First they did away with house calls, now Donald Berwick wants to dramatically restrict office calls. Or at least, that’s what the temporary (recess appointment) Medicare chief and rationing proponent advocated in a document he wrote and published before entering government while the head of the Institute for Health Care Improvement.
In Escape Fire: Lessons for the Future of Health Care, Berwick makes a breathtaking proposal that would seem to guarantee each of us all the health care we want, whenever we want to receive it . From page 42:
The new system of access can be summarized in one phrase: “24/7/365.” The access to help that we will envision is uncompromising, meeting whatever need exists, whenever and wherever it exists, in whatever form requested.
Whoa. That certainly doesn’t sound like the Donald Bewick who has waxed romantically about the rationing board NICE and the UK’s NHS.
So, how do we square the two Donald Berwicks? There’s a catch! Berwick simply restricts the scope and meaning of “whatever need exists, whenever and wherever it exists, in whatever form requested” so that, as implemented, it would eliminate most face-to-face patient/doctor interactions. Again, from page 42:
Access 24/7/365 begins to be achievable only when we agree—scientists, professionals, patients,payers, and the health care workforce—that the product we choose to make is not visits. Our product is healing relationships, and these can be fashioned in many new and wonderful forms if we suspend the old ways of making sense of care.
The access we need to create is access to help and healing, and that does not always mean—in fact, I think it rarely means—reliance on face-to-face meetings between patients, doctors, and nurses. Tackled well, I believe that this new framework will gradually reveal that half or more of our encounters—maybe as many as 80 percent of them—are neither wanted by patients nor deeply believed in by professionals…
The health care encounter as a face-to-face visit is a dinosaur. More exactly, it is a form of relationship of immense and irreplaceable value to a few of the people we seek to help, and these few have their access severely curtailed by the use of visits to meet the needs of many, whose needs could be better met through other kinds of encounters.
Dinosaur? “Healing relationships?” (Gobbledygook alert!) 80%!
Sure some efficiencies can be realized by having doctors available by phone, using e-mail, and having test results sent by computer. This is already done in some plans, such as my mother’s Kaiser Permanente Medicare program. But chat rooms, “group visits of patients” (what about privacy?), and other hands off methods, can only do so much and go so far. Moreover, doctors use face-to-face meetings for more than just exams. Sometimes, a doctor can take one look at a long-time patient who might be unwell and tell that something is amiss. In short, doctors need to see patients.
Berwick is thought of by some as a visionary. He is certainly dedicated to bringing new ideas to the practice of medicine. But it seems to me that when he wrote that we all should have total access whenever and however we want it, he wasn’t being straight. He was really talking about another method of restricting care. Moreover, it is one thing for younger and healthier patients to use more modern methods of communication. It is another for the elderly and the relatively uneducated. We aren’t all into I-phones.
That is why I fully expect–and want–his formal appointment as Medicare head to be rejected by the U.S. Senate. Let him go back to the non profit sector where he can bubble over with ideas and promote futuristic medical procedures and processes–outside of the corridors of real power.
November 16th, 2010 | 9:24 pm
[...] This post was mentioned on Twitter by Vince Humphreys and Stand In The Gap, Wesley J. Smith. Wesley J. Smith said: Berwick Wants to Do Away With 80% of “Dinosaur” Patient/Doctor Office Calls » Secondhand Smoke | A.. http://bit.ly/aSgzwg [...]
November 16th, 2010 | 11:13 pm
Berwick is apparently more in touch with modern health care than you are, Wes.
At my HMO, I have a primary care physician but I only see him, I’d guess, 1 out of 4 visits, if that. I see physician’s assistants, I see nurse practitioners, I get prescriptions refilled over the internet. I often e-mail questions and get answers either from my primary or whoever he refers it to, who typically knows more about that particular area than my primary.
Contrast that with my experience growing up, where we had one doctor for everything, and if he was unavailable, well, either you waited or you picked another one out of the phone book. (Oh, and the sub would have no access to your health records.)
