Neurologists Must Maintain Patient-Centered Care Even When Facing Economic Pressures

AAN presidential address focused on value and quality
VBCN - July 2014 Volume 1, No 2

Philadelphia, PA—Neurologists are amidst a social transformation that threatens their professionalism, their ethical foundation, and their patients, said James L. Bernat, MD, Professor of Neurology and of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH. External pressures and perverse incentives have served to promote behaviors that can diminish the professionalism of neurologists, said Dr Bernat.

He delivered these remarks during the Presidential Lecture at the 2014 American Academy of Neurology meeting. The conference drew more than 13,000 attendees and featured more than 2500 research abstracts.

The transformation of medicine to a business is a challenge to professionalism and ethics. As opposed to the learned profession of medicine, which presupposes concern for the best interest of the patient, “the purpose of a business is to make money for the owners or shareholders,” said Dr Bernat. “Patients are not a means to an end, they constitute the end itself.”

In the business model, procedures are incentivized over care, and providers are relegated to the nonprofessional status of service providers and are directed by others. The conflicts created by financial interest eclipse the physician’s primary duty to the patient, causing a loss of public confidence in the objectivity and integrity of physicians.

“Conflicts of interest make patients worry that decisions we make for them and with them may not be made for their best interests,” Dr Bernat said. Elimination or mitigation of conflicts can improve patients’ trust in physicians.

Quantity versus Quality
Dr Bernat cited direct-to-consumer advertising and marketing to create demand for medications and services, bypassing physicians, and patient inquiries into financial incentives for the ordering of tests. In addition, patient care reimbursement too often rewards quantity over quality, he said. This commercialization often results in physician resignation when appropriate medical services or medications are denied by health insurers.

Physicians also contribute to their deprofessionalization in many ways, Dr Bernat said. Medical societies are often used as guilds to protect the financial interests of physicians. Physician participation in speakers’ bureaus to help market products is an internal action that exemplifies the corrupting influence of money in medicine. Medicare data show higher utilization of tests and treatments as reimbursement for each declines. “Insurers therefore consider physicians to be businesspersons, despite the claim that they are professionals,” said Dr Bernat.

From Private Practice to Hospitals
With the decline in established private practices, physicians are increasingly becoming hospital employees. Among the liabilities of such arrangements, physicians can no longer control decisions that have an impact on patient care, and they must report to an administrator who has financial targets and other goals that may not align with those of the individual physician.

Electronic Health Records
Although electronic health records (EHRs) can promote prescribing accuracy and can enhance documentation for patient care, they, too, often encourage copying and pasting of notes, clouding original authorship, and they may encourage “check-the-box” medicine, whereby histories are often conducted by having patients check appropriate items in a list. EHRs are known to minimize patient interaction, said Dr Bernat, because physicians spend more time keyboarding and less time with patient communication. Perhaps their most pernicious liability, EHRs have evolved to document elements for billing rather than the medical encounter, Dr Bernat said.

Correctives to enhance the utility of EHRs include resisting the temptation to take shortcuts, careful editing to maintain accuracy when copying notes, and an office setup that maintains a line of sight with the patient rather than having the physician’s back turned to the patient while entering the medical record.

Patient-Centered Care and Quality Measures
The depersonalization of medicine has contributed to physician burnout, because doctors are too often forced by regulations or circumstances to do substandard or meaningless work, said Dr Bernat. The requirements of Medicare billing codes are an example of a regulation that encourages physicians to maximize coding and billing irrespective of quality of care.

The ethos of doctoring to maintain patient-centered care should be preserved, Dr Bernat said. Quality-of-care measures should be developed that align care with patients’ values and preferences, while also maintaining physician well-being.

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