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Managed care requires making bricks without straw

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

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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. [...]