In his recent book, “The Finest Traditions of My Calling,” Abraham Nussbaum, 41, makes the case that doctors and patients alike are being shortchanged by medical practices that emphasize population-based standards of care rather than individual patient needs and experiences.
Nussbaum, a psychiatrist, is the chief education officer at Denver Health Medical Center and practices on the adult inpatient psychiatric unit there. I recently spoke with him; this is an edited transcript of our conversation.
Q: Your book is in some ways a lament for times gone by, when physicians were “artisans” who had more time for their patients and more professional independence. But you’re a young doctor and you must have known at the outset that wasn’t the way medicine worked anymore. Why do you stick with it?
A: The first thing I’d say was that I didn’t know right away that medicine is no longer universally understood as a calling instead of a job. We are describing health as if it is just another consumer good, and physicians and other health practitioners as the providers of those goods. That is the language of a job. When you remember that being with the ill is a calling, then you remember that it is a tremendous privilege to be a physician. People trust you with their secrets, their fears and their hopes. They allow you to ask about their lives and to assess their bodies. So my lament is not for the loss of physician privilege – goodbye to that – but to the understanding of medicine as a calling.
Q: You don’t like checklists and quality improvement measures that dictate how physicians care for patients because you say this approach turns doctors into technicians and is an obstacle to “moral reasoning.” But those tools aren’t going away anytime soon. How do you do the kind of doctoring you want to do in this environment?
A: Quality improvement seems to be here to stay. Regulators at all levels require it. But I believe that evidence of its success is not as clear as they suggest. The British Medical Journal published a study that found no evidence that introducing quality metrics has resulted in a significant reduction in patient mortality. The leaders of the quality movement’s version of quality improvement developed out of industrial engineering, so they are always comparing the care of patients to things like the production of cars or the flying of airplanes. People are far more varied than cars on assembly line or planes on the runway.
In my own specialty, the current quality metrics all encourage me to perform standardized screens on patients or to document carefully. None of them require me to develop a relationship with a patient so that I can, say, foster hope after a suicide attempt or knit a psychotic person back into the life of their family. Yet that is what my patients want, those human relationships. It is also what physicians want, and the most recent studies suggest that most physicians are dispirited by quality metrics.
Q: But not all physicians are equally skilled or conscientious. As a patient, I feel more comfortable knowing there are rules and standards that doctors have to meet.
A: I don’t think physicians should be free to do whatever they want. Their thinking and decision-making should be held up to scrutiny. A physician’s standard of quality should be evidence-based, but even more it should be patient-centered. The standard should be what the patient defines as what matters. So if you are suffering chronic pain, it is not just a reduction of your score on a standardized pain scale, but your ability to resume the activities you identify as constitutive of your life.
Q: Only 55 percent of psychiatrists take insurance, compared with nearly 90 percent of physicians in other specialties. That puts their services out of financial reach for many people who could use their help. How does that square with your vision of doctors as healers and teachers?
A: It’s deeply concerning to me. I’ve made a conscious choice to work at a safety-net hospital so I can see people regardless of their ability to pay. I hope that through things like the Medicaid expansion and mental-health parity, more psychiatrists will work with [more] people who have mental illness.
Q: Some physicians have chosen to establish boutique practices that accept a limited number of patients who pay extra fees for more personal attention and better access. What’s your perspective on that?
A: It sounds appealing to me. In most descriptions of boutique medicine, they talk about it like a lovely restaurant, one that I couldn’t afford to go to every night. I think it’s an interesting model but not a solution to the large problems facing medicine, in particular the ability to provide care to the most needy among us and the indigent.
– – –
This column is produced through a collaboration between The Post and Kaiser Health News.