Managed care requires making bricks without straw

By Edmond Blum, MD, amednews contributor. March 11, 2002.

COMMENTARY

Observations on the state of medical practice and medical life

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I work as a primary care physician in a large public hospital in Brooklyn, a city hospital still much the way they used to be. Patient care is as fragmented and discontinuous as ever. Urgent care is the order of the day, and preventive medicine is still around the corner. The wards are run by residents with long hours, high turnover and minimal supervision.

But one thing has changed, and for the worse: The managed care ethos has taken hold in our institution. It is characterized by productivity mania. Management is committed to (in its own words) "volume-driven" productivity standards. This means maximizing the "throughput" of patients per unit time, resulting in a one-size-fits-all, assembly-line style of care.

This approach, especially when applied to the inner-city population we serve, is both dehumanizing and dangerous. Among these patients is a staggering incidence of major illness, co-morbidity and socioeconomic problems, compounded by large cultural and communication barriers to care. A rapid-transit style of care can't possibly meet their needs.

The critical issue is the time available for patient care. The traditional model of primary care may have had its faults but still stressed an individualized approach. The new model strips physicians of their most basic clinical skills -- diagnostic, therapeutic, interpersonal and above all the art of listening -- because there is no time to adequately perform them.

Underlying this shift in primary care is a profound change in values. In the managed-care model, the patient is seen not as a fellow human being in need but as a commodity and a statistic. The physician is seen not as an independent professional but as a cog in the corporate wheel. The patient-physician relationship is seen not as fiduciary and sacred but as merely technical and commercial. Quality of care is seen not as diagnostic skill and clinical judgment but as conformity to standardized protocols.

Such a model must inevitably turn the practice of medicine into a perfunctory and dehumanized ritual, and one in which physicians cannot provide quality care with grossly inadequate rations of time. No quality assurance program can mitigate this deprivation of basic clinical skills.

Readers of the Bible may be reminded of a section in the Book of Exodus known as "bricks without straw." In this passage, Moses asks Pharaoh for time off for the Hebrew slaves to pray in the desert, as God commanded. Pharaoh becomes enraged by what he sees as the slaves' laziness, and he orders that they no longer be given straw to make bricks. Yet they must produce the same quota of bricks as before. The slaves would have to find the straw (its chemicals hardened the mud used to make bricks) for themselves. Of course, the slaves could not scour the countryside for straw and make bricks at the same time. But God was on their side, and what followed is well-known: the 10 plagues visited on the Egyptians, the Exodus and the Promised Land.

The employed doctors at my hospital have no control over working conditions or assigned quotas, and are subject to the irrational demands of corporate pharaohs. But for now, we have no Moses to lead us, and there is no promised land in sight. We, too, must make bricks without straw.

Dr. Blum is general internist at a large public hospital in Brooklyn.