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Wednesday Feb 05, 2020

Patients Aren't Widgets; Care Shouldn't Be Volume-based

I bristle at the phrase "physician productivity." Productivity is the number of patients I see every day. In a federally qualified health care setting, where the majority of patients are using Medicare and Medicaid to pay for their visits, the more patients we see, the more money we are paid, and the better chance we have of keeping our doors open. Keeping our doors open means we can provide access to more patients. These are all good things.

[dial on timer or lock]

The term productivity, unfortunately, implies that I am building widgets on an assembly line, and that there is some trick to efficiency. The goal is to make three widgets every hour. This does not take into account the fact that each widget has different manufacturing instructions with different levels of complexity. If I was simply doing refills and referrals, this could possibly work. Repetitive, routine, mindless tasks could be streamlined, and I could produce more than three widgets an hour.

Humans, surprisingly, are not widgets. Patients are humans with insecurities, anxieties and life circumstances beyond their control.

Some might argue that the best way to beat the system at its industrialized game is to go off the grid -- perhaps by creating sustainability through a membership model or finding different revenue streams to support clinical work. I've thought about working in a different practice setting for my own sake, but that still leaves the burden of marginalized care on the patients who are in the lowest income bracket. They are unable to pay extra to any system beyond what they already receive.

I am often witness to patients managing complex health issues within the constraints of poverty. Common examples of this include

  • the patient who lives in a shelter, struggling with diabetes, unable to cook at home because she doesn't have a kitchen and can't afford salads prepared with fresh ingredients.
  • the patient (again with comorbid conditions) who has high levels of anxiety and overwhelming paralysis because he doesn't make enough money and frequently must decide between buying food, paying rent, or shelling out copays for his meds or to see me. In this case, spending time adequately discussing lifestyle modifications seems near impossible.
  • the older Medicare patients who "spend down" their savings because they need to be under an arbitrary income bracket in order to qualify for some benefits. Now they can't afford the $40 copay for each session of physical therapy. It is frustrating because supervised strength training is all most patients need to prevent falls.
  • a single mom with kids ages 2, 7 and 15 who can't afford a $50 humidifier (a long-term investment, no less) to help with cold symptoms and dry air in their overly heated apartment. I fear asking what else she can't afford for her kids or whether the bills are paid on time.

Last year, I almost did a little jig in the middle of the waiting area when the generic version of the asthma controller medication, fluticasone-salmeterol, came on the market. I would no longer have to jury-rig a nonevidence-based treatment plan for patients with asthma. (How can you not cover a medication that helps people breathe?! Or one that is physiologically necessary? Hello, insulin?)

New York City is expensive. Taxes are high, food is overpriced, rent is inflated, and transportation costs money. It is also a city with many resources for patients below the poverty line. There are shelters, public housing, food stamps, and a fairly wide net that catches those with the fewest means.

Because there are so many services, primary care doctors complete forms so patients can have assistance at home (they need someone to help them with grocery shopping and to cook healthy foods) and transportation (the subway is great but has so many stairs and so many fast moving people).

We spend a lot of time translating treatment plans for patients, via patient messages, during visits, and over the phone. This is all on top of the act of physically seeing hundreds of people per month, patients who don't need to see a specialist for their asthma, diabetes, depression, joint injections, benign mole removals, IUD placements, newborn visits, prenatal visits, or well-child checks.

For me, the push to see more and more humans is overwhelming. The more patients I see, the longer I need to recover from the energy drain of human interaction. But from a patient perspective, my poorest patients see this as the norm. They travel far, pay money, and wait a long time to see me for 15 minutes. For them, it would be the same no matter where they went because of the payment constraints set by the only insurance coverage they are able to obtain. (There is also a racial component that I would be remiss to leave out: People of color are disproportionately marginalized in this system).

It is possible to see the humanity, the stories, the faces, behind the numbers we measure. But only if we decide to. I have no prescription for this mess. All I know is that as long as we equate patients (people!) with products, the health of our most marginalized patients will suffer.

Lalita Abhyankar, M.D., M.H.S., is a family physician practicing in New York City. You can follow her on Twitter @L_Abhyankar.(twitter.com)

Read other Fresh Perspectives posts by this blogger.  

Posted at 03:23PM Feb 05, 2020 by Lalita Abhyankar, MD, MHS

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