dr. solomon's dilemma


tom delbanco, m.d.

solomon profile
financial incentives
cost v. care

photo of tom delbanco, m.d.
He is Chief of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center. He is a well-known leader in the field of patient-centered care, and, when he arrived at the Beth Israel Hospital in 1971, created one of the first nationally recognized hospital-based primary care practice and teaching programs, called health care Associates. Currently, he is a Professor of Medicine at Harvard Medical School and chairs the Picker Institute. Dr. Delbanco is a practicing internist.
What are the biggest changes in the practice and delivery of health care in the last decade?

The biggest change I've seen is the fact that my colleagues are getting angrier. I'm seeing a lot of angry, upset, frustrated doctors, and patients are confused about what we're all about. There seems to be a real transformation in the way we relate to patients, relate to one another, and relate to ourselves as colleagues in our hospital.... There's a real sea change in the way doctors are facing the world, and in the way patients are facing the world. It's a change that holds a lot of opportunity and a lot of scary things.

What's the sea change? From what to what?

Doctors thought of themselves as independent, self-possessed, self-controlled characters who ran the world and didn't work for people, particularly. Now they're part of large bureaucracies and being told what to do, and they don't like it. Patients have been much more passive than they are today. They're learning to be more aggressive about their own health care. They're learning to really take us on. They're learning to use us as expert consultants, rather than people who tell them what to do. That transition is a real fundamental change in the clinician/patient relationship.

What's happened to quality of care in this sea change?

While there's a lot of moaning going on, the quality of care is improving. We're much better at doing things than we used to. When I was training, I had many patients who I would give comfort to, and hold their hands, and hope they'd do well. Now I see many people like that walking around feeling very healthy. The problem with our new technology that everyone yells about is that it actually works--that's why things are so expensive these days. That's why it's so hard to really get the economics right. But I actually think we're taking better care of patients than we used to, in spite all the rhetoric to the contrary.

There was a period, four or five years ago, when all the sense of anger and animosity and frustration was directed at HMOs. There was a decision here to take on a fair amount of that health management, and that involved taking on financial risk. Do you think that's been a smart move?

Doctors were taught to take care of people, not to figure out economics and to run things. We're really caught in the middle, with a new set of responsibilities, so we flail around, and we're angry at everybody. We're angry at the people who control the money. We're angry when we're told that we have to think about money, and not patient care. We're angry when we're told we have to think about the whole picture in the country, rather than that individual patient standing right in front of us. We don't quite yet know how to deal with it.

But actually, it's teaching us to be different--to take on different kind of sets of responsibilities. The younger doctors today are going to handle it just fine. The older people are having a lot of trouble with that transition. We weren't trained to do that. We weren't educated to do it. We resent it a bit, but in the long run, I can take better of a patient if I have the right resources when I need them for the given patient. And I won't have those resources unless I think about money once in a while, or more often than I used to. It's not wrong for us to do that. It makes us more responsible, and we should be doing that.

That's a big transition, and it's hard to make. But we're not going to have enough to take care of everything for everyone all the time. It just doesn't work that way. It doesn't add up.

What are doctors saying to each other about their relationship to patients?

One of the saddest things about doctors right now is that, when I came here 25 years ago and I saw two doctors standing in the hall, they would usually be talking about a patient who is a problem--what could they do to help this patient. Now they're talking about managed care. They're talking about economics. They're talking about the government. They're talking about the press. They're talking about everything but their patients, and that's a tragedy. We have to get beyond that.

Do doctors here worry about the survival of the institution that gives them a chance to practice medicine?

Doctors are worried, not just about themselves, but also the places in which they work. When they hear about the millions of dollars that are in the red for institutions such as ours, of course they're worried about it. I'm quite impressed by how they're slowly getting over the fear and the anger about everything, and actually getting to work to try and fix things, and come up with solutions to some of the problems a hospital like this faces. People who have been here a long time and love this place are kind of exsanguinating, bleeding with it, and they'd like to stop bleeding. So we're all working together, and it's going to work better in the future. But it's a very scary time in medicine. Anyone who says it's not is hallucinating.

Why is it scary?

