The Patient, Stupid

James Carville, President Bill Clinton's political strategist for the 1992 presidential campaign, coined the phrase, "The economy, stupid," to remind staff that this was one of the three fundamental messages for the campaign. The other two messages were: "Change vs. more of the same" and "Don't forget health care." With the Supreme Court's decision on the Patient Protection and Affordable Care Act, it would appear that it has taken 20 years for the third part of Carville's strategy to come to fruition.

But when it comes to health care, our profession might just say that so far, change hasn't come and there is more of the same. Many measures of health in America are moving in the wrong direction. Americans are getting fatter, they are getting sicker, there are more back surgeries being performed, and we are spending more on health care. Health care and the health of Americans are not improving.

In the past few years, media commentary has frequently lamented the number of patients MDs see and the short time allotted to each patient encounter. One backlash of this in the medical profession is the concierge practice, where patients pay extra to get better access to their doctor. One would have to be naïve to believe that health care is a completely altruistic endeavor and that one should bankrupt oneself providing care for patients without regard to the economics. Remember, the economy, stupid.

I recently saw data from a managed care organization which showed that care for nonsurgical back pain initiated by doctors of chiropractic would save hundreds of millions of dollars over care initiated by any other type of health care provider. Yet it seems that our profession is the one that is singled out for reduced reimbursements and restrictions on treatment plans. It is incomprehensible that on the one hand, we can provide clinically effective and economically effective care (i.e., high-value health care), and yet on the other hand, find roadblocks to doing so at every turn. Moreover, given the fact that reimbursements to chiropractic physicians represent less than 1 percent of all health care expenditures, something is amiss.

I know it feels good to blame it all on others– and surely some of this is still a backlash of the AMA boycott of chiropractic. Why else would high-value care have such low value to third-party payers? However, we have to ask how we have contributed to the situation in which we find ourselves. Maybe it is our focus or the perception of our focus that is created by some in our profession.

I have read and heard that what is most important is chiropractic, not the chiropractor – 'tic is more important than 'tor. I think this is one of the problems facing our profession. First, it looks bizarre to outsiders when they see chiropractors write words with inappropriate capitalization (e.g., Chiropractic [not a proper noun], ChiropraTIC or ChiropraTOR) or an anti-intellectual approach to spelling ("enuf said"). Second, health care isn't about the 'tic. No one but chiropractors care about the 'tic! The laity don't have a clue what the 'tic or the 'tor is. Health care shouldn't be about the 'tic or the 'tor. The 'tic is as irrelevant as the 'tor is – health care is about the patient, not about us individually or our profession's principles.

Dr. Jim Parker used to say that money is the by-product of services rendered. I've also heard other practice-management people talk about how the patient comes first. But in my opinion, far too much of the talk is about the doctor. Ask an acquaintance who is not a chiropractic patient to read the practice-management advertising or materials and see who they think the focus is. I'll bet they will tell you it's not the patient, but the doctor.

I read one practice-management manual that contained considerable material about what the doctor wants. It talked about getting patients to do what the doctor wanted and needed. I get advertisements for practice-management seminars that never talk about how to provide high-quality care efficiently; just about how to get more patients. People in our profession actually boast about seeing hundreds of patients per day. To non-chiropractors, this smacks of the mega-church where more is better because more souls are saved. Patient centered?

I even received an e-mail inviting me to a seminar to hear a consultant who boasted of seeing more than 800 patients in one day. I know this seems like hyperbole, but in an ethics seminar an attendee said he observed this DC treat over 700 patients in a day. To treat 700 patients in a 10-hour workday, the doctor can spend an average of 51.4 seconds with each patient! I know of a person who worked in an office like this who had the job of using a stopwatch to time the DC's time with a patient to ensure he didn't spend too much time – a minute – with a patient. Patient centered?

I heard recently from a young doctor who was told by his boss that during a report of findings, the most important thing is to get the patient to cry. Then the patient would sign up for a prepaid extended care plan. Patient centered?

This focus is just plain backward. We need to refocus our attention on what patients need and want. While Carville said, "The economy, stupid," for us doctors the phrase to live by must be, "the patient, stupid.