Health Care in the United States : A Perspective from the Front Line

Health Care in the United States A Perspective from the Front Line

GLADYS GONZALEZ

Memorial Sloan-Kettering Cancer Center 1275 York Avenue

N e w York, N e w York 10021

Health care should be a basic right, not a privilege.

INTRODUCTION

In the realm of health care, the concept of communication includes honoring confidentiality, truth-telling, informed consent, and standard ethical procedures. I have worked primarily as a liaison between the physician and the patient, and between the institution and the patient. From my experience of having worked within the confines of rigid rules and regulations, I have always felt troubled by the lack of compassion and sensitivity toward the patient. Ironically, despite the aim of each institution in which I have served and each physician with whom I have worked, the human element has been compromised by the strict rules and regulations that were in effect. As a first-generation American, I am sen- sitive to the concerns of the non-English speaking patient, particularly to the lack of understanding among health-care personnel of patients’ diverse cultural rituals and beliefs. Communication is fragile from the outset because of the dynamics of being a patient. It is important for all concerned-physicians, institutions, clinicians, technicians, and staff workers-to realize the importance of good, effective communication in the delivery of health care. In this chapter I will focus on health care in the United States, past and present, and on my experience in this field, particularly as it relates to the issue of communication.

A CULTURAL PERSPECTIVE

In the United States, the variety and mixture of cultures, nationalities, and religious beliefs can make it difficult to treat patients. Cultural and religious beliefs play an important role in how people perceive their state of health or illness. The patient’s socioeconomic status and educational level may not necessarily be factors in how satisfied he/she is with his/her medical care. During the past decade, much emphasis has been

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placed on cost containment, providing optimal care, and improving access to health care for all United States citizens and residents. But although it is a central concern of the medical community to reach out to the community at large, the medical community fails to adequately meet the needs of the culturally diverse population. Within our multicultural, diverse communities, the probability of compromise of health care is much greater when patients and physicians do not share the same lan- guage, ethnicity, value system, and class. Sensitivity to patients’ diversity strongly influences the delivery of care. Failure to recognize the importance of the rituals and customs of a patient’s ethnic group can lead to misdiagnosis and poor adherence to treatment regimens and follow-up care. In addition, lack of knowledge of a patient’s belief system and how that patient perceives his or her illness or health may be interpreted by the physician or health-care practitioner as an annoyance and may create a barrier to effective communication. An American-trained physician may, for example, give the impression that Western medicine is superior when treating an Asian patient who has a high regard for his own traditional medicine. It is becoming more important in health care to view the patient holistically, considering ethnicity along with other factors.’d

I was reared in one of the largest cities in the United States. Within a ten-block radius lived members of at least four very different ethnic groups. Each group had very different belief systems and worldviews. No doubt each group had a different view of health, illness, and medicine. This was evident in the milieu of the local clinic or emergency room. It took me years to fully understand the anecdote I will now relate.

A friend’s four-year-old sister had been sick for a few days. The child had become pale and weak from vomiting. In a short while the child could no longer walk. Her mother fed her warm homemade soups and swaddled her in blankets. The mother practiced folkloric medicine, feed- ing the child warm liquids, and prayed for her to get better. I could not comprehend why the child’s mother did not take her to see a doctor. Finally, she did take the child to the local emergency room. The child was immediately admitted for acute appendicitis. Luckily, the child’s appen- dix was surgically removed before it could rupture, and she became well.

The mother’s reason for not seeking professional medical attention sooner was her lack of confidence in the American health-care system. This was a result of harsh treatment she had received as an immigrant. In addition, she strongly believed that her folkloric remedies would cure her child and would also spare her the embarrassment of not speaking good English.

In some physician practices, support staff workers take an active role in patient care. Receptionists, secretaries, or line staff may have to ask a variety of private, personal questions during an office visit or telephone

GONZALEZ: HEALTH CARE IN THE UNITED STATES 213

call. This screening process serves as a means of efficiency and to aid the physician. If the physician knows at the outset the reason for a patient’s visit or telephone call, he can better assist or comfort the patient. This screening also has financial and administrative advantages. A physician can see more patients when his support staff has thoroughly screened calls and patients. With information provided by the patient, the support staff can direct the call or patient to a technician or nurse. It is unusual for a patient to speak to a physician before going through such a screening process.

