Tuesday, August 20, 2013

Unprofessional Behavior: What it Means To Be A Professional

One college course Mad Dog remembers  was taught in the department of Sociology called, "The Professions" and the professor, a very humble man from the Midwest, spent considerable time trying to define what constitutes a "profession." This imbued Mad Dog with, not a definition, but a sense of the difficulty of defining the idea of a profession.
Part of the problem for Mad Dog, and for the professor,  was neither had ever really had any significant experience as a professional. 

One aspect of being a professional is having been exposed to all the things which are relevant to the execution of the things professionals in a given area do. So the professional football player has seen it all--he recognizes all the patterns and the plays he may see, and he has been coached and taught, so nothing is really a surprise. He may not be able to process everything quickly enough, but he is not surprised. Of course, this is not really true--you see coaches diagram things on the sidelines, teaching players what just happened, things with which they were unfamiliar.  All professions involve ongoing learning. 

Real professionals notice things non professionals do not. They see details and integrate them into meaningful action as non professionals do not. So a doctor notices the subtle jerking at the wrist of the alcoholic, asterixis, when nobody else in the room picks up on that.  The cornerback notices a tell in a wide receiver who always puts two fingers on the ground when he is going on a deep route, but three fingers when he is falling back to block. But, of course, sometimes the professional misses that sign or simply never learned it.

Most professions have a language, which is used not just to exclude others or to make the professionals seem elite, but because it's functional, a shorthand. Of course, in medicine there is no functional reason "pruritus" is better than "itching" but most doctors use that Latinized word out of pride or habit.

Pride is a big part of professional behavior. Mad Dog has long held that 90% of what he learned in medical school in terms of "facts" and "content" and "core knowledge" turned out to be wrong, but what persisted as true were the values by which doctors operate:  You put the patient first, even at your own inconvenience, even at risk to yourself, and you see your duty through as if every patient were your own sister or brother.  

That value has gone out the window with the new generation of doctors, who work "shifts." The new doctor severs his relationship to the patient at the stroke of midnight, when he signs off work and hands over his patients to his replacement on the night shift. Of course, this does not always happen, but with the new rules about limitations on hours interns can work, that is the unintended consequence of the idea of limiting overwork and on team work. If the team takes care of the patient, then no one doctor has to, or can,  feel really responsible to get that patient through the night. 

Now we have MBA's ordering doctors about, determining their work hours, the doctors' salaries, the amount of time they can spend with each patient, what sort of services the doctor can provide for the patient, or how the doctor should use his time with the patient.

Good example:  A patient is referred to an endocrinologist for possible thyroid nodules. The patient's primary care doctor examined the thyroid and thought it might be a bit lumpy. Off goes the patient to the endocrinologist who might do a sonogram of the patient's thyroid and answer the question right then and there.  But no, in order to bill for a full new patient consultation, the endocrinologist has to ask the patient about whether or not he has abdominal pain and diarrhea to fulfill requirements for a full "review of systems" so the doctor can charge the patient the highest consultation fee. The doctor has to ask about drug allergies, which likely will be irrelevant, and about whether or not the patient drinks or smokes. 

 All of this questioning eats up the clock, adds nothing to solving the question at hand, but is required by some legal regulation which determines the "level" of the consultation, and thus the level of payment and the MBA insists all this be done so the maximum charge can be wrung out of each patient. 

The sonogram of the thyroid however, cannot be done at that first visit,  because it is compensated at a low value for the doctor, and the organization for which both the MBA and the doctor work make more money if that study is done in radiology.

So, the patient walks out of the office without her question answered: Do I have thyroid nodules? She has to make another appointment with radiology,  and await word on the endocrinologist's review of the sonogram he could have done in his own office, but for the law laid down by the MBA,  who rules the practice. 

Revenue for the practice has been maximized, but the doctor has been denied the opportunity to answer the patient's question as quickly and easily as possible and the patient has been left dangling. 

Has that doctor been professional? 

And consider the MBA, is he a professional? He has maximized profit for the organization which employs him and the doctor, but has he enhanced or diminished the quality of patient care in doing so? One might say, the MBA's job is not to enhance the quality of care,  but to maximize the quantity of profit in the practice.

If capitalism and the profit motive are the greatest, most rigorous drivers of "efficiency" one might ask, what sort of efficiency are we talking about? Certainly not efficiency of diagnosis in this case, which would have led directly to the endocrinologist taking the patient into the sonogram room. 

No, it is the efficiency of the billing mechanism which has prevailed, dollar driven not patient driven.


No comments:

Post a Comment