Healthcare and Cognitive Medicine
Tuesday, March 27, 2007
There was an item in the March 22, 2007 New England Journal of Medicine that caught my eye. It was an opinion piece by Drs. Paul D. Ginsburg and Robert A. Berenson. Ginsburg is the president of the Center for Studying Health System Change in Washington, DC and Berenson is a senior consulting researcher there, as well as a senior fellow at the Urban Institute. I admit that I never fully understood how the system of payments for clinical care evolved, and the countervailing forces at play in the effort to reform healthcare. In clear and concise language, Ginsburg and Berenson explain the background and lay out what, to my mind, is one of the most glaring problems facing both physicians and patients: the undervaluation of thinking in medicine.When you come to a doctor, he or she talks to you about your symptoms, examines you, and sits down and tries to formulate a diagnosis and explain what tests are needed and what treatments are appropriate; this aspect of practice is termed "cognitive" or "thinking" medicine, and is very poorly reimbursed by Medicare and private insurers in general. This means that physicians who practice cognitive medicine, like general practitioners, pediatricians, and internists, are pressed to see as many patients as possible in shorter periods of time in order to sustain revenue and defray overhead. On the other hand, clinical care that involves procedures, particularly surgery, or sophisticated imaging techniques, like CAT scans and MRI scans, are much more richly reimbursed. While I believe that surgeons and radiologists should be rewarded for their skills and the intensity of the treatments they deliver, it seems penny wise and pound foolish to not value cognitive medicine.
First and foremost, a correct diagnosis begins with the dialogue between patient and physician. Rushing through an appointment is a set-up for cognitive errors, particularly anchoring where you fix your mind on your first impression, and premature closure, where you shut your mind off to other possibilities. Once you miss the diagnosis, there is a real risk to the patient. In addition, for those who calculate healthcare costs, it is much more expensive to care for someone whose disease has progressed rather than having been diagnosed early. Furthermore, preventive medicine is all about communication. We have all heard, in detail, about the benefits of stopping smoking, losing weight, exercising regularly, and reducing stress in terms of heart disease, cancer, and mental health. Changing behavior is difficult, but, in my experience, most likely succeeds when there is time allotted to the discussion, a close bond between the patient and doctor, and continuing encouragement. It boils down to words and positive feelings, and the health benefits can be extraordinary. Much of what primary care physicians do involves preventive medicine. Unfortunately, the system, based on its payments, is telling us that this has meager value.
It is time to change this. As Ginsburg and Berenson point out, there are powerful lobbying forces against changing payment schedules, and even though a bone is thrown on occasion to increase payment for a certain cognitive practice, at the same time, payments are reduced for other kinds of thinking medicine. It ends up as a wash, if not a reduction in rewards for those doctors who are trying to prevent disease or make a thoughtful diagnosis that takes time. In my own specialty of blood diseases and cancer and AIDS, much time is spent talking to patients about their needs and values as they face harrowing problems. These patients seek to integrate their beliefs and values into risky choices. Such discussions take time, but they are vital, both to the physical wellbeing of the patient and his or her emotional and spiritual state. Again, this dimension of medicine seems to be discounted in the healthcare reimbursement structure.
