Intruders!

INTRUDERS!
by Peter Smyth, MD Board President

"Our next regulatory challenge is the preservation of the physician-patient relationship."

This is a statement which was made repeatedly in program sessions of the April 2000 annual meeting of the Federation of State Medical Boards. It is also a blinding flash of insight into the obvious, belated though it may be.

In recent years, even causal observers of the medical profession have remarked on the increasing number of external intruders attempting to drive a wedge between the physician and the patient. These intrusions are aimed at the heart of the practice of medicine, and disrupt the clinical process and the physician-patient relationship which have been the foundation of medicine since it became a profession.

It is in the best interest of everyone, physician, patient, payer, regulator to keep this process and relationship intact. It is also the obligation of at least the profession, the consumers, and the regulators to guard against any efforts to foster these intrusions.

The essence of being a physician is found in the lessons taught in Clin. Med. I:

A good history and physical, based on rapport with the patient
All necessary diagonstic testing
A soundly based diagnosis
A treatment plan based on the diagonosis
A monitoring program to access patient response
Objectivity
Clear and informative patient records.

The skills obtained from these lessons create clinical judgment in the practitioner, distinguish physicians from all other health care practitioners, and form the saltient features of outstanding clinicians. The practice of these skills forms the physician-patient relationship, within which the physician is obligated to exercise his or her best clinical judgment on behalf of the patient.

Sadly, today the world outside the examination room is in competition with itself to create intrusions into the physician-patient relationship, and to restrain the physician from exercising the best clinical judgment on behalf of the patient. These intrusions take many forms:

Proscriptive laws - federal state and local
Government funded health care plans
Physician-patient time restrictions
Cost containment
Profit sharing
Risk management
Referral restrictions
Prior authorization
Mandated disclosures of patient data
Dated facilities, equipment and information
Malpractive coverage restrictions
Litigation
Phobias, fears and phantasms of all manner
And many, many more

Each one of these presents the physician from doing the best possible job for the patient, and renders less than the best possible care to the patient.
Each time this occurs, the individual practitioner, and the profession as a whole are degraded. And the patient receives a level of care below the best available from the practitioner.

The Minnesota Board of Medical Practice has a long history of opposing any attempts at unneccessary intrusion into the pracitioners' freedom to exercise their best clinical judgment, and of supporting efforts to promote this freedom. A few examples are:

Opposition to triplicate script proposals
Opposition to "black box" prior authorization processes
Opposition to federal data bank
Oppostiion to federal intrusion into clinical issues
Opposition to proposals which allow non-physicians to exercise clinical judgment
Support for "intractable pain" legislation
Support for defining "prior authorization" as medical practice
Educational efforts

The Board also practices clinical judgment by assessing complaints within the "current and prevailing standard of care for the specialty" and within the clinical context of the practitioner's physician-patient relationship as reflected in patient care records. This may involve extensive records review, and the use of external consultants within the specialty of the practitioner against whom the complaints are filed.

Interestingly too, is the fact that nearly all complaints which are filed with the Board related to some breach of the basic methods, or some lapse of skills related to the lessons taught in basic clinical courses.

These run the entire gamut of breaches, including: failure to establish patient rapport, failure to perform a sound work-up, use of short-cuts, breach of objectivity, failure to document a patient's care, and others.

Had the physicians invlolved in the bulk of the complaints submitted to the Board fully utilized these basic methodologies, the complaints may never have been filed.

While the Board is not in a position to assess the nature of the issues involved in medical malpractice cases, it is a good guess that many of those, too could have been avoided or settled on the physicians' behalf if the basic methods had been fully utilized.

Another interesting and distressing fact is that a growing number of complaints submitted to the Board which are outside the Board's jurisdiction are related to external intrusions, which prevent the physician from exercising proper clinical judgment. These involve actions by facilities, institutions, plans or other external parties which constrain the physicians' clinical options, or in some cases, prevent the patient from ever seeing a physician.

These are complaints, many submitted by physicians themselves, over which the Board has no authority to act, since the Board's jurisdiction extends only to the physicians' licenses. In most cases, authorities over the external parties are also unable to act. The result is a reduced level of patient care, with no recourse.

Quality medical care and the freedom of the physician to practive his or her profession at the highest possible level is in the best interest of everyone - the state, the profession, and the public. Achieving and maintaining such a situation, however, requires the efforts of everyone, as well. The Board is grateful for the help it has already received from the profession, and anticipates that the Board and the profession will continue to work together on these issues. We all recognize that many of the intrusions mentioned above, such as managed care, government financing of health care, tort law, etc., are simply a part of the landscape of the practice of medicine today.

However, the Board of Medical Practice welcomes comments and information from practitioners on how the board can be helpful in efforts to promote the freedom to exercise clinical judgment within the current and prevailing standards.

Minnesota Board of Medical Practice
2829 University Avenue SE, Suite 400
Minneapolis, MN 55414-3246

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