AAOS Now

Published 7/1/2015
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Paul Levin, MD; James Rickert, MD; Thomas Boniface, MD; Alexandra E. Page, MD; Charles Carroll IV, MD

What’s Wrong with Patient-Centered Care?

In one of his last columns as editor-in chief of AAOS Now, S. Terry Canale, MD, described an unsatisfying transition of his office practice from a more patient-centered model to what might be called an efficiency-centered model (“Confessions of an Orthopaedic Surgeon,” AAOS Now, November 2014). It was an honest, sobering description, and Dr. Canale is to be commended for being self-critical and forthright enough to describe a phenomenon that we, as orthopaedic surgeons, readily recognize.

This “efficiency” model is not unique to orthopaedic surgeons. Many physicians from various specialties have increased patient volumes to counteract lower reimbursements. Academic centers and private practices alike have accepted the “15-minute” visit as necessary in today’s model of patient care. This strategy invariably shortchanges patients. Physicians spend less time meeting, examining, educating, and guiding patients through treatment. Family physicians spend an average of 18 minutes per patient; oncologists, 23 minutes, and other specialists, 21 minutes. Even so, that’s three times longer than the average 6 minutes and 24 seconds measured by Dr. Canale.

An unfortunate strategy for maintaining the short visit/high volume practice is to refer patients for unnecessary consultations and to order medications or request diagnostic imaging of questionable efficacy. This model ultimately affects patient adherence and outcomes.

Our failures as orthopaedic surgeons in communicating with our patients have been well documented by the AAOS; we have been called “high tech/low touch.” The AAOS has recognized this and has attempted to address these failures in communication with the Communication Skills Mentoring Program. Unfortunately, a study recently published found orthopaedic surgeons to be last in successful office communications. For many of us, this has lead to professional dissatisfaction and early burnout.

Several initiatives support a return to the patient-centered model of care, reversing the high volume/low satisfaction (patient and physician) model. Our rapidly evolving healthcare system is being designed to reward quality and not quantity. Accountable care organizations and population-based medicine will be rewarded financially when office visits are more productive and resources are used wisely. This is definitely the time to return to the patient-centered ideals upon which orthopaedic care is based

The best job in the world
We are truly lucky and blessed to be orthopaedic surgeons. We care for individuals who have sustained an acute injury or degenerative changes that rob them of their ability to work, to function, and to enjoy life. We are often able to successfully restore function and return them to both their occupations and their avocations. We have all experienced a personal and professional “high” when grateful patients and their families return to our offices after successful orthopaedic interventions.

Beyond these relatively unique opportunities for professional satisfaction, orthopaedic surgeons also enjoy enviable incomes. Surveys consistently rank orthopaedic surgeons at or near the top of salary scales among other physicians, and the average orthopaedic surgeon’s salary is two to four times that of our primary care colleagues.

Despite anxiety about the future during a tumultuous period in medicine, the orthopaedic profession continues to flourish. Although many of the changes occurring in the U.S. healthcare delivery system are frightening and may result in modest declines in physician reimbursement, orthopaedists have the ongoing opportunity to be both more personally and professionally fulfilled.

Abundant evidence demonstrates that, among physicians, professional satisfaction is achieved through the development of successful relationships with patients. Maintaining a primary focus on patient care will prevent our professional lives from becoming dreary and unrewarding. In addition, successful relationships and successful communication may be the pathway to improved incomes in the future.

As orthopaedic surgeons, we all know colleagues who have experienced burnout in a relatively short number of professional years. Clearly, driving too hard, seeing too many patients, and being on call too frequently lead to both professional and personal unhappiness and dissatisfaction.

The solution?
Dr. Canale proposed an “obvious solution” to the busy office dilemma: take longer with each patient, see fewer patients, make less income, and feel less liable, less stressed, and more fulfilled. Unfortunately, he really didn’t see it as a viable solution. However, professionalism requires that we establish a fiduciary responsibility toward our patients. Simply stated, all of our interactions with our patients need to be focused on our patients’ needs, not on any personal gain.

Our patients give us the rare gift of sharing their lives with us; in return, we pledge to help them heal. Many skills that build rewarding physician-patient relationships, such as motivational interviewing or shared decision-making, require just a little more time with patients. In fact, taking those few extra minutes may, in the long run, save time because the communication we have with patients will be more effective.

Positive relationships with patients also increase patient satisfaction, professional satisfaction, and staff satisfaction. Office hour sessions are truly more fun! In other words, remembering that our patients come first and treating them as individuals creates a real WIN-WIN-WIN; our patients are happier, we are happier, and outcomes are improved. Francis Weld Peabody, MD, a professor of medicine at Harvard in 1923, said it best: “For the secret of the care of the patient is in caring for the patient.”

James Rickert, MD; Thomas Boniface, MD; Paul Levin, MD; Alexandra E. Page, MD; and Charles Carroll IV, MD, are members of The Society for Patient-Centered Orthopaedic Surgery.

Additional Information
http://www.aafp.org/news/practice-professional-issues/20131003healthaffairs-paytime.html

http://jop.ascopubs.org/content/8/3S/2s.full

http://www.ajmc.com/journals/issue/2014/2014-vol20-n10/The-Duration-of-Office-Visits-in-the-United-States-1993-to-2010

http://www.aaos.org/news/aaosnow/may09/cover1.asp

http://www.aaos.org/news/aaosnow/nov14/youraaos1.asp

References

  1. Quigley DD, Elliott MN, Farley DO, Burkhart Q, Skootsky SA, Hayes RD. Specialties Differ in Which Aspects of Doctor Communication Predict Overall Physician Ratings. RAND Corporation, Santa Monica, CA, USA; UCLA Division of General Internal Medicine & Health Services Research, Los Angeles, CA, USA.
  2. Levin PE. Professionalism and Ethics, OKU 11, pp. 3-13, 2014