Tuesday, September 25, 2012

Double Agent

 Yesterday, I heard Dr. Glenn Treisman talk at the Department of Psychiatry's  Grand Rounds at Johns Hopkins on "What is a Doctor."  You'd think we'd all know what a doctor is, but Dr. Treisman always has a unique and humorous slant to those obvious slices of life.  His talk was about the forces pulling physicians to look out for the best interests of the patient, while also looking out for the best financial interests of the institution they work for as well as the best financial interests of society.  He threw in some historical references and his talks are always entertaining as well as informative.

At the beginning of any professional presentation, the doctor must "disclose" any conflicts of interest -- in other words, if he receiving any money from pharmaceutical companies.  Dr. Treisman started his talk with a series of Disclosure slides which reflected both his wit and a statement of the problem.  He let me borrow them to reprint here:
 
First slide:
I am engaged in Doctor-Patient relationships that I was taught ethically constrain me to work in the best interest of my patient
I work in an institution that was founded by Johns Hopkins to provide care to the poor and indigent of East Baltimore
I have been instructed to provide “Excellence” in my work
Second slide:

I am paid by Johns Hopkins which has directed me to:
Decrease the time patients are in the hospital
Maximize reimbursement for hospitalization
Maximize the revenue I generate
I am barraged by “cost-saving” efforts by insurance companies that use bullying insurance reviewers and time wasting paperwork barriers to decrease the delivery of the care I recommend for my patients.
Third slide:

I have been recently informed that I am a “steward of resources” and that I need to conserve medical resources
I have been recently informed that “Patient satisfaction is the coin of the realm”
I have been informed that my Ryan White funding is contingent on efficient care (shorter visits) and improved measurable outcome targets 
Fourth slide:
  •  I have been informed that I am to use “Evidence-based interventions” and follow guidelines and protocols that I find less than optimal for many of my patients
Some of these conflicts of interest may have affected the views and information presented in this presentation, or perhaps are the subject
  

Ah, Dr. Treisman has a lot of "disclosures," touched with a little sarcasm, but he does a good job of illustrating the conflicting pressures doctors are being put under to act as agents for society and institutions in ways that conflict with being the advocate for the best interest of the patientSo that you know, he works with AIDS patients in an outpatient clinic, and with inpatients on one of the country's two psychiatric inpatient pain units.  His patients travel from all over the country to be admitted to this unit, often arrive in a state of desperation, and the struggles with insurance companies to permit their care are considerable.

Just a word on the graphic: it's from a show called Get Smart (the 1970's perhaps) about a spy named Maxwell Smart who had his phone in his shoe.  It's where I learned about "double agents."  I figured I needed to explain this one.