March 22, 2006
Op-Ed Contributor

The Doctor Will See You for Exactly Seven Minutes

By PETER SALGO

WHEN politicians speak of America's health care needs, they often miss an important point: the doctor-patient relationship has become frayed. Patients aren't unhappy just because health care costs too much (though they would certainly like it to be more affordable). Rather, people sense a malaise within the system that has eroded the respect they feel patients deserve.

There has been a shift in attitude within the profession. I see examples of it every day. I was making rounds in my intensive care unit recently when one of the interns presented a case. "This is the first admission for this 55-year-old male," he said.

"Stop," I said. "He is a man."

"That's what I said," the intern replied.

"Not exactly," I answered. Clearly, the intern didn't get it. Neither do a lot of other health care professionals anymore.

The problem has been sneaking up on us for almost two decades. As health-care dollars became scarce in the 1980's and 90's, hospitals asked their business people to attend clinical meetings. The object was to see what doctors were doing that cost a lot of money, then to try and do things more efficiently. Almost immediately, I noticed that business jargon was becoming commonplace. "Patients" began to disappear. They were replaced by "consumers." They eventually became "customers."

This may seem a trivial matter, but it is not. You treat "patients" as if they were members of your family. You talk to them. You comfort them. You take time to explain to them what the future may hold in store. Sometimes, that future will be bleak. But you assure them you will be there to help them face it.

You treat "customers" quite differently. Customers are in your place of business to purchase health care. You complete the transaction such a relationship suggests: health care for money. And then they aren't your customers any more. Taken a step further, you can make the case that the less time you spend with your customers, the better your bottom line will be. This gets everyone's attention.

"Length of stay" became a buzz phrase in hospitals in the 1990's. So did "throughput," an awful neologism for the number of patients per hospital bed per week. One of my colleagues joked that a hospital stay was a lot like a taxi ride. The institution collected a big fee when a patient got admitted, just as a cab driver saw most of his fare when he first turned the meter on.

The additional money collected over time wasn't nearly as impressive as that initial charge. The economics of the situation favored short trips, or lengths of stay, and lots of new riders, or throughput. The arithmetic worked, but I didn't notice a lot of people laughing.

Doctors in hospitals all over the country began hearing the same business language and facing the same pressures to "keep things moving." I used to be asked how well my patients were doing. Suddenly administrators were asking how long I was planning on keeping sick people in the intensive care unit. Each day a patient spent in my unit was a day some other paying patient would have to wait for a bed. Eventually, I was warned, some of those patients "in orbit" would go elsewhere, and we would not only "lose their business," but we risked losing future referrals from other centers.

It wasn't just hospitalized patients who were taking up space other "customers" could use. Outpatients "consumed" health care "resources," too. Publicly traded H.M.O.'s, for example, began restricting doctors to an average seven-minute "encounter" with each customer. This apparently kept shareholders happy. But it reduced the doctor-patient relationship to a financial concept in a business school term paper.

Doctors know you cannot provide compassion in seven-minute aliquots. But we have felt powerless to change things. The medical establishment has, many of us feel, simply rolled over and gone along to get along. It has sacrificed patients' best interests on the altar of financial return.

This leaves the solution to the problem in the hands of our patients. You, the patient, are the system's best hope. In the age of seven-minute health care, you need to realize that you employ doctors. That is, your doctor works for you. Although doctors shouldn't think of patients as customers, you can, and should, adopt a business mind-set when shopping for health care.

Evaluate what it is you expect from your doctor, then ask for it. If you are unhappy with your doctor, fire him. If you cannot get more than a seven-minute face-to-face encounter with your doctor, he needs fewer patients. The true power in the health care economy rests not with the doctors and certainly not with the backroom business staff. It rests with you. If you insist on being treated with care and respect, you will be. And the system will improve as a result.

A pediatrician I know put it quite succinctly. "There are a lot of doctors in town," she said. "There's no need to settle for one that doesn't treat you well."

In one respect the business people are right. Restoring the doctor-patient relationship will not save anyone any money. But I submit that it doesn't have to. There are other ways to curtail health care costs. Some involve high technology; others do not. None of them requires patients to sacrifice their self-respect.

We can and must reduce health care expenses. But we cannot do it at the expense of patients' well-being. The doctor-patient relationship is critical to the integrity of the health care system. It is not disposable. Turning doctors into shopkeepers who regard patients as customers is unacceptable.

How will the M.B.A.'s and the politicians respond to what can only be termed a "patient-driven revolution"? They will have to cope. I suspect doctors will be thrilled.

Peter Salgo, a professor at the Columbia University College of Physicians and Surgeons, is an internist and anesthesiologist, as well as the host of the PBS series "Second Opinion."