Coping with Organizational Intrusions on the C
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Doctor‐Patient Relationship: A Qualitative Study
Courtney B. Jackson, PhD
John B. McKinlay , PhD, FACE
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Rebecca S. Piccolo , ScM
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Lisa D. Marceau, MPH
ACADEMYHEALTH ANNUAL RESEARCH MEETING
ACADEMYHEALTH ANNUAL RESEARCH MEETING
JUNE 28, 2010
Overview
• Background
• Methods
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• Results
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• Implications Implications
Doctor‐Patient Relationship of the past…
They once had the stage
to themselves
Patient‐Centered 21st Century Medicine…
The stage is now so crowded!
Doctor‐Patient Relationship of the past…
They once had the stage
to themselves
Patient‐Centered 21st Century Medicine…
The stage is now so crowded!
Methods
• Vignette factorial experiment • Explain variability in physicians’ clinical decisions
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• 178 physicians in NY, NJ, & PA
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i NY NJ & PA
• Structured interview, qualitative think aloud, self‐administered ,q
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questionnaire
• Supported by a grant from US National Institute of Health grant (DK66425).
Focus of this presentation
Focus of this presentation
• Qualitative think aloud data
Qualitative think aloud data
• Study participants asked open‐ended questions: yp
p
p
q
treatment goals challenges and opportunities in providing care predictions of outcome • Uses physicians
Uses physicians’ own words
own words
Research questions
Research questions
1. How do primary care physicians view intrusions on the p
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doctor‐patient relationship?
2. How do primary care physicians respond to these intrusions? How do primary care physicians H
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view intrusions on the doctor‐patient relationship?
1. Inefficient 2. Potentially harmful
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3 Undermine physician authority 3.
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4 Erode trust
4.
Erode trust
1 Inefficient
1. Inefficient
“I had somebody here clearly with neurologic findings, reduced “I
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reflexes on the right side, history of low back pain. This patient needs an MRI of their lumbar spine, there’s no doubt. But what do p ,
I have to do first? I have to send them for X‐ray because if I don’t send them for X‐ray, I’m going to get a pre‐cert on the MRI…Well, as far as I’m
as far as I
m concerned, I
concerned I’m
m throwing money away to get X‐rays throwing money away to get X rays
that I know are going to be useless…And it delays the time that I’m actually getting my patient diagnosed. Is that a tragedy? No, but it’s just so frustrating that it’s all paint‐by‐numbers, and I don’t practice medicine paint‐by‐numbers...And I would actually save these insurance companies tons of money if they would let
save these insurance companies tons of money if they would let me practice medicine the way I need to practice it.” [160002]
2 Potentially harmful
2. Potentially harmful
“It’s very hard to be able to give your patient the best care when certain medicines aren’t approved.” h
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[185105]
3 Undermines authority
3. Undermines authority
“What frustrates the hell out of me is somebody with a high school education telling me what I can and cannot prescribe for my patients. That infuriates me. I’ve had 11 ib f
ti t Th t i f i t
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years more of education than somebody who is telling me I can’tt do something that I feel is best for my patients. And can
do something that I feel is best for my patients And
it’s not because I have delusions of God‐hood. It’s because I read the evidence‐based medicine, and I’m trying to use the drug that has the best indication and the best response.” [160002]
4 Erodes trust
4. Erodes trust
“We live in a very cynical world, and doctors and the medical establishment are not held in the same esteem they were There are conflict of interest issues
esteem they were. There are conflict of interest issues that [patients are] aware of…..
[patients] see you as not necessarily just thinking in
[patients] see you as not necessarily just thinking in terms of what’s best for them, but maybe you’re… brainwashed by the medical establishment... you’re selling out to the drug companies.” [141052]
How do physicians respond to these intrusions?
How do physicians respond to these intrusions?
1. Defiance
2. Adaptation
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3 “Gaming” the system
3.
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4 Resignation
4.
5 Retreat
5.
1 Defiance
1. Defiance
“I’m
I m in a situation where I
in a situation where I’m
m modifying the way I participate modifying the way I participate
with insurance companies based on whether or not they’re g g
going to have good reimbursement. So …[I’m] down to one g
[ ]
insurance company. But since I started that, I have patients that will pay me, because they know that I will take the time and do what needs to be done.” [167195]
2 Adaptation
2. Adaptation
“I think it’s nearly impossible as a busy primary care provider to take good control of a diabetic unless you build systems that facilitate your care. If you think you’re going to go in there and spend an hour doing a personal education with a diabetic, you’re not going to pay your light bill and you’re going to be ’
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out of business real quick.” [185167]
3 “Gaming”
3. Gaming the system
the system
“The reality is we cannot spend as much time as we would “The
reality is we cannot spend as much time as we would
like…And if you don’t see enough patients, you’re not going to have no revenue, because your expenses are going up
to have no revenue, because your expenses are going up every year.” [162234]
“I mean if it’s something that’s just really overwhelming… I won’t address more than two problems in a visit. …[I]f I can’t focus on it [in the time allotted], I know the patient can’t, and so…I might break it up, and I might make him return sooner and just for a specific issue.” [187642]
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” [187642]
4 Resignation
4. Resignation
• Accept lower reimbursements, lower incomes
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• Identified life stage or circumstances which make this tolerable
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5 Retreat
5. Retreat
“Our income has dropped about 40% in the last 4‐5 pp
years…You know, it hurts. Yes, obviously. …The guys coming up I think are being pushed out. I know doctors who are getting second jobs, because they can’t cut the mustard. And it’s very, very sad.” [143525]
How do physicians view intrusions?
How do physicians respond to these intrusions?
1. Inefficient 1. Defiance
2. Potentially harmful
2. Adaptation
3. Undermine physician 3. “Gaming” the system
authority 4. Erode trust
4. Resignation
5. Retreat
Implications for practice
Implications for practice
• “Do what is best” versus “do what is cheapest”
• Quality of care suffers
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• Exacerbate existing health disparities
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Implications for policy
Implications for policy
• PAs, NPs
• Contradictions of existing policies and practices
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• Shortage of primary care providers
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Patient‐Centered 21st Century Medicine…
The stage is now so crowded!
For more information, contact:
Courtney Jackson, PhD
Courtney
Jackson PhD
New England Research Institutes
9 Galen Street
W
Watertown, MA 02472
MA 02472
617.972.3002
cjackson@neriscience.com
www.neriscience.com