COMMENTARY

Good Enough for Your Spouse (or Significant Other)?

Seth Bilazarian, MD

Disclosures

August 29, 2014

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Hi. Seth Bilazarian on theheart.org on Medscape, for Practitioner's Corner. A lot has been written recently about physicians being disgruntled, discouraged, angry, quitting -- even unfortunate reports of physician suicide. There is a lot of discouragement about healthcare delivery among physicians, and as a community practitioner, I certainly feel much of this anxiety, anger, frustration, and disappointment. There is a lot of pessimism and there is certainly a lot to be said about why there should be pessimism.

People know about rapidly increasing and unsustainable costs -- a broken system at almost every level, uncooperative payers, incompetent government systems and computer systems. Greedy and incompetent physicians have been profiled as have patients with inappropriate expectations about the ravages of diseases. These are all issues that are plaguing our healthcare system. Many of these issues have come about and resulted in a subtle form of corruption. Everyone bears responsibility, but as physicians, certainly we bear a significant amount of responsibility for this problem. How to move forward in this system is really very difficult.

What Would You Recommend If I Were Your...

What I hear often from patients (and throughout my career I've heard this) when I make a recommendation for coronary bypass surgery or TAVR or AF ablation, or starting a new therapy such as an anticoagulant, is, "What would you do if I were your mother, wife, brother, sister, or some family member?" They assume that physicians offer a better standard of care to their family and friends than they do to their patients, and this suggestion is difficult. Of course, if it were true, it would be very difficult to admit that. What if I were to say, "Oh, well, if that's the case, I would offer you a different treatment"? It would violate the oath we took when we first became physicians to give patients our best care.

Do doctors and their families get different treatment? Many people have written about this. There was an article in the New York Times [1] saying that doctors are getting VIP treatment -- perhaps more a story about overtreatment than about special treatment. Another blogger[2] has written about the importance of training employees to think like they're taking care of their own mother. A recent book written by Sandeep Jauhar, a cardiologist, is called Doctored: The Disillusionment of an American Physician . It discusses the hazards of overspecialization as a prominent problem in healthcare delivery and its impact on overutilization of care. There are very few encouraging media pieces about physicians' role in healthcare delivery. Sometimes when I see these articles I get very disappointed, but I do wonder whether it's like the old saw that everyone hates Congress but loves their congressman. Maybe there's general dissatisfaction with physicians or enough is being written about it that there is [an appearance of] dissatisfaction, but patients keep coming back to me because they have confidence in me.

Only Bad News Makes the News

One blogger, Pamela Wible,[3] wrote about why you should love your doctor. It's a piece I recommend, but what I would suggest to you is to read the angry, frustrated comments of physicians posted subsequent to that piece. Clearly, our role is substantial. Much has been written about poor treatment. Harlan Krumholz wrote in Forbes [4] about undertreatment and delays in treatment. There was even a recent rant[5] at the Aspen Ideas Festival by an internist, Rushika Fernandopulle, who comments on a frankly unbelievable case of permanent pacemaker recommendation.

There's really very little written about physicians' positive impact, and this is what's frustrating to me. The newspapers don't write about kindness and extra efforts people make, only about the broken parts of the system. It's not really exciting news, but in one 24-hour period as I was preparing for this blog, our cardiac cath lab staff stayed until 10:00 PM for a nonemergent reason. A 90-year-old patient came in with complete heart block and had 10-second pauses. Our options were to put in a temporary pacemaker and then a permanent one the next day, or to save the patient two procedures and just stay late and put the permanent pacemaker in, which the staff did, which was just an example of love for a patient who the staff didn't even know -- caring for the patient as if he or she were their own family member.

The day after that, the hospitalists interrupted morning rounds to discharge another patient of mine after PCI so that the patient could make his mother-in-law's funeral and support his wife. No small task with the enormous amount of discharge paperwork that's now federally required. Daily, we deal with arduous tasks of authorizing care from payers for procedures and for needed drugs. I recently read a blog by Wes Fisher[6] about his difficulty getting approval for a pacemaker from United Healthcare. The same day he posted that, I was having the exact same issue sending reams of data and doing personal phone calls to get my patient with syncope after TAVR approved for a pacemaker. Many times I said to myself, "This is not my problem. This is the patient's insurance. It's not my fault. I've done what I can." Fortunately, I pressed on. This is not really exciting news, but it's part of the work that we do.

There is growing malaise, growing administrative hurdles faced by medical professionals. There is maintenance of certification, which either you're going to do or you're going to make the difficult decision about taking on the hazards of joining the boycott. There's the anticipated implementation of ICD-10, which will be very onerous, difficult, and time-consuming. There's EHR adoption, and now there are even vendor changes that require us to go through that whole process again. I once blogged about how EHR adoption was the worst year of my life professionally. Maybe that's going to happen again. There is stage 2 of meaningful use. There are CMS audits that we deal with and the burden of documentation. I've previously blogged about the review of systems and how, if you miss one element of the ten-element review of systems, your note is completely invalid -- a standard that is really not held to by anyone (certainly not CMS). Where else does it have to be perfect or it's a zero?

GEFYS

These developments have really distracted me and other physicians from making patients our first priority. I've never been accused of being Pollyanna, but I still believe that those bad cases represent the exception, not the standard of healthcare delivery. In my own role as a physician leader at a local hospital, as a cardiac cath lab director and a cardiovascular steering committee director, I began to think about ways to encourage other members of the team, doctors and nurses but also myself, to prioritize patient care. At Lawrence General I began a small movement, a pay-it-forward concept that I call GEFYS, which stands for "good enough for your spouse (or significant other)." I have this little card that I share [with "GEFYS?" printed on it]. I'm not sure of its impact, but I really have been impressed by the consideration doctors and nurses give to it when I introduce the concept. It gives me hope that we can all rekindle the calling that made us choose a career in medicine in the first place. It's a small but not insignificant shift in the conversation around the hospital. It can begin to change physicians' hearts and help them reflect on the honor and gravity of our work. But it also reminds me of the critical aspect of patient care: to treat our patients with the highest aspect of love and attention that we would give our own family or loved ones. In my comings and goings, I keep the card tucked in my jacket pocket, and I sometimes even rub it when I'm getting frustrated, when I'm facing some kind of bureaucratic issue or hassle.

My last word on the subject is that I think we all have to remind one another to keep in mind what's true and pure and right and noble and admirable about our profession and why we went into this in the first place. It's not easy when we feel under siege. Conceding on these issues -- capitulating, as I thought of doing with my pacemaker patient when I was being hassled about approval for a pacemaker implantation -- actually makes us part of the problem rather than a last refuge of hope for a really broken system. This slight tactile reminder for me -- maybe just the touching of it, feeling the raised letters in my pocket -- can be of value as a reminder to stay centered. Occasionally, we get some good news, a reminder of why we do this. Patients don't often send notes, but one sent a note to the cath lab, thanking us for the care we provided when we put a stent in the patient's coronary artery and relieved him of his anginal symptoms. This got posted on the cath lab board to remind us all why we do this.

If you're interested in this tactile reminder or this gimmick strategy to try to keep you centered, send me your address and I'll mail you a copy. Until next time, I'm Seth Bilazarian. Thanks.

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