Cassel: Doctor-patient relationship needs to rest on even ground

Katie McLean | Staff Photographer
Christine Cassel lectures on the importance of a more open, two-way relationship between doctors and patients in her morning lecture Thursday in the Amphitheater.

The Merriam-Webster Dictionary lists the first definition of “patient” as “bearing pains or trials calmly or without complaint.” The thesaurus provides some of the expected synonyms: “tolerant” and “stoic.” But then some “related words” take a slightly darker turn — “subservient,” “conformist” and, taking the sentiment to its bleakest extreme, “slavish.”

While there are many times patience is, as they say, a virtue, Dr. Christine K. Cassel said people seeking medical care don’t like calling themselves “patients.” It makes them feel powerless. And that’s a dynamic between consumers and health care providers that Cassel wants to help change; she believes people seeking health care need to have a more balanced doctor-patient relationship than has historically been the case.

“If we’re going to be consumers, we need to be informed consumers,” she said. “And your physician should want you to be informed.”

Cassel, the president and CEO of the National Quality Forum, spoke at Thursday’s morning lecture about the need to better inform the public about their health care options. That’s important, she said, because it will limit the increasing amounts of overtreatment and overdiagnosis that contribute to the large amount of money spent on health care today in the United States.

Currently, health care spending accounts for 17 percent of the United States’ gross domestic product. To keep this percentage from rising, as it has in recent years, Cassel suggested that the health care system needs to address what she called “waste,” costs stemming from problems such as the failure of doctors to coordinate, the fragmentation of the health care system, insurance fraud and overtreatment.

During her lecture, Cassel focused on the area of overtreatment, which she believes could be improved by a “culture change” in terms of doctor-patient relationships. The relationship needs to be a two-way street, with an informed patient who is willing and able to have a dialogue with his or her doctor.

“The role of an informed consumer and of an informed patient is to ask questions,” she said.

The American Board of Internal Medicine, for which Cassel formerly served as president and CEO, has launched a campaign called “Choosing Wisely.” The campaign’s goal is to inform those seeking medical care that doctors sometimes suggest unnecessary treatments or procedures, Cassel said. The idea is to empower consumers — to make them ask questions. She said patients need to be informed enough to ask doctors whether or not a procedure is necessary.

“That’s really the idea of ‘Choosing Wisely’ — is empowering the patient to have that conversation with the doctor,” Cassel said, “and for the doctor and the patient to have the same information, the same evidence-based science.”

To Cassel, the initiative pushes back against some cultural realities that have led to this overtreatment phenomenon. First, Americans often have the idea that “more is better.” It’s rational, in a way — it seems like another test can’t hurt. But, she said, that’s not necessarily true. Every procedure has its risks, even if they’re small.

And this leads to the second point — what Cassel called a “therapeutic cascade.” A minor abnormality in test results can lead to a doctor suggesting more procedures, perhaps because he or she genuinely thinks they’re needed, but sometimes because the current fee-for-service model provides a financial incentive. This trickle of tests can quickly turn into a deluge.

“You can say, ‘OK, that’s the protocol,’ and therefore get on the conveyor belt,” she said. “In every situation, you are the person who has to ask that question: ‘Do I really need this?’ and,  ‘What is it going to offer to me?’ and, ‘How is it going to benefit me?’ ”


Q: I’m standing looking, and I’m glad you looked this chart up  — at a chart that includes FOX and MSNBC and The Wall Street Journal and The New York Times. So I want to started by asking, who disagrees with you, and what do they say?

A: That’s a very good question. Thank you for that. This is definitely a nonpartisan issue, so thank you for pointing that out. There were — I was actually prepared for there to be a lot more pushback when we first launched this campaign. I thought we’d be getting a lot more pushback from doctors, particularly from doctors whose whole sort of business model was to do a lot of these kinds of tests, and perhaps from people who would be accusing us of rationing, for political reasons or other things. We didn’t hear either of those. We carefully monitored all the websites and the blogs, and only 5 percent of the medical blogs were negative, and they were predictably from two sources. One is people who really didn’t want consumers asking them these hard questions, and I think understandably, and the other was the standard question, which I’m sure will be one that is coming your way about malpractice. And if we just fix the malpractice system, then we wouldn’t have to have all of these problems. I’m the first one to say that I think that the malpractice system is one of the big obstacles to better doctor-patient relations in this country, but it actually contributes very little to this overall cost of care. … So a very small amount of pushback from doctors, surprising openness of consumers. I think the reason for that is — I think more and more consumers do have these high-deductible plans and are actually experiencing this themselves and needing to ask themselves these questions. So it was the right message from the right messengers, and I think another important part of it is we didn’t have any insurance companies as part of the partnership, and we didn’t have any of the government players. So this was not government, and this was not insurance companies; this was doctors and consumers who were putting this message out — so two sources of trusted information.

