Over the years, my patient Jim struggled with his diabetes. His hemoglobin A1C (a measure of three-month average blood sugar) was never below 10 (normal is below 7). It was a struggle just to get him in for his office visits. In his mid-60s and a decorated military veteran, Jim also had a stroke, and suffered from post-traumatic stress disorder.
As he lost his defining strength and independence, he hollered at his wife and daughter whenever they encouraged him to take his medication. And there was absolutely no prying him away from his chocolate-covered peanuts. No amount of counseling or specialist visits could turn things around.
As his primary-care physician, I felt defeated after Jim’s appointments.
All clinicians care for patients who we may deem “difficult.” That label might mean the patient isn’t interested in the treatment plan; is angry, argumentative or self- destructive; is overwhelmed with such problems as poverty, domestic strife or poor education, or even just that the condition is so complex that treating one disease only seems to make another flare.
In Jim’s case, it was a combination of medical complexity, low understanding of his health issues, and a self-defeating mindset. Now I was facing a new hitch. When I looked at Jim’s electronic chart, I saw that most of his “quality metrics” — the medical profession’s version of a report card — were highlighted in red. This meant that Jim’s chronic conditions were not well-controlled, and he was not up to date with recommended health screening tests. In other words, my efforts to help him were failing.
Value-based reimbursement, part of a health law overhaul enacted by Congress in 2015, is supposed to define quality of care through metrics goals for chronic disease management and preventive care. It also determines a portion of physician payment, rather than the traditional system of paying doctors a set fee for each service.
The idea, in other words, is to pay doctors for the quality, not just quantity. It’s a sound notion, given how many health providers and systems have been found to dispense unnecessary care either in pursuit of profits or because they’re misinformed about evidence-based care.
So where does Jim fit in? Are these the metrics he thinks help define his quality of life? And what about his care team? Creating a healing connection with a person whose priorities are so different from our own can feel daunting.
It wasn’t hard for me to see that pressure to achieve metrics goals was causing a lot of my stress. My drive to always get high grades, which served me well getting into medicine, was now competing with my more important values today.
Relieving that stress, I realized, required me to change myself, because I clearly failed in changing Jim. I stopped wrestling so much with Jim about my goals and started trying to learn more about his. It turned out he wasn’t interested in doing things to help him live longer if they wouldn’t also improve the quality of his life. For Jim, quality meant mostly things he couldn’t do anymore, such as ride his Harley or go on long outdoor adventures. When I took more interest in his personal story, his visits became less stressful for both of us. He even showed up for most of them.
Now, when Jim comes in, we spend most of our time together talking about what is most important to him and his family and whether he could make changes to achieve those priorities. I examine him carefully and do the essential monitoring to keep him safe.
Here’s the irony: Since I stopped pushing him and his values away, Jim has come closer to mine. His visits are often the highlight of my day. They may take a little longer, and I still see some flashes of red on his electronic chart, but we both leave the exam room in better spirits. Most important, he is getting better care.
Still, it’s fortunate that I don’t have too many patients like Jim. Doctors are paid for metrics, not longer visits. Quality measures are worthwhile, but I’m not as optimistic about them as I once was. Physicians need time to build effective rapport, trust and truly know our patients — which, by the way, is proven to enhance outcomes. Feeling penalized for treating patients like Jim contributes to the emotional exhaustion plaguing primary care doctors. What’s more, it also slaps such negative labels as “difficult” on patients who may need more than metrics to participate in the true essence of good doctoring: a relationship.