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Compliance with regulations threatens covenant of putting patients first
 Richard L. Lindstrom |
I fear I write this commentary at some personal risk, but I find myself compelled to speak from the heart — or, perhaps more accurately after 38 years of committed service as a physician and surgeon, from my very soul.
Two to 4 decades ago, most baby boomer physicians were trained in a culture that was extremely altruistic. In every moment of our daily lives, we were encouraged to put patients first, ahead of our personal needs, ahead of our families’ needs, and certainly ahead of the needs of regulators, third-party payers, and a growing multitude of government inspectors and prosecuting attorneys. We were indoctrinated in the belief that if we truly advocated for the best interests of our patients, we would be robust to any and all challenges to the sacred covenant known as the doctor-patient relationship. After all, this sacred covenant between our profession and the patients we serve had survived for centuries, enduring the challenges of communism, socialism, fascism and even representative democracy. Worldwide it has bound physicians and our patients together through innumerable wars, depressions, and natural disasters, including famines, floods, hurricanes, tsunamis and every other external threat to date.
Now we face another growing threat that may prove itself the greatest challenge in history: compliance. Compliance is threatening the very foundation of our learned profession. Compliance in our method of charting is now more important than a quality outcome or quality experience for our patient. We focus more of our time and attention on getting the chart and the code right and less on the diagnosis, therapeutic plan and patient education. We are encouraged and incentivized to obsess over charts and codes rather than to look deeply into whether we could enhance the quality or compassion of our patient encounters. Pay-for-performance criteria reward doing the prescribed exam or test and following the preferred practice pattern, not interpreting the findings properly and customizing a treatment plan in each individual’s best interest.
I am concerned that compliance with an extraordinary and growing number of rules and regulations and the potentially severe penalties — not only civil and monetary, but now criminal as well — are putting at risk our once-sacred covenant to always put the best interest of our patients first. Will the physicians of the future find themselves taking an oath to uphold the laws, rules, regulations and mandates of their federal, state, county and city government even when in conflict with the best interest of their patients? Will this oath also extend to placing the rules, regulations and mandates of the ever more demanding third-party payers over the best interest of the patient? To be direct, will compliance take — or, even more discomforting, has compliance already taken — precedence over quality, individualized, patient-centered, compassionate care?
Sadly, and of great concern to many thoughtful and dedicated physicians including myself, the answer is no longer clear. I fear that if it becomes certain that compliance has gained primacy over the covenant of the doctor-patient relationship and its altruistic commitment to the best interest of the patient, many of us will find it impossible in good conscience to continue our practices. If so, society will experience a significant and potentially devastating exodus of a large number of highly experienced physicians and surgeons just as the explosion of our aging population increases the need for our services.
I am hoping that the pendulum swings back in favor of society valuing compassionate, patient-centered care over compliance before a generation of altruistic physicians find it impossible to further compromise their lifelong beliefs and the oath they have honored since graduation from medical school. I believe our strongest ally in this confrontation between values remains our patients, as it is my firm belief that they also value this centuries-old commitment highly. Together with our patients, we must do what we can to defend our ability to put the best interest of each patient first in every medical encounter. If not, medicine as a profession and the healing art will be forever changed.