Q: Can you give an example of a United States medical organization that’s doing high-quality care at lower costs?

A: Well, I have some — one example that comes to mind is Dr. Gilfillan’s employer, the Geisinger [Health System] is one of them. I think the Kaiser Permanente system is a large one, that’s another one that actually I think is able to provide comprehensive care for 9 million people, and to manage that cost curve significantly better than other areas. There are smaller groups, too, around the country — there are regions around the country, and some of those are, for example, Minnesota is one of the places, Minnesota and Wisconsin that actually spend less on health care and have better overall population outcomes. So it’s not so much a particular system of care as it is a particular community that understands care differently. Now, one of the things that all of the examples that I just gave have in common — well, two things that they have in common — one is that they’re largely, if not entirely, in the not-for-profit model, and I do think that there’s some evidence that we have a better shot at rationalizing some of these costs in those kinds of systems. And the other is that the doctors are on salary in most of those organizations, and that’s a place where I think you get away from this fee-for-service pressure that — what they call “pay for volume” instead of “pay for value,” and so some of the discussion that we’re hearing now in Congress about different approaches to how Medicare pays doctors understands that phenomenon and is trying to understand how, in all of the multiplicity of different kinds of health care delivery systems, we could move to models that have less of that fee-for-service system. Another one I just want to give homage to, just very briefly, is within the government — the Veterans [Health] Administration … which didn’t used to have such good scores on quality, but really put its attention to that effort and has transformed itself, really, as a health care system. And it has very, very sick patients, as you might imagine, has doctors on salary, is a not-for-profit model and has sort of a comprehensive care information set about patients, so some of that coordination stuff happens better there.

Q: I’ve got a couple of questions that go together here, and I also would remind the audience that you may also tweet your questions using the “CHQ” as your message. One specific question about anesthesiologists, but that also leads into a more general question, and this represents several about working with your physicians. And I want to ask the specific one, with respect to anesthesiologists, why is it so difficult, apparently in this person’s experience, to get them to work with patients or consumers to explain what they use, and to determine what each patient needs instead of what they want to administer? There’s a more general question about how we can work with any physicians to get these questions …

A: Well, I can’t speak to anesthesiologists as a particular class or entire specialty; I think, in my personal experience, that’s not always true of everyone in anesthesia. It may be, in terms of some certain environment, but I would just say that has to change. And one way that that changes is for informed consumers to begin asking that question, and not necessarily ask it when you’re just about to go under for your major hip replacement — that’s probably not the best time to do this. But I would bet in this audience we have a number of people who serve on boards of your local hospitals, or other health care organizations or community groups that have influence in your community — that is a place where these kinds of questions really ought to be asked. And not just of anesthesia, but of the whole system.

Q: The two that best express this, I think — what percentage of overtesting is due to doctors’ fears of malpractice, and would tort reform be an answer to unneeded tests?

