Awkward

The problem with first-year medical students is that they haven’t yet learned which questions not to ask.

Two weeks ago, I had a student spending the afternoon with me at my office. We met a patient and his wife, and talked with them about the results of a CT scan he had done earlier in the day. After the visit, the student asked me "Why did he have to come to your office today?" Her concern was that the man had difficulty walking and had recently moved into a care home an hour away from Saskatoon. It was a significant effort for them to travel, both to get to Saskatoon and then within the city.

My staff is diligent about scheduling CT scans (and other tests) on the same day as an office visit, so I can review the results with the patient. I pointed out to my student that this saves people an extra trip into town.

Then she got really impudent.

"But he still had to wait between the morning CT and afternoon office, then had to find a place to park near your office and walk here on icy streets. I know he had to come to town for the CT, but couldn’t he get the results by letter or over the phone?"

You know, once they get their teeth into something, you sort of have to humor them. So we broke down the reasons for an office visit:

• Need for physical examination
• Establishing rapport and trust, especially on initial consultation
• Emotional support when discussing bad news
• Complex discussions that involve dialogue (not suitable for the one-way communication of a letter), or the opportunity to pick up emotional cues (not suitable for a phone call)

None of these applied to this man. He’d just had a CT scan so, in this case, there was nothing that a physical exam would add. I’ve known him for over 10 years, and we have a good rapport. The test results were good, so no bad news to break. The results were straightforward, so a letter or phone call may have sufficed. What were we missing?

• I get paid fee-for-service.

Awkward moment.

I don’t make patient care decisions based on how much money I’ll receive. (Or, I’d like to believe I don’t…) But, it’s inescapable that incentive drives performance. This is my job – how I support my family. I work in a partnership in which I’m expected to generate my share of revenue. Under the province’s medical insurance system, I’m not allowed to bill the government for letters or phone calls to patients. That means any time I spend on those activities is for free. I could send a bill to the patient, but that means some messy bookkeeping for my staff, and might upset my patients.

Although, come to think of it, I’ve never asked my patients what they would prefer: Paying me directly to receive their results by letter or phone? Or spending their money on gas, meals, and lodging to travel to Saskatoon to visit me in person? That might be an interesting survey to conduct.

And, if anyone is going to do that survey, can they please ask patients this broader question: What do you want from specialists? The iconic “specialist referral” is often necessary, but maybe it’s not always the right tool for the job.

At Saskatoon Health Region’s Quality and Safety Summit this week, the Deputy Minister of Health pointed out that people don’t really want to consume health care. They’d rather be healthy. If you’re in the ER with a heart attack, you’re probably grateful for the expert treatment you’ll receive, but you’d rather be walking the dog. Perhaps you’d give higher value to a health care system that was designed to maintain your health, by promoting exercise, proper diet, and a healthy lifestyle. But, we’re sort of used to doling out high-tech acute care, so that’s what you’re going to get.

In the same vein, we’ve built a specialist referral system that mandates a physical visit with the specialist. Patients don’t want to see a specialist; what they want is resolution of a health concern. That may be best done with a specialist visit, but there may be other approaches.

I’ve been thinking about this a lot over the last few weeks, as there’s been a glut of men wanting vasectomy reversals. Actually, they don’t want vasectomy reversals – they want information about the procedure, success rates, and costs (it’s one of the few uninsured procedures for which we directly bill patients). As often as not, men decide not to go ahead with vasectomy reversal. They could have saved a trip to see me if I had sent them an information pamphlet explaining the procedure, and inviting them to make an appointment to see me if they were convinced they wished to have the operation done. The same goes for many other common conditions that aren’t serious, but are still valid health concerns.

But, what’s my incentive to do that? Why should I put effort into developing the information pamphlets and sending them out or posting them on our website? Sure, it gives people the information they want, saves them the nuisance of a visit with me, and opens up the appointment time they would have taken so I can see someone else sooner, but I’d be cutting my own fiscal throat. As long as I’m paid fee-for-service, that’s what you’re going to get from me: Lots of services that I’m paid for.

Expect something different? Then I suggest you read On the folly of rewarding A, while hoping for B.

The beauty of first-year medical students is that they haven’t yet learned which questions not to ask.