Saturday, September 22, 2012

Concentration of Effort, Academics, and Managed Care

I follow the Nephron Power blog because I have maintained a life long interest in Nephrology or at least since I found out what it was in Medical School.  The conventional wisdom at the time was "Oh you're going into psychiatry - take as many medicine electives as possible because you will never have the chance to do medicine again."  If there are any medical students reading this - I ended up doing another 22 years of following renal function, treating people who were delirious and in renal failure, treating manic patients who were in renal failure waiting for a kidney transplant, and consulting with Nephrologists.  I  can say without a doubt that the Nephrologists who I worked with are some of the brightest, most thoughtful and hardest working people I have ever known.

I still  consider the Renal Service where I worked in medical school to be the model for academic medicine and how to teach medical students and residents.  It was located in two adjacent hospitals and headed up by a cranky old guy.  I say "old" realizing that he was probably about the same age that I am right now and he had the appearance of being cranky like a lot of old guys can get.  You could tell he was very bright, very interested and not above giving the medical students a hard time.  He made sure that on all of the consults we had conducted the appropriate "liquid biopsy" by performing our own urinalyses on patients we were seeing.

We rounded three times a day seeing all of the hospitalized patients in the morning, clinic patients in the afternoon, and hospital consults in the evening and at night.  My last action as a medical student was staffing two Renal Medicine consults at about 8PM the night before I graduated.  The other team members included another two attendings, two fellows, three Internal Medicine residents, and another medical student.  The physical layout of the service was two hospital wings and a very busy clinic with a separate day for a Hypertension clinic.  The hospital service was in the same hospital as the transplant team and we would also care for patients with transplant complications.

The  atmosphere on this service was electric.  Everyone was on time, interested, bright, academic and effective.  To this day - I consider this team from the 1980s to be the prototype for what a teaching service in a Medical School should be and in many ways how serious medicine should be provided.  When I left the hospital that night after the last two consults staffings of my medical student career I can remember thinking - should I have gone into medicine and become a nephrologist?  My fantasy in psychiatry became to recreate this model or at least parts of it in psychiatry.

Flash forward 26 years.  Most people would be fairly surprised to find out that you can come close to my fantasy in very few psychiatric units.  The patient flow into and out of many psychiatric units generally does not depend on academic considerations like providing the best medical and psychiatric care to patients.  In most cases patient flow does not depend on the judgment of psychiatrists.  My ability to care for patients with the most severe illnesses did not come about because there is an elite cadre of psychiatrists who are academically interested and have the necessary resources to provide that level of care.  It came about because the system where I worked needed a place to put these folks and I happened to be a psychiatrist who was interested in all of their problems.

I got very close to recreating at least the inpatient side of my old Renal Medicine service, but these days there are just too many administrative problems along the way.  It is impossible to take a learned approach to medicine and psychiatry with administrators breathing down your neck about an absurdly short length of stay.  It is a clash of paradigms and as far as I can tell the administrators have won.  You cannot possibly address complex problems when someone is telling you that the only reason a patients should be in the hospital is that they are "suicidal" or "homicidal" - both very loosely defined business terms for getting the patient out in time to capture about a 20% profit on the DRG payment.  Let's suspend the reality that this person is just  too ill to function or that their illness has created an impossible situation at home or they are not able to care for their new medical diagnoses until they have recovered their cognition to some extent.

If you are really interested in a rigorous approach to tough problems these days you will run afoul of a huge managed care infrastructure that is there to process patients in and out of hospitals based almost entirely on business decisions.  That makes life a lot less interesting for physicians and a lot more frustrating for patients.  Patients coming out of the managed care environment have an almost universal experience that they were hardly seen in the hospital and when they were, there was not a lot of interest in solving their problems.  They end up saying what they think people want to hear in order to be released and after they have been discharged realize that nothing has changed.

In the final analysis these are contrasting models but nobody pays much attention to the contrast.  An academic full spectrum of care model versus a severely rationed model where care is based on an administrators notion of "dangerousness".  Clinicians aware of the full spectrum of illness, grappling with all of the nuances and offering the necessary care versus a doctor sitting in an office prescribing pills as fast as they can.

That is what we are talking about and in that context - I will take the Renal Service any day.

George Dawson, MD, DFAPA

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