My access to both basic and specialized health care is far better this way than in the old days. Berwick’s right, the old country doctor is a dinosaur.
Wesley J. Smith Reply:
November 16th, 2010 at 11:15 pm
Berwick is wrong, padraig. I agree those things are fine as far as they go–as I stated in the post. But 80%? And to claim that it gives us all total access whenever we want to have all the healthcare we demand? You are smarter than that.
November 17th, 2010 | 11:14 am
What Berwick said, Wes, was “I believe that this new framework will gradually reveal that half or more of our encounters—maybe as many as 80 percent of them—are neither wanted by patients nor deeply believed in by professionals…”
So #1, you’re exaggerating by only mentioning the 80% part. Berwick’s estimate was far more conservative.
#2, my personal experience shows you can get quality health care seeing your primary doctor only 1 out of 5 visits, which is 80%, so even that high estimate is realistic.
#3, he’s only talking about visits that both the patient and provider feel are unnecessary, which means they are getting all the health care they need. He’s talking about providing the same level of care with less wasted time.
And as far as “all the health care we demand”, who’s promising that? No insurance company, that’s for bloody well sure. That only happens in hypochondriac heaven.
November 17th, 2010 | 12:31 pm
I would like to see some streamlining of medical care for common conditions. I have a doctor that I see to manage my long term health needs, but I’ve always found it inefficient that in order to get a prescription for codeine cough medicine when I have a cold I need to wait until he’s available, drive 45 minutes to his office and another 45 minutes back, and pay $150 to get a $10 medication.
Some countries allow pharmacists to dispense commonly needed but (understandably) restricted medications. I don’t necessarily advocate that path, but perhaps there are ways we can compromise between the two extremes for treatment of colds, flus, and minor infections.
November 17th, 2010 | 2:22 pm
Jen, if there’s a reputable HMO available to you, I highly recommend it. Since they’re provider-owned they’re very motivated to streamline procedures. Also, they’re very prevention-oriented, since it’s cheaper than late treatment.
November 18th, 2010 | 6:36 am
In order to make an accurate diagnosis, doctors MUST have, in person, interaction. The diagnostic process, requires the doctor to assimilate all of the physical findings, such as skin color, and texture, heart, breath, and bowel sounds, and the nuances, of these that can only be detected with stethoscopes, pulse, alterations, detected by palpation, of the various organs. They take this information, combine it with their vast (hopefully!) knowledge of anatomy, physiology, biochemistry, pathology, and clinical experience, to formulate a diagnosis, and subsequent treatment plan. This can only be accomplished, the “old fashioned” way, by personally examining the patient. Indeed, all large part of the diagnostic process, is done, as a result of the physical examination, and the history, provided by the patient.
Diagnosis, is a complex intellectual indeavor. Even amoing the most intellectually gifted, and morally motivated, cognitive errors, and distorions, in the diagnostic process, can arise. And this occurs, when doctors physically examine the patient! A book, by Jerome Groopman,M.D., provides illumination, on the cognitive errors that doctors are prone to.
Padraig’s point about Physician’s Assistants, and Nurse Practicioners, is good. but only, when they physically examine the patient, and have immediate access to a physician, to deal with the nuances of the diagnostic process. Certainly, Physician’s Assistants and Nurse Practicioners have extensive training, but if they’re too autonomous, a misdiagnosis, is at risk. Physicians training contains much more of the didactic process, than PA’s, or NP’s. So, if the patient has a complicated, or relatively rare condition, only a physician might have the knowledge necessary to detedt it, and treat it, or know when the condition warrants being treated by a specialist (e.g., neurologist).
November 18th, 2010 | 6:37 am
Also, lawssuits might result, further complicating the financial aspects of health care.
November 18th, 2010 | 6:51 am
There’s no question, that doctors must interact, physically, with their patients. The diagnostic process, is complicated one, and requires a doctor to physically examine, as well as take the medical history from the patient.
Diagnosis, is a complicated intellectual process. Doctors are prone (as is anyone) to cognitive distortions, even when the patient has been fully examined physically, let alone when they haven’t!
