We have many successful physicians. But we have few who do right by their patients. The dichotomy is jarring.
It appears because healthcare suffers from moral hazards. The perverse incentives are everywhere. We pretend to ignore them. So instead of moral hazards, we say moral injury, or find some clever catchphrase to belie the truth. We claim physicians are suffering because they are overworked. But physicians have been working fewer hours decade over decade since the 1970s – though the relative time a physician spends on non-clinical tasks is increasing.
So, to be a great physician today, you must prioritize the system of healthcare over the individual patient. This is the dichotomy.
A decade ago, a successful physician saw as many patients as possible throughout the day, but spent hardly any time with any one patient. Today, a successful physician is one who best documents the patient encounter, jotting every phrase or code necessary to maximize the financial reimbursement. As a result, physicians went from treating patients bedside to essaying the most elaborate patient notes.
These are the symptoms of a system rife with moral hazards. We see it throughout healthcare. For any proposed solution, we find an ulterior motive. These are the on-ground realities of a healthcare system laced with questionable incentives. When hospitals began incurring penalties for readmissions, hospital leaders began changing the readmitting diagnoses.
No proposed solution, whether it is to improve outcomes or reduce costs, can work until we fix the moral hazard problem. It emerged when we transformed clinical medicine into a healthcare system. Out of that complexity formed a matrix of incentives. None of which are alone wrong, but when combined, produce recurring patterns of moral hazards.
Leaders in healthcare no longer respond to the intended effect of any policy. They react to the implicit moral hazards within it. While we may never find an exact solution, we can at least begin to address the matter with effective leadership.
Right now, these leaders lack the ability to guide because they have lost touch with the individual patient. We put too many degrees of separation between patients and health leaders.
The moral hazards appear within the separation. It explains why healthcare leaders prioritize reducing length of stay with little regard to the individual patient experience; why patients discharged with congestive heart failure suddenly get readmitted with acute respiratory distress. The leaders never see the patient; they only see the data points, and by proxy, the financials.
Data never convey empathy, so health leaders remain blind to it. They never see how financial decisions affect the patient experience. This underlies the network of moral hazards.
When we separate cause and effect, people lose sight of the consequences of their actions. Clinical decisions are not burdened by the weight of the outcomes. And without such anchoring, we lose sight of why we care for patients.
The solution, or at least the start to it, is not difficult: Fill the empathy gap by connecting cause and effect. Ensure patients and healthcare leaders interact over more than data-driven cash flow statements. A leader who sees the faces of patients affected by his or her policy will make decisions quite differently from someone who only sees the metrics.
Empathy is funny like that. We never notice it until it is long gone. Only then does it become apparent by what appears in its absence. As healthcare grew, it became more complicated. Eventually, it grew beyond the comprehension of any one person. This is when medicine became a healthcare system: a necessary change to accommodate the growing patient population and the influx of technology into medical care.
But now the system has grown beyond recognition. The incentives designed to make healthcare more efficient have created undue separations, disconnecting parts that were never meant to be split.
Within these crevices emerged the moral hazards, creating empathy gaps to fill the void.
It is time we acknowledge them in healthcare. So we may study the effects of empathy on patient care. Hopefully, we learn that it is more than an emotion derived from experience; it is the essence of good clinical care.