relationships with and insights into patients that have been a hallmark of their practice, the burdens of seeing as many as 20 individuals a day, plus the burdens of paperwork can leave them frustrated and burned out. They may become brusque with people, with one study suggesting that too many primary doctors give patients 11 seconds to explain why they’ve come in before interrupting them in unproductive fashion.

When the idealized treatment system goes awry, it can have serious consequences, as other recent research has found. Experts in Boston and Chicago examined data on 300 million Medicaid prescriptions, finding that in 28% of cases patients — notably children — had not seen a doctor recently but still were dispensed antibiotics, and in 17% of cases studied these important medications were ordered without evidence that the patients had a bacterial infection needing treatment.

Unnecessary and wasteful use and abuse of antibiotics, of course, has become a giant concern globally, as these and other practices — including in agriculture to boost animals’ size and well-being or to fight off plant ills — has slashed the potency of crucial infection-fighting treatments, also fueling the rise of resistant, fast-spreading, and deadly “superbugs.”

In my practice, I see the harms that patients suffer while seeking medical services, especially when doctors don’t listen to colleagues who may be more familiar with an individual’s needs and when practitioners make snap judgments. Medical errors and misdiagnoses are major problems in the U.S. health care system and both pose grave risks to too many patients.

It isn’t easy to find excellent doctors, notably the primary practitioners on whose care, counsel, and judgment you will rely and be comfortable with. But good practitioners, in more than idealized ways, can work with colleagues to guide your optimal care, including helping you to avoid needless, painful, invasive, and costly treatments from others who may be excessively focused on testing, doing procedures, and increasing their income.

We’ve got a lot of work to do to ensure that modern medicine isn’t a churning, money-driven factory and that it works well for patients and their doctors.

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
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