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Wednesday Dec 16, 2015

At the Crux of Art and Science: I'm a Family Physician

My mother walked the hospital corridors with me at her side. I escorted her around the facilities, showing her my place of work. She turned to me with a proud look in her eyes and said, "Remember that what you do is sacred."

I don't think I will ever forget that day. Growing up in an immigrant household, there was nothing more revered than the work of doctors and clergymen. In my culture, they almost go hand in hand. Care is taken to heal the soul, not to simply treat an ailment. There is a keen art in doing so.

Or at least, there was.

I'm not sure how or when medicine turned from an honored profession to an outcome-based mill. I certainly don't recall when patients turned from people to products. However, this is how practicing medicine now sometimes feels.

We are hindered by protocols, quality measures and satisfaction scores, which make fostering relationships with our patients difficult. And as family physicians, aren't relationships the reason we chose our specialty?

Don't get me wrong. Quality plays an important role in delivering good patient care. What I do not agree with, however, is how the health care system defines quality.

With so much information available in an instant, it is all too common for patients to come to me with a diagnosis in hand, seeking a pill they want to try or a remedy they have seen on TV. The problem is that not all information strewn about various media is valid. How many times have you had patients demand antibiotics for sputum they perceived to be greenish in color?

This concept of drive-through medicine is costing the country millions of dollars in unnecessary testing and medication. So how do we fix this "Have it your way" culture at a time when we're judged, at least in part, on patient satisfaction?

A regular reminder I share with not only my patients, but also administrators, is that health is no more a product than is the wind. It flows and is dynamic. Protocols are guidelines, and I certainly am not a dictator when it comes to the care of my patients. Ultimately, they need to remain informed about their conditions and live with the consequences of their decisions. I am their consultant, I remind them, one who collaborates to help them reach their goals.

I am not a personal assistant. Although I guide my patients regarding their health and wellness, that does not necessitate total agreement. Not every ache and pain requires a CT scan or MRI. Not every cough or sniffle requires an antibiotic. Not every person requires a Pap smear or colonoscopy. To best serve my patients, I need the ability to practice the art of medicine.

In the world of fee-for-service health care, we are measured by how many patients we see per day. We feel the pressure of time limitations. Important conversations about effective treatment options often give way to scheduling restrictions. However, we all know that so-called productivity does not necessarily equate to quality. Somehow, a term used to assess factory-based businesses has crept into the medical field.

I am increasingly reassured that the AAFP’s consistent work to change our health care payment structure to a more value-based model is a win-win. But quality takes time, and more family physicians need to be at the head of the table for discussions affecting all aspects of the health care delivery system so this message resonates at all levels. Who would better understand work flow, quality measures and patient-centered teams than a family physician? We need strong family physicians in leadership roles to continue advocating and directing a shift in the current payment model.

The research stands for itself. Family physicians not only give good care, we do so in the most cost-effective manner(www.annfammed.org). A recent retrospective study found that greater family physician comprehensiveness of care, especially as judged by claims measures, is associated with decreasing Medicare costs and hospitalizations.

So how do we educate our patients about sticking to tests and treatments that are necessary and evidence-based? We remain engaged. We continue to advocate and fight for a system of care that values quality instead of procedures. We focus on health and wellness instead of simply fixing broken bodies. We put the patient back into the center of our care. Otherwise, we will continue to face challenges based on information patients receive from Dr. Google.

In essence, we must remember that more does not equal better. In fact, more can actually be detrimental. Just ask my patient who suffers from urinary incontinence after having a radical prostatectomy for low-grade prostate cancer while in his 70s.

Or ask my patient who was taking more than 20 different medications for management of various symptoms before being whittled down to the six she really needed.

Ask the elderly patient who was taking three different brand names of the same anti-arrythmic drug before her family doctor went through her medications with her.

Ask the young lady who developed Clostridium difficile infection after being treated for multiple "respiratory infections."

The list could go on and on.

After all is said and done, we cannot reduce the practice of medicine to a simple black and white algorithm. Trust between physician and patient must be first and foremost. We must resist the urge to allow insurance companies, pharmaceutical agencies and the media to give misinformed guidance in how we provide care to our patients. If not, then our role as family physicians becomes diluted.

How do we change this "Have it your way" culture? One patient at a time.

Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.

Posted at 04:16PM Dec 16, 2015 by Marie-Elizabeth Ramas, M.D.

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