A: So let me just say a couple of things about that. The evidence, which is quite significant out there, is that the cause of overtesting due to malpractice, plus malpractice premiums, adds only a couple of percentages to the overall health care bill. Well, in a country that spends two — now about to be three — trillion dollars on health care, a couple of percent is worth aiming at. So that would be my answer to that, even though it’s not the major cause. But I think there’s an even deeper reason to consider this, which has to do with the culture of our system: If a patient feels that somehow the doctor isn’t being forthcoming with them, then they’re going to be suspicious. One of the things they’re going to do is demand unnecessary things, because they’re going to feel like they don’t have that trusted relationship. And the second is that the doctor’s going to feel suspiciousness of a patient and maybe out of defensiveness order a test. One of the groups that was very late coming in to the “Choosing Wisely” campaign was the American College of Emergency Physicians, and I’m not ratting on them by telling you this, but they had a very open debate on their website about whether they should join “Choosing Wisely” or not. Because if you think about it, the emergency room is a place where a lot of those decisions get made. A person comes in who you don’t know, you don’t know if you’re ever going to see them again, if you make the wrong choice — three years later, a lawyer shows up. And that does happen in our society. As I said earlier, I think that we as a nation really need a better approach to harm that comes to patients from negligence; that’s really what the malpractice system is meant to address. What we find out is that the malpractice system actually helps a small percentage of people who have been harmed by medical negligence … they get it 10 years after the event happened, and most of the money goes to lawyers. So this is not a system that works. And there have been many attempts out there to try no-fault insurance that works for everyone in the system; it’s like a workers’ comp kind of thing, understanding that a mistake can happen. There are physicians out there — I urge you to check the work of Tom Gallagher, a young physician researcher at the University of Washington in Seattle, who has done extensive research about doctors giving apologies to patients when they make a mistake and not sweeping it under the rug, but getting the family together and telling them that they made a mistake. It turns out those patients don’t sue you when that happens, because you create — they more often say, “How can we help the hospital so that they can reduce the chance of this happening to somebody else?” And so, in fact, some of the big health care systems that I described have begun to institute this apology method, and offering, if somebody really was harmed, offering to pay them and keep the lawyers out of it. So I think we need more and more systems like that to address this problem.

Q: Now we’re hearing from the physicians. What is the risk — this is from Twitter — what is the risk of patients misdiagnosing themselves on apps and websites? We also have a question about the patient who turns a simple headache into a brain tumor, and also the question about advertising for proprietary drugs.

A: Can I just see a show of hands of how many physicians and health professionals we have in the audience here? I’m just curious. Oh, OK, good — I’m not alone. Those are all very good questions. So the one about patients diagnosing themselves — I mean, in practice, there’s a term called the “Internet-positive patient.” I’m sure that the doctors all know what this is. This is a patient that comes into your office with a pile of printouts from the web, and, you know, “I have this, I think I have that, I think I have that.” Well, that’s the price we pay for living in an information-rich system, and that’s I think why it’s so important that those of us who are able to navigate through all these different sources of information begin to find ways of knowing which ones are reliable and which ones aren’t. And even physicians recommending to patients certain kinds of websites I think would be not a bad idea. Consumer Reports, if you follow them, and I’m really not here to advertise for them, but they are doing more and more of this health care evaluation, of different sources of information. They may be involved in some effort to do that, as well. So the answer is that the patient may come up with the wrong diagnosis if they check out a website, but the chances are just as likely that they’ll discover that they don’t have a brain tumor, they just have a headache, and maybe they don’t have to miss work to go to the doctor. The other thing they need is a health care provider who they can call 24/7, because a lot of times the problem is, when this happens on a Saturday afternoon, you can’t get anybody on the phone. So access to primary care in a more comprehensive way, I think, would help that. But these websites are here to stay, so for my colleagues in health care who are in the audience, I think what we need to do is understand how we can partner with them, how we can know to recommend the good ones. And if a patient comes in with information from something that’s not evidence-based, to be able to advise them about that. It is part of being an informed patient in this day and age.

Q: What about nurse navigators, who guide people to answer their questions for people who can’t do their own research?

A: This is a proliferating field right now — I think it tells you something about the complexity and the fragmentation of American health care that there’s a whole new set of professionals who are navigators in health care. It also tells you that we have a real shortage of primary care, because that’s really, in some ways, what a primary care organization would do. It’s not just the doctor; it’s also the nurse and others within the system. For geriatrics, it’s often a social worker who helps you navigate not just the medical part of the system, but long-term care, rehab, home care arrangements and other kinds of things. All of that is very complex, and I think there’s a really important role for this kind of navigator. Now I don’t mean to diminish that, but I think that we need to see if we can fix the system by creating more comprehensive teams that work together, rather than having somebody outside of your provider who you add on as another layer of complexity to the system. I’d rather see those navigators be part of the health care team.

Q: What should a patient or consumer do if she or he believes that Medicare was billed or paid too much for a medical visit? Is it worth speaking up, and how does a consumer report abuse?

