Too many regulations in medicine
Read this Article created by Dr Steven Dayan, facial plastic surgeon in USA
Whose Patient is it Anyway?
Two incidents over the last week have caused me to pause. Last Monday I had a patient scheduled for rhinoplasty and cheek filler. She was consented by my staff for both procedures, but the local hospital where I operate only had her consented for the rhinoplasty. As I was about to put the filler in her cheek, I was abruptly blocked by the rigid operating room nurse who, in front of the entire staff barked, “Dr. Dayan, you cannot do that! I will not allow that, she is not consented and that would be assault!!!” Whoa… assault… who me? I have dedicated my life to taking care of people and have been raised with a mantra of always do the right thing. “But I have her consented I said, see it is on my consent form… No she shouted, it is not on our consent.” So instead of getting into an inappropriate and winless conflict, I deferred and decided to do it in my office the next week. So we learned our lesson. Going forward, we need to make sure that our consent forms match those of the surgical center and hospital. Later that same week, I was alerted that the OR has a new policy. They don’t want the rhinoplasty surgeons cutting the strings on the decongestant pledgets inserted into the nose. I typically prefer to cut the green strings as they get in my way during surgery and I have been doing that for 15 years on over 2000 rhinoplasties, however, the OR staff is dictating to me and my scrub nurse of 10 years that my technique will no longer be permitted. I looked up and asked the head nurse,“Whose patient is it?”
And with that, I began to really consider this seemingly easy question...
Is this just an isolated incident at a local health care facility in Chicago from a strict staff? Or is it a reflection of a greater movement nationwide? I am sure the OR staff is just following their orders with a policy that is intended to do what is best for the patient, but what can’t be overlooked is that the obvious premise in these mandates—the physicians can’t be trusted to decide what is in the best interest of their patients. Are we as physicians losing control of our patients and our profession? Like most, if not all my colleagues, I was trained that when you accept the responsibility of another’s health and well-being, you take on a fiduciary responsibility to always do what is best for them, and put your own interest aside. While I appreciate the nurse’s concern when it comes down to a decision of what is in the best interest of my patients, I like to believe I can, and should, be trusted to make that call. Could it be that I am articulating the frustration of what many physicians across the nation, regardless of their field, are feeling as well?
Physicians are experiencing a tsunami of regulations, liabilities and doubt that seems to be escalating monthly, if not weekly. It’s no wonder that in a 2015 Medscape survey of over 19,000 physicians from 26 specialties, only 64 percent of physicians would choose a career in medicine if they had the chance to do it all over again. Ann even smaller 24 percent would choose the same practice setting again. This is down from 69 percent, and 50 percent respectively in 2011. (1) Interestingly, plastic surgeons were fourth from the bottom when it came to career satisfaction. Only 51 percent would choose to go into medicine again. Additionally, the increasing regulation, cost and business burden are leading to the rapid senesce of private practice. According to a report by Accenture, the percentage of doctors in independent practice fell from 57 percent in 2000 to 39 percent in 2012. (2)In less than a decade, the number of surgeons in private practice has decreased from just about half, to only one third.(3) It is no surprise that 46 percent of all doctors and 45 percent of plastic surgeons report feeling burnt out.(1)
Clearly, we’re witnessing a seismic shift in U.S. medicine. Like most revolutionary periods, true perspective only occurs in hindsight. In my 15 years of practice, I’ve seen a major dimming in the authority and respect that doctors once had. I think we can all agree that the god-like complex was perhaps too overbearing, and may be what lead to the oppressive rules and regulations now being descended upon us. And yes the restraints will likely temper the occasional rogue, but at what risk? Today, the increasing oversight and regulations imposed upon us, forces all our judgments to be questioned. From what medicines and doses we use, to what indications for surgery and even how we communicate. There is probably no regulation more telling than the one that suggests we are so feeble that we cannot accept a pen without being influenced to alter the care we deliver. As opposed to lawyers and politicians who of course can be trusted? How far are we from mandatory body cams on our shoulders? Maybe we should ask the police force for whom fiduciary responsibility and action are now widely challenged and doubted. While videoing all of our encounters may serve to protect us, the underlying notion insinuating that our word and charts cannot be trusted to honestly represent our conversations, is boldly evident. The questioning of our character, genuineness and motives has trickled down and been dispersed to the consumers most efficiently through the power of social media.
All ethical and honest doctors can agree that an informed patient is a good one, but the denigration of physician’s character and personal attacks that now litter social media, is a far departure from the intellectual discourse of the past. The social democratization of the internet has provided fantastic educational benefits, transparency and a closer doctor-patient relationship. But the yin to that yang may be the low barrier to denigration of the physician’s authority and judgment coming from a cohort that does not have the benefit of perspective only gained after years of medical training. Witnessing some of the most famous, competent and well respected doctor’s in the country being flippantly attacked by an anonymous, unfiltered and often misinformed mudslinger is hard to swallow. We have to wonder how this affects our profession long term. How do we respond and cultivate future pioneers and explorers so that the best of our field is allowed to still be good and lead, yet not be cut down at the onset?
The irony is that as physicians, we have arguably been awarded the most awe-inspiring and enormously broad privileges by the state. Traditionally, we have been trusted to cut open, probe and prod a patient all with intent to positively influence their lives. But this right does not come easy. We endure years, perhaps decades of training to gain one very special skill. It is not about anatomy, hand-eye coordination, or the ability to understand the bioavailability of medicines. If it was just about that we would not have the increasing delegation of our services given to paramedical providers with abbreviated training, who can easily follow flow charts embedded within EMR systems. It’s our ability to make difficult judgment calls that we majestically gain and learn which makes us unique. Every day we make thousands of important judgment calls: Should we go up or down on the blood pressure meds, should we operate, raise that flap, tie off the artery, give antibiotics, etc. Where the frustration lies is that we sacrifice and commit ourselves to a life that transcends our own to putting others interests ahead. This commitment to another is the very essence of what constitutes the doctor-patient relationship. It is at the very center of what makes us doctors. Yet today we are losing that trust by the regulators and highly questioned by the consumer as to how we make that judgment.
As we are at times suspected of an ulterior motive and not having our patients best interest at heart, now sterile evaluators, impersonal flow charts and interchangeable medical providers are used to determine and deliver the care. While such a system may be the most economical and efficient way to deliver care to a large mass of people, I am not sure it is the best. What really suffers at the heart of it all, is the breakdown in the doctor-patient relationship—the sacrosanct union for which we all went to medical school. When this relationship is fractured, then a generation of physicians are not permitted or do not feel compelled to take ownership of the patients care. The physician may no longer feel a responsibility to be on-call for their patient, to follow up with consultants and reports, or to research alternative care options. The patient becomes a case that can be “signed out” and passed on. It is in this author’s opinion, it is then that the best in care slips through the cracks.
Fortunately for us in aesthetic medicine, we still enjoy a profession in which the doctor-patient relationship is mostly maintained—we choose our patients and they choose us. We still have a sense of autonomy, and this is likely the driving force attracting more individuals to aesthetic medicine. I wonder if our strength as a unit can be used to set an example and help to guide medicine through this transition. If we as a group can show how important the doctor-patient relationship is to good care and how the judgment that we’ve been granted can, and still should be hallowed. If not, then I fear the country once heralded as the best in the world in medicine and medical advancements may fall to middle of the pack. Then perhaps the question I posed in the first sentence may transition to, “Who needs a doctor anyway?”