Some patients find this acceptable. However, the screening practice may be seen in some cultures as an invasion of privacy, an outright viola- tion of confidentiality. Some patients may be reluctant to seek medical care under such condition^.^^

We Americans live in a consumer-driven society? As part of the self- help movement, we are encouraged to take on some of the responsibility for our care.4 Patients have a bill of rights, there are patient advocates in hospitals, we go for second opinions, do research, check doctor’s creden- tials, and question procedures and charges. But in some cultures, the physician is viewed as a strict, authoritative figure. To question him is to show disrespect.’

It is typical to find a variety of ethnic groups working together in the health-care field with the goal of providing optimal care. However, how can this goal be attained if there is a lack of understanding or appreciation of ethnicity? Cultural differences often create misunderstandings, misin- terpretation, and conflict in health care and sometimes result in inferior are.'-^*^*^-^ In order to bridge the gap between the health-care system and the population it serves, there is a need to address the issue of communication.

HISTORICAL OVERVIEW OF HEALTH CARE AND HOSPITALS IN THE UNITED STATES

Hospitals are shaped by the needs of the society, its attitudes, beliefs, values, and economy. In early America hospitals were primarily religious and charitable institutions, established to provide care for the sick, rather than medical care as such. The earliest hospitals were actually almshouses or poorhouses that housed the indigent and

The traditional physician was of the affluent class, because only the wealthy could afford the high cost of medical schoo1.8J2 The family doctor would treat a person from infancy through adulthood. In effect part of the extended family, he knew the entire family h i s t~ ry .~ ,~ The relationship between physician and patient was largely based upon the priestly, paternalistic model. In this traditional model, the patient did not actively take part in his/her health care. The family as a whole was considered


first and took an active role in making decisions. Often the dominant person in the family would be responsible for the patient's care:"

The period around the turn of the century was one of rapid growth in the health-care field, specifically in inpatient care (hospitalization). The advancement of industrialization led to advancements in medical technology and biomedical science. Medical care that was once practiced by a physician making house calls with his black leather bag was now being moved into a hospital setting, where special equipment was available. The medical specialist was becoming essential. Nursing as an occupation changed, too, becoming more supportive of the work of physicians. Voluntary hospitals and hospitals specializing in specific diseases became more common during this period, which also saw the development of religious and ethnic hospital^.^,^,"

World War I1 began another period of evolutionary change in the health-care system in the United States. The health-care field was becoming very lucrative. That, along with advances in technology and government support, persuaded more individuals to become physicians. The rapid growth in the number of physicians required the support of other disciplines in the health-care field-e.g., technicians, clinicians, and nurses .8,9,11

As a result of giving large numbers of people physical examinations prior to induction into military service, the government became increasingly aware of the population's poor health. Government health programs were created to provide benefits for the poor. The Medicaid and Medicare programs were initiated in the 1960s. Medicaid is mandated by the federal government to provide care for the poor and is administered by the federal, state, and city governments. Medicare is a federal program to provide care for the elderly and the catastrophically ill; it is administered by state and local governments. There has been a long-term effort on the part of the government to control disease, ensure health, and apply uniform

For the most part, health care in the United States is a free enterprise, provided by nonprofit organizations. Health care became a vast enterprise, particularly in the area of hospitalization. Hospital insurance developed rapidly to cover the high cost of hospitalization; a patient's entire life savings could be consumed by expensive hospital care.I3 The rapid growth of hospital insurance was a major factor contributing to the increased use of hospitalizati~n.~~~

THE HEALTH-CARE SYSTEM IN THE UNITED STATES TODAY

We now have two distinct agents in the health-care field: administrators and health-care managers on the one hand, and the clinical entity on the other. The administrators focus on finance, operations, facilities man-

GONZALEZ HEALTH CARE IN THE UNITED STATES 215

agement, and risk management (quality assurance and utilization review). The clinical entity consists of physicians, nurses, technicians, and other health-related occupation^.^

The health-care system in our society is divided into four interrelated components: ambulatory care, inpatient care, long-term care, and mental health service^.^ Of these four components, in-patient care is the most costly and the most in need of change. There are five types of hospital systems in the United States: (1) Teaching hospitals are research oriented, highly technical, and complex; they are funded by federal grant. They provide care for the indigent. These are large institutions, located in urban areas. (2) Multisystem: one umbrella institution has two or more hospitals serving under a lease or legal incorporation, under the direction of a board. (3) Public hospitals are owned by agencies of the federal, state, or local governments. Typically these hospitals provide specialized care for American Indians, government personnel, and veterans. State hospitals are typically designed to provide long-term care for the mentally or chronically ill. (4) Private hospitals vary in size; most are much smaller than the types mentioned above. They focus on specialized care and tend to have a revenue margin. (5) Rural hospitals are smaller, nonurban institutions that focus on the needs of their surrounding community. They have less access to federal funds.8J1