A: The consumer can report any suspected abuse or problem with billing on the Medicare website. There’s a part of [the Centers for Medicare and Medicaid Services] that’s called the Center for Public Integrity; it’s the group that does the fraud — so it’s the opposite of fraud, it’s integrity — so they want to sort of look at the vast majority of people who are not defrauding Medicare. But the patients really are the first line of defense for the Medicare system, and for the taxpayers about this kind of crime that happens. So I would urge people to take that responsibility seriously. … I can’t tell you how many times I would get requests to approve wheelchairs or other kinds of durable medical equipment or things for patients I didn’t know, for patients who I knew didn’t need them, for patients who didn’t even know that they were signed up for this thing, because there’s all kinds of ways that people find to take advantage of the fact — and here’s the good news from the doctor’s perspective — Medicare is the most efficient payer out there. They electronically pay you immediately, they don’t ask you to defend what you’ve ordered, they aren’t like the insurance companies in that way, causing great delays and a lot of paperwork. But the cost of being so efficient is that it’s too easy, then, for people who shouldn’t be billing Medicare to do that. So I would urge people to go on to the website if you have any such suspicions and to make that report. If you’re courageous, you might confront the person who did it and just ask them, because it might be a mistake, and that would be sort of the best place to start, I think, before starting a report.

Q: … Pricing, overpaid administrators, questions about how we don’t know what our services are costing. What do you have to say about that, and how can we find out more?

A: Well, I am not the first one to make this observation, but it’s just — I think Gilfillan said this, too — it’s like going into a restaurant and they don’t tell you what it costs until after you’re done eating it. That’s what our health care system is like. In that little story I told you about my husband — at the time, we thought he was going to need this procedure; it was out of network, so I wanted to find out how much we would have to pay for it. And I was on the phone for eight hours over two days and couldn’t get an answer. I pulled every kind of rank I knew how to pull. And they could just not give me an answer. So it’s a serious problem; the administration knows it’s a serious problem, and they’ve now released a huge amount of data that Medicare has on pricing that’s very technical, and it’s going to need be adjusted into information that consumers can use. But there are a lot of sophisticated organizations out there that are working on that right now, so I think all of us — particularly for consumers and those of you who are on boards — I think all of us need to be pushing for that transparency.

Q: What’s your opinion of paying for concierge medicine?

A: Well, it depends on what you mean by that. Concierge medicine was developed because our fee-for-service model doesn’t really support primary care. So rather than have to be on the hamster wheel of seeing a patient for five minutes, ordering a bunch of unnecessary tests, if you pay your doctor a retainer, then the doctor can actually have fewer patients and be more available to those patients and answer the questions and coordinate your care. Isn’t that what you would want? It’s like having a doctor on salary. The problem is that some of the high-end concierge practices are very, very costly; they can cost $10,000, sometimes $20,000, sometimes more, a year; that way, the person that’s in that system gets very good care, but people that can’t afford it, don’t. But there are also innovative practices — there’s one called GreenField [Health], outside Portland, Ore., where you pay a fee of about $50 a month. And that allows them … to have extra nurses on staff, to be available 24/7, to have the electronic records, to do all the things that that money would allow you to do. So I think the idea of concierge care is getting more to a system where the doctors are on salary. So on that level, I like it. I think the problem is about what the price of it is.

Q: What’s your opinion on the effect of urgent care centers on price and quality?

A: I actually like this phenomenon, because I think what it tells us is that our current system is not easily accessible or user-friendly. The whole phenomenon of “minute clinics” — CVS, Walgreens and even Wal-Mart having these clinics, as well as other kinds of urgent care — I think a lot of people are kind of worried about that, because they’re going to miss an important diagnosis, et cetera. But if you’re a working mother and you have a kid with an earache, rather than call a pediatrician who can see you maybe two weeks from now, you can actually go during your lunch hour, get it taken care of and not have to take the day off work. And you pay a modest amount. There is a place where they tell you what the prices are; they’re listed on the wall. And so I think it’s an important, what they call “disruptive change” —  people in the business community think that disruption is where you get creative innovation. And I think that the minute clinics are really an important disruptive force that is going to find its way in, one way or another, to our health care system and be a good thing.

Q: Harkening to your first slide, can you please provide examples of things other countries are doing to achieve better outcomes?

