On Point

Health care professional: healer or line worker?

Editor's note: For two intense and sometimes emotional hours last spring, Emory physicians, nurses, and other caregivers expressed their frustrations, aspirations, and concerns. Are they healers or line workers? Can one find balance in an academic health care center where teaching, research, and patient care compete for attention? As part of Emory's ongoing Year of Reconciliation, the six panelists and, later, members of the audience, pondered openly about how we got to the current crisis in health care and how we can do better.

During my residency, my dad and I would talk about what was going on in our lives. My dad was a sales manager and frustrated with business. He said all people cared about was money, not the quality of the product. During the 1980s, his company went through mergers and acquisitions: companies were spun off, bottom lines became more important. Dad said the same thing was going to happen to medicine.

He was right. What we're facing now is what every other industry has faced in this country for 20 years. The old adage that nothing is as constant as change is true, but a lot of us didn't want to accept that. I think back to Kubler Ross's stages of dying. The first is denial: we thought that medicine was not going to change. Next is anger -- everyone is ticked off at the insurers, they are ticked off at Emory, they are just ticked off at everybody. Then comes the bargaining and after all of that comes acceptance. I see all these different stages when I look at myself and talk to my colleagues.

We have to accept that it's a different day, and we can't go back. We brought some of this on ourselves. In the 1970s and 1980s, we were wasteful. If we said this is the best way to do something, it was the best way. But we were not cost-effective. I remember doing lumbar disk surgery when the patient stayed in the hospital for seven days. Now it's an outpatient procedure.

We have collectively denied that problems exist. We have been slow to respond. As a result, I think the pendulum has swung from one extreme to the other. Where physicians used to make the rules, insurance companies and health care policymakers are making the rules.

We have to take the responsibility ourselves to acknowledge that the system has changed and to help change the system. And we have to do that in a very thoughtful way, not just shoot from the hip.

I have some possible solutions. We can't avoid dealing with what's happening. A lot of physicians say academic medicine has changed, so let's run away, let's go into a private practice in a small town where there is less managed care. Or we can work harder, but something has got to give. I'm a practicing neurosurgeon with a high-volume clinical practice, and I do academic research. My interest is in design of implants so I work with industry. I do not do basic science.

My resolution is to prioritize and choose. There are only so many hours in a day for research, taking care of patients, exercise, spirituality, time with family. We have to give up something. But that's hard for physicians.

One of the reasons it's hard is that we have disparate mission statements. John Henry's mission statement is very different from that of Michael Johns', and different from mine, and we have trouble reconciling those differences. I look at myself as a microcosm of that. Whether it's Emory Healthcare, Harvard health care, any health care, it's difficult to balance how much time we have for research, how much time for patient care, how important are our families, and how important is our own personal health, be it physical, spiritual, or mental. So I have to set my expectations differently.

Our patients' expectations have to change too. We live in a land of entitlement where people expect everything. No country, no city - London, Paris, Tokyo - can come close to the quality of health care practiced in any hospital in this country. Americans have this right to health care at a very low cost. The onus is on physicians to educate consumers about what they are getting -- a pretty good bargain.

We have to take responsibility for being cost-effective. We're comparing various surgical approaches, we're publishing. Unless we do that ourselves proactively, the insurance companies are just going to take advantage of us.

Last, ignorance is our enemy. Information is our tool: it's important to our patients, it's important to insurance companies, and it's important to physicians. My plea to administration is give us information to help us understand. Sometimes we get and give the wrong or incomplete information. We may be giving information about how much we bill, but we don't see all the other intangibles. We're getting information about overhead but we can't break that down. I think our job is to educate insurance companies, consumers, and patients and to improve the quality and flow of information.

A couple of things will happen from that. One, we'll get better understanding, and two, maybe, together, we'll be able to offer possible solutions.

Regis Haid

With shortages, cost reductions, and reimbursement issues, nurses have been asked to do more with less, and more nurses are retiring or leaving the profession. I am one of those many nurses who will retire in the next 15 to 20 years and am worried about who is going to take care of me and many of you in the audience today. We are working hard to bring back many of the nurses who went into nursing as a calling, as a ministry to help people. We need to provide opportunities for those re-entry nurses and also to address the needs of new employees and those currently in our work setting to keep them here. For example, we recognize the fact that people have lives outside the hospital and have gone to a 36-hour work week. It's a balancing act.

Karen Brown
nursing department director (8E, 10E, 11E)
Emory University Hospital

One of my major concerns is how do we interest young individuals, medical students, residents, and fellows in pursuing academic careers? That's becoming increasingly difficult for a whole variety of reasons. One is their perspective of our struggles with the changes in health care. We have to become better mentors. And to solve some of the problems that we face, especially for the next generation of physicians, we have to pay much more attention to understanding the business aspects of medicine.

David Stephens
director, infectious diseases, School of Medicine

Consider how other providers of other services reacted to being devalued. Pilots said go fly it yourself. Baseball players said go entertain yourself. We all see commercials on television where pharmaceutical companies have completely bypassed providers of care. They say "take my drug, take my drug. Your liver might die, your eyeball might fall out, so then go and consult your physician."

Health care providers have sat back and accepted the devaluation of their services. This is not acceptable. As physicians we have continued to try to provide care despite being devalued. Physicians in general go into medicine for reasons far more important than money; otherwise this devaluation never would have gone this far.

It is important now for an institution like ours - one that is charged with teaching and training more physicians - to give us a voice on behalf of the patients we take care of. Reposition the folks who sacrificed so many years to acquire the intellectual property to take care of patients in a way that is envied all over the world.

Camille Davis Williams
clinical chief of obstetrics, Crawford Long Hospital

I try to retain perspective, to look at our lot versus that of 99% of the rest of the world, both in terms of money and security. That doesn't mean, though, that things are perfect. A few examples of residual issues . . . I've got tenure now but I really don't know what tenure implies. I've got a $1 million grant for my "Healthy Doc" project, but it only covers a quarter of my salary. What can I do to put together my salary for the rest of my time and still do this project well and fulfill other obligations? What does it do to my research to accept pharmaceutical funding? And when these grants are done, where does the next fundable idea come from?

Erica Frank
principal investigator, Healthy Doc project
director of Emory's preventive medicine residency program

In business, they say "let the buyer beware." We don't say that in medicine. In the healing professions, the basis of professionalism is placing the patient's welfare first, over and beyond our own interests. So the most important thing for us to do at a time when we are feeling pressures from all sides is to maintain that professional creed. Today, at least in my field, we have to transmit caring within very brief encounters. The focus of a lot of the concern I hear is about how little time we have with patients. We are not businessmen, we are not line workers, we are professionals. As long as we can listen to our patients, be their advocates, and keep our promises, I think we'll stay that way.

William Branch
vice chair for primary care
director of general medicine in the department of medicine

In this Issue

From the Director  /  Letters


How to remake a hospital


Moving Forward  /  Noteworthy

On point: Healer or line worker?

Nation at a crossroad


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Send comments to the Editors.
Web version by Jaime Henriquez.