Something Has Got to Change
by Mark Levy, MD

As a recent retiree and of a certain age, I have had an opportunity to view the practice of medicine from “the other side of the table”(or screen), both myself as a consumer and as an advocate for friends and family members. I have seen a system full of well-intentioned healthcare professionals but rife with inefficiencies that frustrate the provision of care and efficiencies that have created unintended and adverse consequences.
 
For example, we have created Urgent Care Clinics (UCC). Still, they operate without a universally defined scope of care, so my acquaintances visit centers with the souvenirs of their misadventures- fractures, lacerations, burns, etc.- sometimes receiving care and sometimes being sent on to the local Emergency Room without apparent rhyme or reason, but always with a bill. Phone triage services are often as clueless as their clients about whether a given UCC will or will not be capable of providing the medical care needed.
 
Our schools and employers often require “Return to work/duty/school…“ notes from a physician, which creates needless expenses and appointments, not to mention needless delays in getting back to work or school and bottlenecks in access for those who truly need it. 
 
I don’t know how often arranging follow-up care has been left up to friends and family just released from the hospital, operating room, or emergency room. I am not allowed to drive myself home post-colonoscopy. Yet, we somehow feel that recently “stabilized” patients dealing with anxiety and major health issues are somehow capable of navigating a system that is arguably much more complex than our roadways.
 
As inefficient as the scheduling process can be for the consumer, the “efficiencies “we have created in medicine are equally problematic. For example, we have created the Numeric Rating Scale (NRS) and other similar tools to assess pain and use them to guide treatment. Inadvertently, we have created the impression that eliminating all pain is “the goal” for some. In part, because of this, we have prescribed 4 times as many opioids as physicians in other high-income countries and, in the process, have contributed mightily to the opioid epidemic. Nowhere in the Hippocratic oath does it say that physicians should strive to eliminate pain. Rather, we are meant to alleviate suffering, which is multidimensional, encompassing social, physical, personal, spiritual, existential, cultural, cognitive, and affective aspects. While simple rating scales are quickly administered, easy to document in an EMR, and frequently used and relied on, they miss too much critical information. 
 
The same is true with over-reliance on other screening tools alone for diagnosis and treatment. For example, take the PHQ-9, administered every time I go in for my Medicare Annual Wellness Exam. The PHQ-9 was initially developed by a pharmaceutical company looking to boost sales of their SSRI. While it has stood up to validation, it has a very high false positive rate. It is more than twice as likely to indicate that patients are potentially depressed compared to a physician-conducted clinical evaluation. 
 
Finally, there has been an explosion in the availability of online medical care for issues such as hair loss, erectile dysfunction, contraception, and treatment of UTIs, URIs,  etc. By virtue of being able to be asynchronous (the provider and the consumer can access the site at different times so that requesting care and receiving it can happen when convenient for each party), virtual care has been able to be consumer-friendly in a way that most office-based practices are not. Not to mention their ability to provide care without the hassle of scheduling, driving, parking, etc.. Yet, this new efficiency means further fragmentation of medical care. Increasingly, for those of us who are lucky enough to still have a PCP, we can expect to also have hospitalists, specialists, and perhaps, when we want convenience, an online company caring for us. With this, we further weaken the trusted, personal, longitudinal relationship I have always thought was the most important part of my doctor-patient relationship. 

By creating a healthcare system that is hugely expensive, hard to navigate, not consumer friendly, and that is overly reliant on tools that devalue interpersonal, direct, and deep, meaningful communication, we have arrived at our current crisis. Patients suffer from poor access to care and poor coordination of care when and if they can afford it. Healthcare professionals suffer from burnout, with inadequate numbers of us available to provide primary and mental health care. We suffer moral injury when we feel that the systems most of us now work for have interests misaligned with those of our patients.  Society suffers from the fallout of medical bankruptcies, the opioid epidemic, and falling trust levels in yet another institution.
Something fundamentally must change.

Disclaimer: The views expressed in "Physician Perspectives" are those of the author and do not necessarily represent the official policy or position of the KCMS.