One of the troubling elements in modern healthcare is the degree to which over-specialization can distill common sense out of the complex equation of patient care. It is certainly not rare for a patient to go to prestigious clinics like Mayo, see an internal medicine specialist who notes a complaint of a sore shoulder, and be told that they are being referred to an orthopedist specializing in shoulder surgery. Extra day(s), new visit schedule, additional extra tests at patient and insurer expense (“But it’s MAYO!”), and not a wit of additional investigation on the part of the original physician. Often, no real exam of the shoulder. How about a simple x ray? Did you fall on it?
This systemic inability in medicine to take on anything but the narrowest of tasks is a common practice in HMO/ACOs everywhere. If there is any question of the medical issue being a tad more complicated than a sore throat or a vaccination, off to the specialist. The more elite the specialist, the more likely that there will be some justification to spend the extra dollar. Primary care providers cannot spend the big bucks. The “specialist” can take the fall if everything turns up negative. There has been some effort to engage so-called “patient-centered care” by making everyone accountable to “the patient”. In 2001 the Institute of Medicine (IOM) issued a definition of patient–centered care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” This has generally not been the culture of the modern ACO clinic.
This kind of thinking — previously known as “passing the buck” — turns up in the strangest places. A story recently caught my eye that is tragic by any measure and involved a physician organization. Is this a coincidence? Or is this simply another iteration of passing the buck because there is no longer a direct level of accountability between doctor and patient. Some might have seen the tragic story of Kayla Mueller as reported by Yahoo News:
Mueller was killed in ISIS captivity in February 2015, 18 months after she was taken. She was kidnapped as she accompanied her boyfriend, Omar Alkhani, to Syria to help install communications equipment for Doctors Without Borders, also known by its abbreviation in French, MSF. The organization’s top U.S. official said the group had no obligation to help the young American woman because she was not their employee.
Doctors Without Borders is generally recognized as a benevolent, apolitical organization that distributes medical aid and professionals from many countries. Kayla and her boyfriend were contractors to MSF (Doctors Without Borders) in Syria in 2014 to help them set up their communications center. But after several MSF workers and Kayla were captured by ISIS, negotiations began. MSF were able to raise money for their workers’ release, but when it came to helping the Mueller family, it was “not their job”. The excuse given was that Kayla was not technically “an employee”, and she therefore deserved no help from MSF in facilitating her release. She was killed after 18 mos in captivity. Her parents told ABC News, ““… Somewhere in a boardroom, they decided to leave our daughter there to be tortured and raped and ultimately murdered…”.
Somewhere in millions of exam rooms patients are being left with their symptoms to fend for themselves or are being lateraled to the most convenient specialist. This type of thinking is apparently becoming part of being a physician, with or without borders.