In addition to this, many doctors want to re-take the history from the patients and re-examine them for themselves, rather than rely on a brief handover or potentially sub-optimal notes from another doctor. Clinical signs can be subtle, as can points in a patient's history that may point to a diagnosis. I see patients often frustrated at being asked the same questions by each doctor they see, but most of the time this is in their best interest.
I try to preempt the frustration by saying that we each take our own history for the purpose of making sure no details are missed, but rest assured, I’ve gotten the overview from your other docs. I then make sure to complete a sentence for them once in a while, to evidence that that is the case.
A good percentage still get frustrated. Can’t be helped. Patients reshape their narrative, remember new details, just plain open up more to some docs, etc. the repeated history taking really pays off in improving patient care.
Where I find patients get most frustrated is when docs come in for a specific job, and patients don’t have the health literacy to understand what that is or is not. “Doc, can I go home today?”
“ I’m just the consulting cardio here to check out your heart for your primary doc, Doc McStuffins, I have no say in that at all, you need to ask McStuffins.”
“Oh. But when do you think I can go home?”
There’s no good response to that. No one wants to cough up cash to pay for health professionals time to repeat themselves all day long. But the patient that’s asking? They want that answer. They don’t -feel- like they’re asking an inappropriate or stupid question.
I think this hits the nail on the head. There is a huge information gradient between most patients and the doctor and perfectly bridging that gap takes more [time|money] than any system is willing to support.
I think about this when it comes to providing a patient with "informed consent" for a particular treatment/operation. What does "informed" really mean in this case? A brief overview of the main risks and a couple of statistics? Or a thorough understanding of the pathophysiology of the disease and the trial data supporting the therapy? How long is a piece of string?
It's tough, and I get that. I also know that as a person with neurological trauma that makes speech difficult at best, having to recall what amounts now to 50+ pages of chart every 4 hours is... BS. You might as well be telling someone with a broken ankle to run up and down a flight of stairs every so often while they try to recover.
There is also an argument that, unless there is some sort of ongoing peer review (they did this during my Oncological Adventure(tm)), you're increasing the number of moving parts, and thus the chances of a breakdown. Charting errors are a significant source of medical mistakes.
The problem as I see it is not the intent of the procedure, it's the while (1) do x; mentality. There should be some "ifs" and mitigating functions instead of a hardcoded 1
Most patients get admitted under a DRG, which is a lump sum payment. It’s true that doesn’t apply to every patient, but enough of them that doctors habits aren’t going to be shaped by the minority.
For that matter, you can come in and see a patient without asking the same history as the guy before you, if you’re just checking a box for a billing.
And this certainly isn't the case in the NHS in the UK where doctors have no financial incentives interfering with their clinical decisions (barring saving the service money). What you describe is a pitfall of private medicine.
> And this certainly isn't the case in the NHS in the UK where doctors have no financial incentives interfering with their clinical decisions (barring saving the service money)
This meme really needs to die. The NHS has massive financial incentives that impact clinical decisions. In fact, you literally go on to mention as such in your next sentence.
It turns out that having an incentive to "save the system money" results in a different set of clinical decisions. And no, those don't always work out in favor of the patient. (They're particularly problematic for the patient in cases of long-term care, which is why the NHS does rather badly on complicated and chronic conditions like treating cancer compared to the US and other countries).
> which is why the NHS does rather badly on complicated and chronic conditions like treating cancer compared to the US and other countries).
It might be true that the NHS has poorer outcomes but I doubt that this is necessarily the cause. I live in Norway and have considerable recent first hand experience of the health system. I'm confident that they have incentives to save money too. In fact my wife's cancer nurse when explaining why there was a delay in starting the day's treatment said that preparations like Avastin would not be ordered from the pharmacy until the patient was both present and prepared for treatment because they could not afford to throw it away when the patient didn't turn up or turned out to be too ill for chemotherapy.
It is broadly speaking the same idea as the UK NHS but apparently has better outcomes for diseases like cancer. There are fees to pay, similar to an insurance excess or what the US calls co-pay; but those fees are affordable and capped to a couple of hundred pounds a year.
This meme really needs to die. The NHS has massive financial incentives that impact clinical decisions.
Not to mention that many if not most NHS-employed doctors run private practices on the side. Some only spend a day or two a week on their NHS duties. Others such as GPs are NHS-branded, but every GP practice is a private business that bills the NHS for time and materials.
In a discussion of NHS vs private practice, the fact that some (certainly not most) NHS-employed doctors also do private work, has no baring on the incentives placed upon them within their NHS employment.
I am certainly not saying the NHS system is perfect, and all private medicine is bad, so if that is the impression you got then perhaps I was unclear.
In almost every single clinical situations within an NHS hospital that I have seen or can think of, the clinicians treating you will not receive any extra money, bonus, promotion, etc. for the treatment they provide you or do not provide you.
I have lived in countries with more private systems, where there is a direct relationship between what treatment/investigations you receive and what money ends up in the doctors pocket. For example, a private doctor in HK referring for not-strictly-necessary-but-ultimatelhy-clinically-justifiable MRI scans at a private MRI clinic which, provides a percentage of the (expensive) scanning fee back to the referring clinician. Contrast that in the NHS, no one gets given money for sending a patient for an MRI scan, and in fact, if it isn't going to change the management of the patient, the request is likely to be refused to constrain resources. In the HK system, neither the doctor nor the MRI provider is incentivised to not do the scan, quite the opposite.
The NHS system is not perfect, but pointing out different the pros and cons of different incentivisation structures that do have an impact on patients is not something that is a "meme that needs to die"…
The NHS does worse in treating cancer than other countries, but many of those countries (Germany, France, etc) have public health care also. It's not clear that the difference in performance is because of public, vs privately, funded medicine.
> The NHS does worse in treating cancer than other countries, but many of those countries (Germany, France, etc) have public health care also. It's not clear that the difference in performance is because of public, vs privately, funded medicine.
Right, I'm saying that the difference isn't simply a matter of private vs. public funds, the way OP claims. You can really trivially create a private system that has the same bad incentives with respect to costs and care as the NHS does. You can also trivially create a public system that has the same bad incentives with respect to costs and care as the US does.
That said, Germany and France aren't really publicly-funded as well the way people think. Both rely on a private network for care delivery (unlike the NHS), so it's a bit of a stretch to say that they're "public health care" systems. Even if you're looking at funding, in those two countries, taxpayer funds only cover 75% and 70% of expenses, respectively.
