Thursday, April 24, 2014

"Knight, knave, or pawn? Which is your doctor?"

     I am trying to go through some of my stacks of saved tear sheets. This was always a habit of mine -- to tear out sheets from medical journals, articles, the AMA newspaper and even lay print sources and stack them up somewhere to read later. Unfortunately time would often interfere with this "Read later" intention. And even as a retired physician, lack of time still interferes. So these stacks of paper reside in various places in my home. We are fortunate to have a big home and so these stacks can accumulate for some time. However, finally even in our large home, they begin to impinge upon my positive attitude and begin to weigh on me. Then I must develop a mood in which I can ruthlessly go through them and throw away a huge percentage. It was during such a purge that I came upon this article from JAMA, September 1, 2010 -- Vol 304, No 9.This was a commentary by Sachin H. Jain, MD, MBA, and Christine K. Cassel, MD entitled "Societal Perception of Physicians:  Knights, Knaves, or Pawns? "  Both authors are affiliated with the Office of the National Coordinator for Health Information Technology, Washington, DC. There are many writings in our medical journals that I think should be more available to the general lay public. This article is just such an article. I recommend that all past, present or future medical patients -- that basically means everyone -- read this with concentration. It is short but very well written.

The above site gives you the first page of this article but will only let you see the second page if you sign up to JAMA (Journal of the American Medical Association). Therefore I have provided the second page below:

     "Le Grand's work on post-World War II British social policy found that perceptions of human motivations gradually transformed, with the prevailing view of the typical British citizen morphing from knight into knave as the costs of maintaining an expensive welfare state increased.
     "US perspectives on physicians have undergone a similar transformation with the increasing cost (both to taxpayers and to individual patients) of health care delivery. As physician behavior has been tied to these rising costs and increasing scrutiny has been applied to the quality of care delivered, policy discourse often reflects the perspective that physicians are an obstacle not an enabler to a functioning health care system. Rather than being counted on to exercise their professional ethic to address problems in health care delivery, physicians should be guided to do what is right with an increasing menu of incentive payments (ie, pay for performance or value-based purchasing) or strict regulations. Rather than being counted on to maintain their knowledge and expertise on their own accord, they are subject to periodic examinations to demonstrate continued proficiency.
    "These views are grounded in evidence of unwarranted variation in care, clear evidence of waste and even fraud, and decline in knowledge over time.The modern US physician is regarded as either a knave or a pawn and is seldom regarded as a knight. but the evidence that has led to distrust of physicians does not apply universally and many physicians still are the knights in the health care system. How can society be sure not to undermine those motivated by professionalism while guarding against those motivated by self-interest?
     "Not all policy prescriptions have abandoned the view of physician as knight. Prepaid models of health care payment such as accountable care organizations and the patient-centered medical home place responsibility in the hands of physicians -- with the idea that physicians will be responsible stewards. In these examples, physicians must be counted on to organize and structure care delivery, responsibly use resources, and measure and improve individual and population outcomes. Still, it is perhaps the knavish conception of physicians that makes these physician-driven models of health care delivery more the fodder of pilot projects and demonstrations than models that are rapidly adopted and widely disseminated.
     "Le Grand offers an important lesson and warning: it is critically important to understand and get 'true motivations' right. Disaster may follow if persons largely of a knavish quality are treated as knights; but the same maybe true for 'policies fashioned on a belief that people are knaves if the consequence is to suppress their natural altruistic impulses and hence destroy part of their motivation to provide a quality public service.' Le Grand further warns that policies that 'treat people as pawns, may lead to demotivated workers...again causing adverse outcomes for the polices concerned; while polices that give too much power...may result in individuals making mistakes that damage their own or others' welfare.
     "The US public would be wise to heed Le Grand's advice and carefully consider whether its perceptions of physicians match reality. For their part, physicians must thoughtfully consider whether and how they contribute to the perception that they are knights, knaves, or pawns."

 Le Grand J.  Motivation, Agency, and Public Policy: Of Knights, Knaves, Pawns and Queens, New York, NY; Oxford University Press, 2003.

Choudhry NK, Fletcher RH, Soumeral SB. Systematic review: the relationship between clinical experience and quality of health care.  Ann Intern Med. 2005; 142(4) 260-273

Committee on Quality and Health Care in American; Institute of Medicine. Crossing the Quality Chasm. Washington DC: National Academies Press 2001.

McClellan M, McKethan AN, Lewis, JL, Roski J, Fisher ES.  A national strategy to put accountable care into practice.  Health Aff (Millwood). 2010; 29(5) 982-990.

Enthoven AC, Tollen LA.  Toward a 21st Century Health System: The Contributions and Promise of Prepaid Group Practice. San Franciso, CA; Jossy-Bass; 2004.

     Naturally, reading this led me to consider my own career which is now in the past, but which spanned a time period notorious for rapid and dramatic healthcare system changes. I know from my own experience that remaining a "knight" in the current healthcare system, though obviously desirable and expected by most patients, is exceedingly difficult. It involves expenditure of precious time during and after the patient visit and as a result since the main thing that primary care physicians have to sell is their time, being a "knight" reduces the physicians pay. Still many physicians are willing and do accomplish this exacting task. I like to think that I did at least some of the time. As an example, as was often shown in studies, being a woman physician, I spent, on the average, more time with my patients, and therefore saw fewer patients in a day. But I must admit that sometimes the battle that was required against insurers, and other providers as well as sometimes against the patient's own views themselves, often became overwhelming. When that would happen, I would not uncommonly resort to the "pawn" role. Sometimes it was just easier to say: "I'm sorry, but your insurance doesn't cover that test." During my years of practice, the amount of regulations, the interference of insurers and most recently the governmental requirements and guidelines became more and more obstructive to the "knight's" role. I think that is why many physicians volunteer in other countries or on the Hope Healthcare ship, and in other such opportunities. There they can totally fulfill the "knight" role. It is certainly a refreshing role to fill and a goal that all we MDs had when we graduated from medical school.

     I must make a comment about the "knave" role. I know that such physicians exist. They are the "in and out" physicians who hurry patients through their system, increasing the bottom line by volume, and decreasing the time that the MDS themselves spend with direct patient care. They may indeed learn a new procedure and perform it with excess in order to pad their bottom line. But I do think these physicians are rare. Even the super specialist feels a need to relate closely with the patient. Our selection for medical school and the education and breeding that goes into those 4 years of training holds too strong a power for most MDs to become outright "knaves." Indeed, the question is how to weed out or at least identify those few "knaves" without making the regulations so intense that it turns all of the "knights" to "pawns," and maybe even eventually into more of a "knave." This weighty question is very difficult to answer. But I fear that we have tipped too far into these regulations and requirements. Many physicians, particularly those in primary care, admit to dissatisfaction in their work. I think the latest numbers suggest that as many as 55% of primary care doctors are dissatisfied. That is much too high of a number. It has long been known that job satisfaction is inversely related to the degree of power that the job holder has in his/her day to day work.  I think that this dissatisfaction in MDS and the powerlessness that goes along with it directly relate to the gain in power that has been achieved by insurers and governmental agencies in the healthcare field. We are at a tipping point. And I am fearful that the regulations in Obamacare may cause many more physicians to "hang it up" due to this dissatisfaction.

     These considerations need to be known to the lay public. Society needs to make some very difficult decisions and there needs to be a new way of thinking about exactly what kind of doctor it wants. It would be difficult to achieve a total "knight" medical core, but we must not drive all physicians through the "pawn" stage to either retirement, or the "knave" stage.

     I would appreciate any comments that you might have, whether physician, physician to be, or patient. What do you think?

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