A: Sure. First of all, I would refer you, if you want to really know a lot about this topic, to the Commonwealth Fund website — the Commonwealth Fund is a New York-based foundation that does a lot of this comparison across different countries of different aspects of quality, so you can get more information there. Probably the key things that are different in the countries that has ve different costs and higher quality are more access to primary care, in general, salaried physicians — although that’s not true throughout, but particularly in some of the European countries; they have everybody insured and simple insurance models, so much, much less administrative overhead. Even countries that have private insurance — they aren’t necessarily government-insured, but they have regulated insurance so that everybody plays by the same rules, everybody has the same benefits, everybody has the same forms to fill out, and that way, you reduce the complexity a lot. Then in terms of how the care is delivered, there is much more availability in care when the patient needs it, rather than waiting until you become very ill. So in France, for example, which the World Health Organization last year named No. 1, their primary care physicians commonly make house calls. If you get sick when you’re in France and you’re in a hotel, they’ll come to your hotel to see you. And one of the advantages of that is you can find things early, so that you don’t have to have a person get much, more worse and then need to go to an emergency room, or perhaps be able to avoid hospitalization. The last thing, I would say, because I didn’t address this in the earlier question, is that they don’t have direct consumer advertising of medications. As I said, we’re only one of two countries in the world that do this, so without that kind of commercial force, many patients are eager to get the newest and latest medication, but they get trusted information, rather than information that has been designed particularly for the advertising mechanism to make them want it, even if they don’t need it.

Q: Some have talked about the fact that our medical costs are so much higher than other countries. What percent of those costs are a result of our advanced research and training facilities? Couple that with a question about what we need to do in medical schools to deal with the training about overtreatment.

A: Well, first I would just say that a lot of medical schools are now beginning to take the “Choosing Wisely” information and include that in their curriculum, and hopefully we’ll see more and more of that, because I agree with you that we need to train our young physicians in a different way in this new environment. We also need to train them how to work better in teams, how to be coordinators of care, et cetera, and all of that is part of the challenge for medical education in this environment. But the costs of research — I mean, the United States is justifiably proud, and should be, of our research in health care. The [National Institutes of Health] is the envy of the world, and really is a resource not just for the United States, but for the world, in terms of the medical research that is supported there, and I think we all need to understand that. That’s not included in any of these wedges. Nobody I know would define medical research supported by NIH as “waste,” or the kinds of medical research that we’re talking about here. Much of that research actually needs to go into things that can reduce costs, as well as things that might add cost and might buy better function and longer life. So … we shouldn’t consider the cost of research as part of this problem.

Q: Help us: We know we have the right to say no. When do we say no, and how do we say no?

A: Well, maybe you’ll invite me back next year … It’s more than just an answer to a question or even a whole lecture, but I think it is something that we need more and more attention to as consumers and families, and frankly, as physicians and nurses as well, that the patient needs to understand all of the possible options and risks. And particularly, as my perspective as a geriatrician, as we get older, we actually don’t have good information about many of our interventions in people who are 85, 90, 95, 100 years old. More and more of us are living to that old age in relatively good health, amazingly. I mean, with some chronic conditions and on medications sometimes, but then something comes up — I just heard from a colleague of mine recently who’s 92 years old, retired physician — actually not really retired, still continues to be active — who just had an aortic valve replacement. And last time I saw him before that, he was kind of short of breath and getting frailer, and I thought “Oh, well, it’s beginning to happen.” And he looked much better when I saw him after he had this procedure. Now, he, I know, had a very long discussion with his physicians and his wife and many websites before he made that decision, because there’s a lot of risk in a major heart operation like that for someone at the age of 92, and his decision is, “I’d rather take that risk.” And that’s a perfectly understandable decision to make. Another person could quite easily and just as understandably say, “I’d rather not take that risk.” And so those are the times when we need to really take the reins and be the informed patients. So those episodes are going to happen more and more — for those of you who have older parents, I think you can help them ask those questions, because a lot of people in that generation grew up in a time when you didn’t question your doctor — “This is what the doctor said I should do” — so you’re less comfortable having that decision. But, you know, the daughter or the daughter-in-law can walk in there and have that conversation. And I think that we all have been — many of you, I’m sure — have been in that situation, and I would urge you to do it. I think that if you talk with your friends and groups in your community, you will find more and more people who find themselves in that situation and who have found a positive reception to doing it in the right way. And so I urge you to keep having that conversation.

 —Transcribed by Victoria Wolk