Corporate Medicine Kills Continuity of Care: It's All Just Business Now

For decades, one of the prime driving principles of medical care was the "physician-patient relationship."  And as part of this the idea that "continuity of care" is an essential feature of good medical care was unquestioned. 

Making sure the patient established a relationship with a doctor, who came to know her well, to follow her over years, who learned her way of expressing herself, who remembered what had happened to her in the past all seemed obvious advantages over a system in which the patient had to be "learned" by a new doctor with every visit. 

The difference between getting care at an Emergency Room or a "Doc-in-the-box" was continuity of care. In a brief visit, the physician does not have time to know all about the patient; he is solving a single problem and moving on. Hopefully, if there are underlying conditions or existing medications which might affect the choice of therapy, the new physician can catch that.

With the advent of the Electronic Medical Record, it was hoped that the whole sweep of the patient's history and medications would be available on line to any doctor, and so that information residing in the memory  of an individual physician would no longer be necessary. 

The problem is, the EMR has not lived up to expectations. The boilerplate format defeats any attempt to encapsulate medical history and medication lists are rarely updated and become massive and lose their usefulness. 

But the idea among medical administrators has become "Oh, none of these doctors stays for more than 3 years, so what difference does it make?"

Of course, the reason doctors who are corporate employees are moving is the first contract they get, typically for 2 years is the best they will ever see, so at the end of that period, their pay is cut, their workload increased and they start looking for another job and they are gone by year 3. 

From the administrator's point of view, their MBA programs taught them to look at doctors as if they are simply workers on an assembly line making widgets, so having to replace them is not a failing on the part of management. Doctors do not have to be "retrained" beyond getting them accustomed to a new EMR.

When the Portsmouth Hospital lost six specialty practices over the past year, the offices in the doctor's office building across the street from the hospital emptied out and the administrator who presided over all this was not perturbed. Sure, there was no longer neurology for the stroke patients, pulmonary for the asthmatics and emphysema patients, endocrinology for the diabetics, but there was also no longer all that rent for office space, or salaries for office staff and for doctors. Overhead fell dramatically. The balance sheet looked good.

The balance sheet for the hospital however, did not look quite so good--all those doctors "fed" the hospital, so in financial terms the hospital took a huge hit.  

And of course, what the MBA's did not understand was that losing all those specialists meant the patients got little or no care for those problems, which is to say, patient care suffered. But who has good metrics for "quality of care?"

The CEO of the hospital lost her job, but the administrator of the doctors' practices across the street got congratulated and got a promotion.

The fact is, continuity of care may not be as essential as we once thought it was. It certainly makes the patient feel happier, but sometimes having a new doctor every 3 years means the patient gets reassessed and things which are not working get questioned and improved. 

And patients do vote with their feet.  The rise of nurses doing Minute Medicine in pharmacies, of Walk In clinics where you need no appointment and can just show up when you find it most convenient and the ongoing use of Emergency Rooms by people who have a cough for three weeks or who need a blood pressure medication renewed or who have been having headaches and vomiting for two months but just haven't found a doctor all suggest people do not value that idea of good ol' Doc Brown, who knows me and who took care of all my family. They just want a prescription or a pain reliever, simple transaction with an anonymous provider. Don't give me something complicated; just give me a shot of something to make me feel good.

Who knows? Maybe this brave new world of corporate medicine, in which every patient is simply a customer and every practice a cost center really is more efficient.  Maybe the old one on one doctor/patient relationship is as outdated as making shoes by hand for each customer.  Maybe medicine will benefit from assembly line medicine.