By Caleb Thompson, MD

Each generation of physicians emerges from training into a medical community shaped by a range of technological, social, and political factors. Because of the prevalence of cardiovascular disease in Western society, cardiologists are often placed at the convergence of these ever-expanding issues. As a fellow-in-training and future interventional cardiologist, learning the motives that drive these influences, and incorporating this knowledge into one’s practice, can be a tremendous challenge. The patient-doctor relationship is perhaps the greatest asset we, as physicians, have to meet this challenge.

In their book, Reframing Organizations,¹ Lee G. Bolman and Terrence E. Deal state that change “always creates division and conflict among competing interest groups. Successful change requires an ability to frame issues, build coalitions, and establish arenas in which disagreements can be forged into workable pacts.” This potential for division exists in most, if not every, patient-doctor relationship.

The common notion seems to be viewing this division as a sort of self-expanding wedge, consisting of all the factors that come between patient and doctor (technology, government regulation, the health insurance sector, medical enterprise, etc.). An alternative view suggests that the division consists not only of the issues, but also from an inability to frame them properly.

The Human Resources View

One way to frame these issues is through a human resources perspective: in this view, the patient and doctor are individuals with skills, needs, and limitations. Take, for example, the transition from paper charting to the electronic medical records (EMR). Hospitals that have successfully made this transition have invested not only in software but also provided “super-users” (employees who become experts in the new technology), training for physicians, third-party support teams in patient-care areas, and continuing dynamic tech support.

In contrast, many patients gather web-based information on medical conditions and filter this through a 15-minute visit with their physician, at times receiving what they perceive as differing explanations. Too often the doctor’s response is: “Don’t believe everything you read on the internet.” While this response acknowledges a schism between patient and doctor, it mistakes technology as the culprit. Moore’s Law, which states that the number of transistors on integrated circuits doubles every 24 months, explains the rapid expansion of technology and, indirectly, helps us understand the sense of inadequacy patients and doctors feel when incorporating technology into health care.

A successful transition requires viewing the issue at hand (patient management) through the appropriate frame (human resources). Using a human resources frame one quickly sees that the web itself isn’t the problem. The patient lacks the resources to understand medical information. Instead of implicating the web as a confounding factor in the patient-doctor relationship, web-based education could become a powerful tool in strengthening this relationship.

Incorporating Reform in the Structural Frame

Authors Bolman and Deal also describe the structural frame, which focuses on the alignment and clarity of formal roles, policies and procedures, and organizational hierarchies; they suggest that “problems [in an organization] arise when structure is poorly aligned with current circumstances.” Whatever one may think regarding the passage and implementation of the Patient Protection and Affordable Care Act, health care reform in the United States has provided many opportunities for discord among patients and doctors.

When viewed through a structural frame, much of this discord can be attributed to a system which grows organizationally more complex without any significant pruning of outdated elements. (A list of government health programs speaks to this: HHS, CMS, FEHB, VHA, TRICARE, Medicare/Medicaid, SCHIP, PACE, SPAP, CLIA, MSSP.)

Conversely, the concept of an Accountable Care Organization seeks to streamline health care delivery and reimbursement by promoting networks of providers and hospitals who voluntarily work together to coordinate quality care for Medicare patients—thereby avoiding unnecessary duplication of services and reducing costs. The development of several regional STEMI systems in Minnesota over the last decade provides another example of how a change in structure confers benefit on the patient and doctor. The adoption of comprehensive STEMI protocols led to 91% of patients being transferred to PCI centers, compared to 59% prior to implementation. Minnesota has the lowest cardiovascular mortality rate in the United States; this rate declined 50% from 2002 to 2009. What Accountable Care Organizations and the Minnesota STEMI protocols show is an alignment in structure congruent with how patients and doctors currently seek medical attention and provide care.

Above are a few examples of how reframing issues can improve the patient-doctor relationship. Two other perspectives—the political and symbolic frames—focus on providing arenas to address conflict, as well as the loss of meaning and the importance of creating new symbols, respectively. Commonly, more than one frame is needed to diagnose issues affecting patient-doctor relationships and to develop strategies to move forward. As a cardiologist practicing in the 21st century, this “multi-frame” thinking will be necessary to guide the evolution of the patient-doctor relationship and ensure it remains a cornerstone of modern medicine.

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Reference

1. Bolman LG, Deal TE. (2013). Reframing Organizations (Fifth Edition). Hoboken, New Jersey: Wiley, John & Sons, Inc.

Caleb Thompson, MD, is a cardiology fellow at Ochsner Heart and Vascular Institute in New Orleans, Louisiana.

Keywords: Health Care Reform, Public Opinion, Medicaid, Software, Patient Protection and Affordable Care Act, Government Regulation, Electronic Health Records, Prevalence, Cardiovascular Diseases, Accountable Care Organizations, Medicare, Insurance, Health, United States

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