Sunday, May 12, 2013

The Physician's Evolving Role in Healthcare: Lead or Be Led

This is a guest post by Wen Dombrowski, MD

During medical school and residency I realized that individual physicians can choose to Lead or Be Led. Each of us can try to design and manage the systems of care we would like to see (whether care models or technology that enables them), or physicians can be victims of what others decide we should do (such as administrators, sales reps, or well-intended developers without user experience insight).

I recall over a decade ago there were critics who lamented the rise of HMOs and Pay For Performance would end the Practice Of Medicine as we know it. Various medical organizations encouraged physicians to run away from these changes so they could continue business as usual. But while many physicians had their head in the sand and academic faculty were often shielded from practice management realities, the business world continued to evolve with new budgets, rules, and technology.

There are parallels to then and now : physicians are facing unprecedented changes -- some embrace or at least reluctantly accept change as inevitable, but many physicians have told me "I don't understand what any of that ACA/ACO/PCMH/MU/ABCDEFG is about, so I'm just going to ignore it and just be a doctor." Then they are surprised when their hospital, state, and federal policies don’t reflect what they would want.
When I tell people I chose to focus on healthcare administration and technology, many often ask "why did you stop being doctor?" My response is that I am still a doctor, and every day I use my knowledge of diseases and workflow to help not just 20 patients per day, but to improve the health of thousands of patients each day.

This brings up the question of what defines a Physician?
Both healthcare professionals and nonprofessionals often only think of the 10 x 10 foot office or hospital rounds. But like many other physicians, I chose medicine because it is a Helping Profession, and I want to help as many patients as possible to maintain and improve their health. We each have a responsibility to use our talents and tools to help patients...for some this may mean being a neurosurgeon, researcher, public health official, or CMIO, et al.

There are several converging factors in healthcare influencing upcoming trends such as telehealth and decision support:

* High cost of medical care
* Shortage of health professionals
* Rising consumer demand for convenience and instant answers
* Increasing development of predictive data analytics algorithms and internet connected technologies.

Telehealth will be a game changer for physician roles. Home monitoring, video visits, and other ways to connect patients and health information to clinical experts will disrupt the current face-to-face-only model of care.

Clinical Decision Support is often discussed in the context of physician decision making, but I think it’s inevitable that some CDS tools will move to the lay health worker and consumer level. However, I don’t think CDS computer algorithms can fully replace humans, especially with complex cases that don't fit the common presentation of common diseases. Also, artificial intelligence projects like IBM Watson are limited by Publication Bias because research about rare diseases or drug trials that show adverse effect are not published. These challenges create opportunities for physicians to position themselves as the Expert about complex rare cases and/or get involved in developing AI algorithms that make sense.

The technological and economic context of healthcare continues to change rapidly. Physicians can either proactively lead the change, or settle for whatever others impose on them.

About the author:

Wen Dombrowski, MD
Physician executive intersecting Technology, Business, and Policy


  1. Wen,
    Very nice presentation of the changing expectations of healthcare in the US. However, it is not that simple. The older doctors are not refusing to update as much as they have been through fads, before, and are not sure this one will last. And, if it does, it will likely go through several iterations; maybe it is better to wait till the dust settles. In addition, it is not time for the US to give up personal medical care, physicians play an important role in patient care. There is no way a computer can communicate effectively with patients. An, as of yet, physicians still are better at taking a physical exam and history.

    In the distant future, will physicians always be needed or replaced by machines is still up in the air. I believe that physicians will likely be on of the last jobs that will be replaced by computers and machines just because of the complexity.

    In the meanwhile, older physicians play a very important role in medicine. They are experienced in communication and understanding of issues that most younger physicians have yet to learn. When we care for patients, the older physicians have an understanding of the emotional issues that come with an illness. They have insight into subtlety.

    I think the medical system needs a mix of both old and new. The younger physicians are there to bring about change and the older ones are there to slow it down and advise the younger physicians about the ways to make it better.

    Lastly, on a personal note, my mother has had a recent change in her health status. She is quite appreciative of her physician who takes time to talk to her and explain the issues that affect her care and her future.

    I am a proactive physician and have kept up changes despite advancing years. But, I submit to you that we should not discount the physicians who are reluctant to change quickly. After all, they might know something you don't....

  2. Hi David,

    Thanks for your comments. Just to clarify, I’m not suggesting computers take over physicians roles, nor do I recommend following fads, nor is my critique aimed at “older” providers. What I’m trying to do is encourage all physicians who lament the changes they see in healthcare to GET INVOLVED IN THE DECISION MAKING PROCESSES THAT SHAPE HEALTHCARE SYSTEMS, instead of just complaining about being victims of the policy/business/tech forces around them (or of their own inaction).

    As a geriatrician, what I value the most is spending time listening to and talking with my patients. But in order for that to happen, the EMR usability, practice management schedule, room space availability, and a whole bunch of other SYSTEMS level factors need to be in place to allow for the personal attention that patients should get.

  3. Shawn, David and wen both bring up good points. Technology is here to stay as wen points out but I would include Davids clinical view and suggest that Doctors who want to lead do so by providing continuity of care and total care. The doctor can reach out on the tela conference if the doctor needs expert advice to the expert instead of sending the patient to see the "expert" who will always have only part of the history and story. Recall the expert will generally provide some words of wisdom before saying but I don't know everything else and I cant make the decisions the pcp needs to. For 99% of stuff most doctors don't need to reach out which is where continuity of care CURES THE INDIVIDUAL AND GLOBAL HEALTH CARE CRISIS. Of course the many specialists who want big pay but no or much less clinical patient responsibility will not like that and the enormous cut in pay that is coming. The "Doctors" who lead, set their private practice additional fees and build loyal, old fashioned, socially valued practices will be there to pay for the one or two tela conferences they need from some indian on-line super store of "experts". The doctor advocate will be there seeing the hospitalist as a VERY WELL EDUCATED FRIEND to his patient even if he is "not billing or giving orders". I imagine that educated friend who is a doctor will be hard for the hospitalist to ignore. should the hospitalist feel they are "too much" or not needed it will take a lot to document that view when a friend who is socially and personally committed is documenting the need. There is good news those specialists who want to be old fashioned doctors can open their doors and see patients. Great news again for primary care doctors we don't rely on insurance!! People can pay 200 / mo or more out of pocket. The Primary care doctors can visit the insurance doctor with his private patient and use the insurance for testing etc. So don't despair. Private practice is coming back soon. Don't be afraid to value your skills and service. Service is always needed. Also if 200 patients pay 200 / mo that is an extra 40,000 / mo which helps the bottom line. Lucky for pcp's is they don't need a big catchement group of patients. Imagine if doctors only treated 200 patients each life would be different for both doctors and patients. Insurance companies who promise the moom might be in a tight spot. Delegated care is generally not the best care. Seeing a new doctor ever time even if he sees you chart is a new experience for both the doctors and patient every visit and is likely to be similar to rolling the ball up hill only to see it fall again. For all of those doctors who want to dot the work and be full time doctors that job will always be there. For those who want to manage and have much less patient contact that will continue to evolve. Do not confuse continuity of care which is people oriented to continuity of the chart. Just my quick comments. Check out my blog and share comments with me.