It's scary because at least we perceive that we don't have the resources we used to have. We perceive that there are times when we can't do the best thing for the patient. We perceive that friends of ours are giving up and leaving the profession. We perceive now that medical students may not be as talented in the future as they have been in recent years, as we learn about the drop off in applications to medical school. And we worry about that.

But the debate goes on today. They're meeting weekly, monthly, and asking, "What elements in our business are paying off, and are not paying off? What should we spin off?"

It is fair to talk in undoctorly terms about segmenting our market. It's fair to say we will focus in this area, and not be all things to all people. In a rational world, Boston, which has a doctor every square inch, one hospital would do well to take care of certain types of patients, and another one would take care of other patients.

When I was young, if I did more and more things to you, I got paid more.  Now,  if I do less and less things for you, I may get paid more.  Both of those extremes are crazy. The trouble is that we're not all that rational and human emotions get in the way. You and PBS want to fight with CBS and ABC, and so you don't always make rational decisions either. If we could get over that very human way of thinking, we could rationally parse out the care of patients in this town--which is so privileged anyway--in a way that would be good for the patients, that would not break the bank, and would keep us all still very excited.

Are you suggesting that breaking the market up into groups that compete is counterproductive?

When we started in medicine, we were taught by all our professors that economics don't apply to medicine, that the marketplace doesn't apply. Now we've learned that we were wrong, and competitive forces are jiggling us around like mad.

I actually think that's been a wake-up call for us. Over time, the only way we'll be able to afford and build a rational system is if we again leave the marketplace--and work together in a rather centralized, heaven help us, nationalized way--all of us working on the same thing, and that's taking the best possible care of individual patients.

What do you say to people who say, "Yes, of course, you've got to focus on the patients. But the way you're talking is old school, old-fashioned."

This business of saying that when you focus on the patient, that's passe, that's gone, and that here's a new century coming on. That's nonsense. The basic principles of health care . . . are still the same basic principles of taking care of someone, of the basic human interactions. . . . We still basically think about --what will it take to manage you, help you, and care for you when you're sick? Those things don't change. They haven't changed for hundreds of years. We have new tools, new technologies, and new strategies. Ideally, we want you much more involved in that than you used to be, and we're going to try and teach you over time to do that. But the basic principles don't change, and it's utter nonsense when people say that.

If those are distractions, should doctors have taken on the financial risk as well as the responsibility of managing care? That's where the distractions came in.

Doctors are not trained to be economists or businesspeople, and I'd be very sad if that were the principal part of our training in the future. You would get much worse care than you get now. But this transition, this kind of pressure we're under, is very difficult, and there's no easy answer. . . . When I was young, if I did more and more things to you, I got paid more. Now, as I'm older, if I do less and less things for you, I may get paid more. Both of those extremes are crazy.

I should do what's right for you. I should probably be paid a salary. I should be rewarded if I give better quality of care to you. I should be rewarded if I work harder and longer hours, but I should basically be thinking of your needs, not my pocketbook, as it applies to the number of patients I see per session, the number of tests I order or don't order, or my hope that you don't call me, because I was paid in advance to take care of you, and if you don't show up, I make a lot of money. That's a crazy way of living.

And that's what you're doing now.

We're in a crazy transition. The country is in a big muddle.

How do you describe the incentives that are at work on doctors today? Are they healthy?

The incentives that we work under are crazy, and we've never gotten the pendulum to swing right. Fifteen years ago, if I did a cardiogram on you every week, and drew as much blood out of you as possible, I was paid more and more money. Now, if I never do a cardiogram on you, and never got any blood out of you, I'll be paid more and more money. Both extremes are nuts. We have to get it right, get in the middle. . . . I personally think there are solutions. The trouble is that my solution may be different from someone else's, and in the end, you get into a political game that gets played out in the Congress, or on TV, or what have you. We've got to get that right. It is a crucial question...

One of the things that we've learned is that we were too scared of the managed care companies. We didn't push back hard enough. We didn't really negotiate. We thought that if we weren't good boys and girls, they would just take patients away from us, push them somewhere else and we'd go bust. That's nuts. We have to push back and work with them, as a team in collaboration, to make the thing work. You're beginning to see glimmers of that happening, because the managed care companies themselves aren't so happy these days, in case no one has noticed. They're in trouble also. Their salvation may be not to do us in, but to work with us more closely. And you're going to begin to see that happening in this country soon.

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