John La Puma, M.D.

John La Puma, M.D.

Physicians know that grades are coming — for number of patients seen, length of hospital stay, formulary compliance and patient satisfaction. But it is not only managed care plans, patients, physician groups and state agencies that grade physicians. It is also the marketplace.

In an especially perverse market twist, Massachusetts has now made public its physicians' malpractice histories for the price of a toll-free call. The office handling the calls reported receiving more than 500 in the first day of operation.

In a parallel twist, other physicians are responding to market demands like marketeers. The Pacific Fertility Center promises that if, after it makes two treatment attempts, a woman doesn't have a pregnancy that lasts at least 12 weeks, Pacific will refund 90 percent of the fee that covers its medical services. The fee does not cover medical screening, medications, other medical services or "egg donor agency fees."

Ethics for sale

To make matters worse, Pacific says its "ethics advisory board, made up of independent, internationally acclaimed bioethicists, has judged the IVP [in vitro fertilization partnership] Plan to be highly ethical." I wonder if my colleagues donated their services to Pacific, or charged only a nominal fee, for surely it would otherwise be difficult to make an independent judgment about this extremely complex problem.

Even ethics has a price.

Public deployment of malpractice histories and money-back medical guarantees is emblematic of the new consumerist face of medicine. Health care is a service, this face says, and it should be selected and evaluated like plumbing or heating — caveat emptor. Advertisable outcomes matter most.

If the malpractice suit against you arrived after your weeks of struggle to save a very low birthweight baby, it is still on your record. If a double dose of hormones is necessary to effect ovulation, and it also happens to effect a hyperstimulation syndrome in your Pacific patient, well, that's not covered.

Outcomes like suits and guarantees are conspicuous, but they are not the whole story. They oversimplify the complex, and reduce process and experience to a single metric.

Yet many Massachusetts callers want to know everything they can about their own doctors before they visit again. They probably like the proof of quality that a money-back guarantee furnishes for toaster ovens and frying pans. Don't we all? If there were a refund available for unsatisfactory office visits, don't you think people would take it?

Medicine, however, is different from toaster ovens and frying pans. The power and trust physicians have built individually with individual patients cannot simply have vaporized. If medicine has changed to "buyer beware," is the change permanent? Should the ethics of the marketplace replace the ethics of the profession?

Pediatrician and ethicist John Lantos of the University of Chicago has argued that patients expect miracles because medicine has been so good at producing them, and because they occur routinely on "ER," "Chicago Hope" and "Rescue 911." Off the screen and on the cutting room floor lie scattered bits of human tragedy, far more common than successful cardiopulmonary resuscitation.

Expecting a miracle is neither wise nor prudent. Neither is illness. Yet physicians will increasingly be held responsible for tangible, measurable outcome assessments in populations that are costly to managed care plans.

Which assessments? Diabetics' glycohemoglobin measurements. Asthmatics' peak flows. The prevalence of pneumovax vaccinations in your at-risk population. Your prevalence of appropriate mammography, Pap smears and seat belt documentation. Your incidence of unstable angina and preventable hospitalization.

"What?" you cry. "I didn't give my patient asthma or diabetes or breast cancer! I just tried to treat it." Or, "I followed the practice guideline our group, or the American College of Physicians or another organization created, and the patient still had a stroke, or was hospitalized or had a complication."

Tough. The principles of consumerism in managed care mean that your patients should do better than the patients of others — well enough to advertise. If your patients are sicker than your colleague's, then relative value units should show it.

If doctors are to be held responsible for patients' illnesses and transgressions, then whole new seminars in documentation of patients' missteps, not to mention medical ethics, will be needed, not only on cruise ships but in medical association meetings.

Because now there are other healers coming to the fore. They too see sick people, and many of those people are our most difficult patients — those with pain syndromes and connective tissue diseases, chronic illness of all types, ill-defined symptoms that physicians have been unable to name or ameliorate.

Just like physicians, these alternative healers have professional conferences where it is sometimes hard to tell the commercial exhibits from the instructional seminars, but also where therapeutic song and dance are taken seriously. And patients do not seem to be asking for guarantees from these healers — just time, understanding and demonstrated efforts at partnership.

The collective mistrust of physicians as a whole has served to galvanize individual patients into answer shopping, sometimes thought of as doctor shopping. In many cases this shopping is sad, as such patients often do not have a physician they regard as compassionate, and do not have a therapeutic relationship with anyone.

Different incentives?

Is there a way out of this mess? Rewarding physicians for spending more time with patients, instead of less, might go a long way toward reinvigorating physicians' image as compassionate healers.

Financial incentives could exist for other variables, such as achieving quality-of-life goals for patients. Objectives measured could include pain-free days for cancer and arthritis patients; ratings of personalness in care (which meta-analyses of satisfaction data show that patients value most); and reduction in polypharmacy for long-term care patients.

Though the illness is the patient's, it is the physician's job to help him get through it so that he can do the things he wants to do. Money-back guarantees only give back money, and it is health and empathy that most people really want.

John La Puma, M.D., practices internal medicine at North Suburban Clinic in Elk Grove, Ill., and is a Chicago-based speaker and educator. With David Schiedermayer, he is the co-author of The McGraw-Hill Pocket Guide to Managed Care: Business, Practice, Law, Ethics (McGraw-Hill, New York, 1996).

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