America, Love It or Heal It

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The Limits of Customer Service in the Exam Room

Under the heading of “Value-Based Purchasing,” Obama’s Accountable Care Act includes measures to link hospital reimbursement to patient satisfaction measures.  Through both public and private insurers, this trend is likely to spill over into the outpatient setting in the very near future.  

Aside from creating redundancy in the market (with some very rural exceptions, patients can act as agents of their own satisfaction by voting with their feet), there are serious limits to physicians as agents of pure customer service.  Our roles supercede service to sole patient sitting on the exam table, and attaching payment to patient evaluation endangers the complex responsibilities that physicians - especially primary care providers - owe to the community at large.

As primary care physicians, we are charged with negotiating sensitive and intimate health concerns.  Control of elevated weight and blood sugars that patients would prefer to ignore, a dogged preference for menopausal hormonal regimens that evidence is mounting against: we handle a myriad of difficult topics with the best aplomb we can muster, but these discussions are not always met with open arms.

We guard the continued utility of antibiotics beyond this generation’s coughs and colds.  In refusing a Z-pack for viral illnesses, we may be engaging best practices, but we rarely leave a happy patient who expected an anti-bacterial cure for their viral sniffles.

We have become the standard-bearers for government’s well-reasoned but burdensome push to bring health care informatics into the twenty-first century.  Health care has fallen decades behind information technology; the well-intentioned rush to establish technology standards through criteria like meaningful use, patient-centered medical home, and e-prescribing cuts into the time we would like to spend talking to patients about patient concerns. 


We are the sentinel in the battle against a growing national addiction to narcotic pain medication.  Deciding when to write another script for Vicodin and when to transition to non-narcotic modalities is an art that takes both training and courage, but with an epidemic-sized population hovering on the edge (or already over the abyss) of addiction, few patients are satisfied when a request for opioids is denied.

We are the unwitting actuaries of the health care budget. We are torn between the newest, most heavily marketed drugs and apparati, and the driving push to curtail spiraling costs: to employ the cheapest evidence-based medications, to grudgingly abide by insurance company prior authorizations, to realize that sometimes the most expeditious answer also places the most burden on the health care dollars that we all rely on as the bulge of the baby boom generation passes through the snake’s belly.  

Moreover, outpatient physicians choose who we care for.  Under reimbursement schemes that punish providers for problematic interactions, the most likely outcome is that problematic patients will find it difficult to retain medical homes outside the home of last resort: the emergency department.  We all know these patients - chronic narcotic seekers, unstable psychiatric patients, those who inhabit the nebulous borderlands between volitional bad behavior and true mental illness.  Maintaining equanimity in the office in the presence of such patients requires subtle skills such as setting boundaries, establishing protocols and limitations, negotiating the news that needs will be met but impulses and whims will not be indulged.  The physicians most willing to take on such patients should not be doubly punished for the ruckus that frequently arises around them - they should be afforded the additional resources it takes to stabilize such individuals and minimize their disproportionate impact on the hospital system.

Linking reimbursement to patient satisfaction hobbles physicians’ ability to uphold high standards and to broach difficult terrain when necessary.  Applied with a broad brush, tying reimbursement to patient satisfaction harbors the potential to interrupt the integrity of the doctor-patient relationship and compromise the larger promise made by physicians to uphold the health of the nation. 


Also published on KevinMD.com.