Physical examination, can yield many nuances, such as heartbeat, breath sound, and bowl sound changes, that can only be detected, upon physical exam.
A doctor’s ability to formulate an accurate diagnosis, is dependant on her knowledge of anatomy, physiology, biochemistry, pathology, and the physical exam and history.
Padraig’s point, about Physician’s assistants, is good. But they, of course are physically examining the patient. Also, Physician’s assistants, and their nursing counterparts, Nurse Practicioners, although highly educated and trained professionals, lack the didactic training and knowledge, that doctors possess, therefore, to allow them too much autonomy, would be to put patient health at risk. There must always be physician oversight, and physician access, must not be restricted, so that PA’s and NP’s can consult with them, regarding particularly difficult, or uncommon conditions.
November 18th, 2010 | 10:36 am
There is something obscene in using the word “product” to refer to healing the sick. Any physician who would speak that way discredits his profession. And is a cancer on the body politic.
November 18th, 2010 | 11:04 am
Bret: “There must always be physician oversight, and physician access, must not be restricted, so that PA’s and NP’s can consult with them, regarding particularly difficult, or uncommon conditions.”
That’s pretty much how they handle it, Bret. My doctor acts as sort of a team leader. In addition to the nurse practitioners and PA’s I’ve seen my doctor’s been good about farming me out to specialists as needed.
It helps that I’m good about getting in for routine physicals, so I’m not getting health care via e-mail. They still poke and prod me at regular intervals.
And hey, any time you want details on my colonoscopy….. ;)
November 18th, 2010 | 2:57 pm
As tempting as your offer clearly is, Padraig, I’ll have to pass. But the details of your urinalysis, I want to see immediately ;-)
November 19th, 2010 | 12:10 am
Physician Assistants and Nurse Practitioners are welcome and necessary additions to the Primary Care system. Nevertheless, through no fault of their own, they will sometimes fail to diagnose certain rare diseases and rare presentations of common diseases that will be recognized by Internists and Family Practitioners who have had more extensive training. It has been my observation that physician supervision of PA’s and NP’s varies widely from practice to practice.
November 19th, 2010 | 10:41 am
Bret: “But the details of your urinalysis, I want to see immediately ;-)”
Pretty dang boring these days. My drugs of choice are ibuprofen and Tullamore Dew. Simultaneous, in a hot bath. Better than any of that crap we tried back in college.
November 19th, 2010 | 6:39 pm
[...] Wesley J. Smith discusses Donald Berwick, temporarily appointed Medicare chief, and his view that the patient/doctor office call is highly overrated. [...]
November 20th, 2010 | 8:47 am
good point, Padraig. Your approach, will help you stay away from the doctor. of course some of the, ah, shall we say, less legitimate drugs, used by some college students, might make them intimately familar with their doctors :)
November 21st, 2010 | 1:50 pm
Over time it seems that I am able to get more and more accomplished without seeing my doctor. This is a great convenience. But he’s been my primary for 20 years and I trust him to spare no trouble or expense to protect my health. I know that I can get a prescription for a sinus infection over the phone but I also know that I can see him if I believe it’s necessary. It seems that the more he has been willing to do over the phone, the easier it has been to get a quick appointment.
So what is Berwick really talking about here, allowing people to do sensible things or force fitting them into a mold to cut costs? Does he know the difference?
Wesley J. Smith Reply:
November 21st, 2010 at 4:15 pm
Charles R. Williams: It seems to me, the latter. He says on one hand that patients should get all the health care they want, not just need, when and how they want it. But then he says it will be via “healing relationships” other than doctors in the vast majority of cases. To me, it’s a way of restricting care while pretending to be doing otherwise.
November 24th, 2010 | 2:17 pm
[...] pal Nat Hentoff, one of the country’s most respected civil libertarians, weighs in against Donald Berwick’s desire to eliminate most doctor/patient face-to-face meetings, Paul Krugman’s assertion that we need “death panels” to control costs, and [...]
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