by Carol A Westbrook
In a recent editorial in the New England Journal of Medicine1, Drs. Stavert and Lott used the tem, “The Bystander Effect,” to describe a new health care phenomenon, in which multiple physicians participate in the care of a patient, while none acknowledges primary responsibility for managing it. In their example, a patient was hospitalized with an undiagnosed, complicated illness, and over 40 physicians were involved in his care, yet none stepped forward to take charge.
The term “Bystander Effect” was coined after the 1964 stabbing murder of Kitty Genovese in New York City, which was witnessed by 38 people, none of whom intervened or called for help. The term refers to the tendency of people to be less likely to offer help in emergency situations when other people are present. In other words, it's not my problem, someone else can take charge.
Stavert and Lott argued that the Bystander Effect is becoming prevalent because of the way our system of hospital care has evolved. But I have noticed it is beginning to appear in the outpatient setting as well, where it is eroding the quality of medical care while increasing its expense.
Consider Mr. Miller, a fictional patient referred to me for anemia. I ordered blood tests, referred him for a colonoscopy, and scheduled a return visit in 2 weeks. During those two weeks, he also saw his cardiologist (heart), his orthopedist (joints), his urologist (prostate), his internist (blood pressure), his primary care physician (cholesterol). Mr. Miller is elderly and retired. When I asked him what he does with his leisure time, and he replied, “What free time? My wife and I spend most of our day in the doctor's office.” From my perspective, Mr. Miller received the expert attention of 7 highly trained medical specialists, and the best possible medical care in the world. From his perspective, he has to deal with two more doctors, more prescription medications to use up his limited income, and no assurance that any of this will make him feel better or live longer.
It is disheartening to see an elderly couple who measure out their days by the number of doctors' visits in a week. It is frustrating for their caregivers, who try their best to attend these multiple clinic visits. And it is dangerous, as multiple physicians may give contradictory recommendations, prescribe medications that interact, and overlook test results ordered by another doctor.
Mr. Miller is definitely getting more medical care than he would have received, say, 10 years ago. But is he getting better care? For that matter, is he even getting care?
Think back to a simpler time when a patient had one doctor whom he knew personally and trusted, and who provided him with care, one human being to another. Today it takes many more doctors to provide the same amount of care.
There are several reasons that our health care system has evolved in this direction. The major reason is economic. There is a limit to how much Medicare or insurance will pay for a clinic visit, but there is no limit to the number of clinic visits. Thus, the economic imperative tends toward increasing the number of doctor visits rather than the quality of the visits. Today's doctor may have a quota of 15 to 25 patients per day if he wants to keep his job. Consequently, he does not have much time between appointments to make calls or send emails, and has little opportunity to get to know his patients as human beings. Care suffers. Physicians become bystanders.
Another force leading to fragmentation is specialization. Treating a relatively healthy patient who has a single problem–such as a sore throat–is straightforward. The patient is examined, boxes are ticked in the electronic chart, and the prescription is electronically sent to the pharmacy. But when a patient has health issues that cross the boundaries of many specialties, such as Mr. Miller, it is easier to reduce him to a collection of unrelated diagnoses, each of which will be managed by a different specialist with more expertise than the primary care physician. This is the very situation that turns doctors into bystanders.
Care fragmentation is one of the most serious flaws in our health are system today. We need to find a way to improve a patient's medical care without having to sentence him to a never-ending succession of clinic visits.
This should be easy in this day of electronic charts and digital communication–in theory, charts can be shared among specialists, opinions can be obtained, and care can be provided via email or phone. But economic forces work against these activities since they are not reimbursed. Insurance will only pay for a doctor's opinion within the context of a clinic visit which includes a history and physical exam. And if a complex clinic patient requires more than the Medicare-allotted time, there is no way to charge for it. Spending more time with one patient means there is less time for another, so the doctor's quota will not be met.
Medical economists are looking at ways to reduce fragmentation. One solution has been proposed by Dr. David Meltzer, a physician and Professor of Economics at the University of Chicago. Meltzer is piloting a program for primary care physicians to manage patients with complex medical conditions who are frequently hospitalized. In his program, such a patient will have a single physician who will take primary responsibility for him, coordinating care among specialists and supervising both his hospital stays and outpatient visits. This labor-intensive practice is possible because each physician is only expected to follow a maximum of 100 patients. (For comparison, I add about 100 new patients to my practice in just 2-3 months!)
What is innovative about Meltzer's program is that it is not innovative; in many ways it goes back to the way we used to practice medicine! Although we recognize that this “Marcus Welby” practice is not feasible under our current insurance system, there are good economic reasons to consider it, since it will decrease medical spending by decreasing the number of clinic visits, reducing hospitalizations, and better coordinating specialists' input. What we hope to learn from Meltzer's project is the value of such care, and how it might be reimbursed.
And there is no doubt that we are going to have to restructure the way we pay for health care if we want to improve its quality. I cannot predict how this will sort out over the next few years as the mandates of The Affordable Care Act (Obama Care) begin to be implemented. But merely pouring more insurance dollars into our medical system without restructuring reimbursement is not going to prevent fragmentation of health care, since that is what caused it in the first place. We need to find a way to pay for and deliver health care that is more personalized, so doctors will again be participants instead of bystanders.
1. RR Stavert and JP Lott. The Bystander Effect in Medical Care. New England Journal of Medicine, Vol 368, No. 1, January 2013.
The opinions expressed here are my own, and do not reflect those of my employer, Geisinger Health Systems.