Health Care Literacy - the conversation
Conversation is one of the most fundamental tools we use each and every day, to guide us in our lives. We gain and relay knowledge through conversation. We share our life's experiences, whether happy or sad. Simply put, conversation is what guides us through our lives. In medicine, the conversation between a patient and their doctor can be a life changing experience. A good patient will be a good listener and will interact, asking questions to insure they understand the plan for their health care. And a good doctor will instruct the patient using anecdotes, analogies and perhaps a little bit of humor to help their patient understand the reason for their condition and the steps necessary to improve their health. Over time, one of the most important aspects of this ongoing conversation is the relationship that develops between the patient and the doctor. At the core of that relationship is trust.
As the financial pressures placed upon doctors increases, a business method used by medical practices has been to delegate the patient-doctor conversation. Delegation of the patient-doctor conversation is a business model used to enable the doctor to see more patients. In the business of medicine, delegation of the conversation is known as using physician extenders. If you've tried to see your doctor lately, you might know exactly what I'm referring to. You make an appointment with your doctor but instead you see the new nurse practitioner. At first you balk, but then acquiesce to see the nurse practitioner jsut to get your prescription refilled, right? You just want to get your health care problem taken care of, so, you say, OK fine, I'll see the nurse practitioner.
I understand the business model of using physician extenders and to some degree, I think there's some value in it. For instance, I have days where I have the same conversation, over and over, about the same condition. Is that using my time wisely? Would it be better to have a mid-level provider like a PA (physician's assistant) or NP (nurse practitioner) speak with the patient? And I understand the business challenges today in medicine with decreasing reimbursement. But to not even see the doctor? I thought I paid for my 'doctor's visit' to see the doctor. It may be a good business model for the provider, but as for the patient, what happens to the conversation? What about the relationship and the trust that comes from meaningful dialog? Is that conversation between the patient and the doctor still uniquely special or has it just become a commodity?
Let me give you an example. One of my immediate family members developed lump on her collar bone. No pain, just swelling. She tried to make an appointment with our local doctor and was scheduled with the practice's new nurse practitioner. Bear in mind, one of the standard of care in the practice of medicine is to do a comprehensive history and physical exam prior to making any assessment of any condition. The nurse practitioner failed to do so. Her first question was to ask whether there any history of cancer in the family. The reply, "yes, my mom died of lymphoma." That was the end of the history and a CT scan was scheduled. The findings of the CT scan were inconclusive and an MRI was recommended. The MRI identified costochondritis, an inflammatory condition of a joint in the collar bone. My family member walked away with a scare, a bill for $2500 and a bad taste in her mouth. She no longer goes to that practice.
I work with a number of nurse practitioners who are very good at their jobs. I am most familiar with cardiology NP's who are to point guards for in-patient cardiology care. But you know what's unique about their care? In every case, the doctor still sees the patient. The NP may see the patient first and do the work-up, but the doctor always sees the patient. When you see a NP on an out-patient basis, like your doctor's office, you'll never see your doctor.
So what's my point here? My point is about the conversation. What happens to the conversation in the physician extender business model is that it is delegated. The relationship between patient and doctor and the trust that is built upon that conversation is thrown aside. My point is that health care literacy is dependant upon the conversation. Take away the conversation and you'll see patients change. Patients will be less willing to listen and less willing to follow through on instructions. Delegation of the conversation may work for the physician's bottom line, but for the patient, delegation of the conversation results in a loss of trust and less effective care.
Jeffrey A. Oster, DPM