Efficient We're Not

And we're not trying hard to get better

Most medical care is not "doing" a procedure, it's teaching, with a provider / instructor and a patient / student. Many providers of medical care are poor communicators and don't enjoy teaching. They prefer "doing" something, and perform poorly as teachers.

In a patient - teaching contest, some of our best trained and most experienced doctors couldn't attract two students. This is a terrible waste of their large fund of knowledge.

Highly trained providers are often involved in the care of patients with chronic problems of heart, kidney, lung, and joint origin. They are reimbursed by Medicare and other insurances at a generous level for this service. A very smart, very well trained, poor teacher / communicator can make lots of money and his patients will remain poorly educated about their illness or condition. This cannot be classified as "good" medical care, but many believe it is because of the status of being attended by a consultant with many initials after his name.

Specialty care clinics recognize the lack of communication skills in some of their most gifted providers and compensate with surrogate teachers whose training is far less remarkable but who can convey a message nicely. Unless the surrogate is a dietitian or trained therapist of some kind, compensation for her services will lag well below that for her boss. Patients often prefer this person for most of their heart or lung care.

A teacher surrogate is often a patient's primary care physician who finds it necessary to interpret what a specialist said, meaning two doctors get paid for the same thing - an office visit for heart failure, for example. It's inefficient, expensive, and it means waiting for two appointments rather than just one. What a crazy system this is!

In a team approach to medical care, teaching should be assigned to those who are good at it and who enjoy that part of patient care. And to make them more efficient, they should not be confined to the one-on-one tutor model, but should be able to teach several patients at once. The basic message is the same, for example, in dealing with all patients with congestive heart failure. It includes advice about diet, avoidance of salt, instruction in physical activity limits, careful use of medications, and recognition of problems associated with medications.

A good provider / teacher can spend an hour with five or more patients, all of whom will receive six-fold more training time, which can include personal attention as needed. Everyone will leave the session better equipped to manage his problem. This is such an obvious great deal, why aren't we doing it all the time?

First obstacle is that troublesome compensation thing. Neither Medicare nor other insurance companies have a code to cover reimbursement for group treatment of chronic disease. Rather than doing so, they persist in paying only for customary one-on-one care.

Second barrier is the privacy issue. Even though everyone else in the room is, say, diabetic, some people feel uncomfortable discussing their problem in the presence of others who may be strangers.

The third is the perception, usually held by those with perfect insurance, that the very best care possible involves one super doctor and one patient who deserves the best.

As we approach what some say is an inevitable melt-down of our healthcare system, it's well to keep in mind alternative approaches which would improve quality and availability of care and do it efficiently. None of the obstacles we just mentioned is insurmountable.

(Editor's Note: For another take on the healthcare "crisis" read Paul Krugman. This link will be effective only until April 21.)