Components of Being “Better” – “Doing Right” (asking uncomfortable questions)

8360961551_ae53a36f1e_t(introduction to this series can be read here).

Dr. Gawande’s next component of being “better” is “doing right.”  As he introduces the concept in the introduction of the book, he states “Medicine is a fundamentally human profession.  It is therefor forever troubled by human failings, failings like avarice, arrogance, insecurity, misunderstanding.  In this section I consider some of our most uncomfortable questions – such as how much doctors should be paid and what we owe our patients when we make mistakes.”

First, I’ll give you his five uncomfortable questions, then ask some that were prompted by his.  In “Naked” he asks if the customs in medical exams are appropriate (more on this later).  The next chapter “What doctors owe” asks just that – what do doctors owe if something goes wrong.  Then he broaches the question of what are doctors worth and how do they get paid in “Piecework.”  As PT’s we can’t relate to “The doctors of the death chamber” (what is a doctor’s role in the State taking a life), but it was an interesting and thought provoking chapter.  Lastly, in “On fighting” he asks how much should providers fight for the patient especially if the situation is grim?

What are your customs in physical therapy exams?  The first chapter in the section (“Naked”) examines cultural issues of a medical exam, including language/ word choice and the idea of chaperones.  This can be a definitely uncomfortable question – it is one thing to practice on your classmates in a group setting, it is entirely different when working with patients 1:1, and then to have a different gender, age, or ethnicity (or all 3).  He points out that misconduct and accusations are rare, and a total prevention of these is impossible (and the wrong priority).  When you focus on this, you risk harming patients by discouraging complete and thorough exams.  With the changing of medicine and the times, old customs were removed but not replaced.  How do we create standards and instill trust and understanding between patient and provider?  He admits to still working this out for himself, but draws lessons from his father (a urologist), and I think at least the first three were a good reminder for me as a physical therapist: dress professionally, keep language strictly medical, explain what he is doing and why, and have a chaperone if working with a female or someone under 18 (this is not feasible in my practice setting, but the door is always open and the curtain drawn).

The chapter “Piecework” really interested me because he writes about the determination of pay and fee schedules.  Insurance and the business side of practice appears to be a headache, and he briefly mentions cash-based practice (sounds like he has reservations).  What is our value as physical therapists?  Do we short-change ourselves by dealing with insurance companies?  Are there any ethical considerations regarding cash-based practice?  How do we balance the business side with the practice of PT?

In “On Fighting” he has a great quote: “In a way, our task is to “Always Fight.” But our fight is not always to do more.  It is to do right by our patients, even though what is right is not always clear.”  I occasionally have a patient on hospice or palliative care (or a patient who everyone is recommending hospice or palliative care but they or the family want to press on fighting).  How hard do you fight as a PT for your patient?  When do you stand up and say that continuing on will not result in progress and an improvement in quality of life?

Other potentially uncomfortable questions that come to mind: 

  • When a hospital system has a hospital, an outpatient clinic, and maybe a home health unit, how do you address the potential for a conflict of interest and how do we stand up for our patient’s rights and choice when we might get rebuked for not recommending it in the name of “continuity of care?” (and is this POPTS by another name?)
  • Where is the line between wellness and treatment? (which can present billing issues)
  • If a patient or your practice really wants the use of modalities, and you know there is no evidence for the condition, what do you do?
  • Does the APTA represent the interest of all PT’s?
  • Given the cost of education and no change in pay, what has the DPT done for the profession?  What can be done about it?
  • Is there a better clinical education model?

Next up: Components of being “Better” – “Ingenuity”

Photo: dudley do-right’s code of honor : red rock cafe, napa (2013).  LicenseAttribution Some rights reserved by torbakhopper HE DEAD

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