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Gotcha: A surgeon dissects patient-centered care

December 15th, 2008

by Dr. Kenneth H. Cohn

As a patient who is also a doctor, I, of all people, should understand the concept of patient-centered care. Still, of late I have done several things wrong in making sure I was treated, and should have known better:

• I worked all day Friday, Saturday and Sunday on-call as an attending general surgeon in a rural Vermont hospital and did not get what the Institute of Medicine recommends for residents for breaks after being on call for a day (more on differing standards for resident vs. attending surgeons in a future post).

• I went into the hospital at 5:30 a.m. Monday to admit a patient with acute cholecystitis.

• I evidently used suboptimal body mechanics loading my suitcase into the car as I hurried on a windy, 7-degree day.

• I drove 140 miles back to a suburb of Boston, where I live when I am not traveling.

• Within 48 hours, I was unable to bend over to put on my pants or tie my shoes because of severe lower back spasm; it felt as though the muscles attached to my posterior superior iliac crest were on fire.


As a result of a Vincristine-related seizure over 20 years ago during treatment of lymphoma, I am no stranger to back pain; I have experienced three compression fractures in my thoracic spine and multiple disc ruptures in my lumbar and cervical spine. In the past, when I experienced severe pain, I called my physical therapist, arranged an appointment and processed the referral through my primary care provider’s (PCP) office.

But this episode was not like other episodes, because my PCP for the last decade had left his practice; I needed to select another PCP, with whom a get-acquainted physical exam was not scheduled until February 2009. Under the rules of my insurance provider, I was not permitted to see a physical therapist until I was personally seen by my new PCP and given a prescription for physical therapy.

I called the new PCP and groveled over the phone to his secretary, who nicely found me an appointment at the end of the day. For a $25 co-pay, I received a prescription for physical therapy, so that I could make a physical therapy appointment for the following day. A bargain until I remembered paying nearly $1,700 per month for family healthcare coverage.

Afterward, the insurance rules postponed my treatment by only a day and made me drive for an hour when I was in acute pain. I know that other patients have it much worse, so I shouldn't be upset. Some patients die waiting for authorization, or as President-elect Obama lamented, spend the last year of a loved one’s existence fighting arbitrary and capricious rules.

I agree with the Healthcare Financial Management Association’s white paper on Healthcare Payment Reform, that the nation’s current healthcare payment system blocks, rather than supports, the nation’s health goals:

• The (non)-system does not encourage social benefit, such as access to care.

• It does not reward wellness or high-quality care.

• It creates financial instability by adding cost and complexity to health administration, rewarding high-cost practices and focusing on expensive sickness-focused interventions rather than wellness.

The last point resonated with me when I learned that in the insurance contract’s fine print, I am permitted 60 consecutive days of physical therapy over the entire life of the policy. I could find no such limits for spine surgery or imaging technology.

So here is the message that I have shared with President-elect Obama on his MyPolicy website:

• Stop the insurance company micromanagement; it adds not only cost and complexity as mentioned in the HFMA white paper, but also creates unnecessary hassles that keep people from working productively at a time when productivity matters tremendously to our health and well-being.

• Let citizens manage their health with their physicians through a variety of channels, such as website interactions that do not force us to drive to our doctor’s office for prescriptions when we are in acute pain and know what we need to do to recover.

• Design systems using interdependent, rather than fragmented, processes, that improve patients’ healthcare outcomes, rather than tolerating arbitrary rules that exist for the convenience of insurers.

Health management organizations ideally help patients and families take ownership of their health. If they do that well, they will decrease healthcare cost and improve productivity.

In Heading Home, the late Senator Paul Tsongas described his lymphoma as a gift because it caused him to put life events into perspective. I, too, believe that good health is a blessing not to be devalued by rules that interfere with recovery and wellness.

In Hospital Impact, Christopher Cornue questioned, "Why isn’t patient-centered care a fact rather than just an effort?" Perhaps with enlightened leadership and eternal citizen vigilance, it could be.

In Rules for Radicals, Saul Alinsky wrote that people who point out a better way often are dismissed as cranks. He broadened the analogy to point out that, as with engines, cranks are objects which make revolutions.

In Collaborative Revolution, I mentioned that Peter Senge’s new book is entitled The Necessary Revolution because he believes that we must implement revolutionary changes rather than relying on incrementalism to improve the way that we work and live.

What do you think?

• What hassles and frustrations do you experience providing or receiving care?

• Can we solve our current healthcare problems with incrementalism by working harder, or do we need more systematic reform?

• Are you willing to share your healthcare improvement ideas with President-elect Obama on the MyPolicy website?

I welcome your input.

Ken is a practicing general surgeon/MBA who divides his time between providing general surgical coverage and speaking, writing, teaching, and consulting on physician-hospital relations. Learn more about what he does by visiting


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