Today I met a nurse practitioner who had resigned from medicine for good a year ago.
A nurse-practitioner is a registered nurse who has returned to school to get additional master’s degree training in clinical medicine and works something like a very caring, less trained physician. This man was good with people and appreciated the uniqueness of individuals. He worked in a Family Practice clinic at Kaiser-Permanente in California and hated every minute of it. What he found intolerable was that he was told exactly how he must practice medicine.
Kaiser-Permanente was one of the first huge HMO’s (Health Maintenance Organization) that took over the delivery of medical care in California. What is an HMO? It is a corporate entity that takes money from businesses in exchange for paying for their employees' medical care. HMO's are different from insurance companies in that they see it as their mission to dictate every aspect of medicine, and to take autonomy away from physicians. Their advocates are fond of saying that physicians "don't know anything about business." These days HMO’s also take money from Medicare, Medicaid, states and individuals, and promise to provide more economical medical care to the people who need it. They hire doctors as employees, or they contract with doctors and other medical providers (like nurse practitioners) to see patients and not to spend a lot of time or money doing it. If doctors spend money on patients the HMO posts lower profits. Not good, since their only motive is to make money.
In my mind Kaiser-Permanente is famous for introducing the 6-minute visit. I remember this being the model for doctors: Don’t spend more than six minutes in the exam room with the patient, because otherwise you won’t see enough patients in a day to cover the cost of your salary and overhead...and there won"t be enough leftover to pay the executives who need to make a profit from your relationship with the patient. It became a joke among doctors. Can you address a patient’s underlying alcohol problem, high blood pressure, high cholesterol and obesity in six minutes? Of course not, so you don't bring up the alcohol problem (which contributes to high blood pressure) or obesity (which is related to high cholesterol); you take one and a half minutes to listen to the patient’s heart and lungs; you ignore other risks for heart disease; and prescribe two medicines--one for blood pressure and another for cholesterol. Then you stand with your hand on the doorknob and say good-bye to the patient. Next? It’s a patient-factory.
Are HMO’s and pharmaceutical companies in bed with one another? Because the only way to see patients quickly is to prescribe medicines and pretend this will substitute for “care.”
Are HMO’s and laboratory companies in bed with one another? Because the only way to assess what’s happening with a patient in six minutes is to pretend that everything right or wrong about a patient’s health will be manifested in the lab results. There are many patients who actually believe this. If the doctor doesn’t do labs they don’t think they had good care.
The nurse-practitioner who quit Kaiser said he could have spent up to fifteen minutes on a patient as long as that included writing prescriptions, making referrals for tests and specialists, and writing a detailed note about the patient’s visit in the chart.
But if you want to “take care of” a patient in six or fifteen minutes, including writing an office note, keeping a flow sheet of test results, and making referrals you must do nothing more than order blood tests and write prescriptions.
These are rote tasks which reduce physicians to computers. A doctor-patient relationship might be developing in that six minutes (really?), but that’s not important from the standpoint of the HMO.
The nurse practitioner who told me his story said that Kaiser required all physicians and providers to follow algorithms for practicing medicine, and when they failed to do so they were sanctioned.
An algorithm is a recipe. Algorithm-driven medicine is “cookbook medicine.” It’s the opposite of personalized care; it’s the opposite of recognizing that we are unique individuals. It defines a patient by a medical diagnosis, then dictates what to do first, second, third in the way of treatment. Thus, a patient who coughs might quickly be diagnosed with bronchitis, given a “Z-pak” and discharged. If the patient has other problems, it’s best to ignore them or the visit will exceed the allotted time-frame. HMO’s have pre-written directions for what to do for a multitude of conditions. Perhaps these should just be published on a website for patients to use for self-treatment. We could make the prescriptions available on-line too, and do away altogether with doctors, who are an unnecessary expense for the HMO--except that some patients seem, perversely, to believe in them.
Ten years ago I had hoped that HMO’s would disappear, that people would see how bad, ultimately, this kind of medical care was, but instead HMO’s have taken over many parts of the country. Where I own a private practice in Florida there is still the possibility of being a solo doctor, but insurance carriers and governmental agencies are closing in on physicians, and HMO's are infiltrating the state, replacing Medicare and Medicaid. Since I am not capable of 6-minute visits, HMO saturation would make me obsolete in short order--if I hadn’t already accumulated other reasons for abandoning my career. In any case my tenure as a physician is very limited.
Today I found myself envying the nurse practitioner who managed to get out of what he called the war zone of medicine before it had done him too much damage.