As a result of the escalating cost of hospitalization, the DRG (diagnostic related groups) system was implemented by the government in 1983. Originally, hospitals and physicians were paid or reimbursed on a per diem basis. This permitted overcharging and too much latitude. The DRG system provides for payment by the case in order to control costs and budgeting. The DRG system, which is heavily regulated, defines appropriate care for each type of case. The DRG system was later amended to better suit the needs of society. Hospital reimbursement went from a retrospective cost-based system to a prospective payment system based primarily on DRGs of specific i l l n e s s e ~ . ~ ~ ~ , ~ J - ~ ~

Despite the worthy intentions of the DRG system, it has led to many problems. It imposes time limits on hospitals and physicians for carrying out specific routines. As a result, it can lead to premature discharge from the hospital and readmis~ion .~~~*~,~J*J~

Currently there are two distinct ways for a person obtain health-care services: fee-for-service and managed care. Under fee-for-service a patient is referred, or refers himself, to a physician; care is delivered; a bill is generated; the patient pays and awaits reimbursement from his insurance carrier, or the provider of health care is paid directly by the insurance carrier. Fee-for-service allows the patient freedom to choose his physician, all services are available, and costs are covered. However, it can lend itself to fragmentation of patient care-for instance, where there is a lot of diagnostic testing, with results going to several different physicians for analysis. Fee-for-service does not encourage or facilitate continuity of


care or cost c~ntainment.",~,~J~J~ Managed care is any system that manages health care delivery and

controls costs. Managed care programs, characteristically known as health maintenance organizations (HMOs) cover most medical expenses provided that the patient uses physicians and hospitals within the organization's network. The patient's financial obligation is usually a nomi- nal fee, known as a copayment. Most managed care models work as a comprehensive medical plan that provides or arranges all care for plan members. They do not provide benefits for care outside of the contracted provider network except in cases of emergency. Managed care involves controlling the utilization of hospital and physician services via pread- mission screening. The basis of a managed care system is the development of a doctor-patient relationship. The primary care physician, the "gate keeper," makes referrals to other physicians or services for the patient, the patient is given care, and a bill is circulated and paid. The primary care physician acts as case manager. Managed care emphasizes preventive services and the early detection and treatment of medical problems. States across the nation have been looking at managed care as a vehicle to reduce costs for publicly insured patient^.^,'^

Despite the efforts to implement a comprehensive plan providing primary care at reduced cost and with improved access, managed care has not rectified all past problems, has worsened some, and has created new problems as well. Managed care programs often restrict freedom of choice. Not all services may be available. The cost of services is covered only if they have been coordinated by the primary care physician. Costs are still inflated. Managed care programs attempt to route patients into their own assigned hospitals or clinics for treatment. However, many patients are not aware of exactly how the program operates and how it can best suit their needs, and some revert to the fee-for-service system. In effect, managed care programs have sent many patients back into city hospital emergency rooms, where they receive acute care and often leave a large unpaid bill.2,4,a10J2,13

Managed care physicians are prepaid a lump sum for the number of patients they see. The physician's income does not come directly from the patient but from the managed care program. There is little incentive for managed care physicians to educate and treat their patients, because the physicians will get paid the same amount anyway. The developers of managed care programs did not anticipate the human element. It is difficult to modify human behavior. Most people go to the doctor when they are sick. Most patients want quick relief, disregard information, and con- tinue to seek medical services as they had previously-for many, in a hospital emergency room.2-5~8~9J2J3

Currently, the philosophy of health care in America is changing. Patients are inreasingly being treated in an ambulatory-care setting rather than in an inpatient-care setting (hospital). As a nation we are focusing


more on preventive medicine. Health care in our society is viewed as a commodity-an unwanted commodity. Managed care and health maintenance organizations (predominantly business and finance oriented) are becoming the model for combating the high cost of health care. They are also viewed as a solution to the problem of restricted access to health care for United States citizens and residents. Managed care raises many ethical issues in the health-care delivery system. Modifications of the system are continually being proposed, discussed, and enacted. One such modi- fication is the point of service (POS) plan. This is like an HMO in that most medical services are covered in full (there is a copayment) as long as the patient uses the organization’s network of physicians and hospitals. Unlike an HMO, the patient can also obtain care from nonnehvork providers and still receive some bene f i t~ .~ ,~J~J~

The ever-changing health care delivery system is affecting the way physicians are treating patients and the relationship between doctor and patient. Doctors are losing their autonomy, as insurance carriers are becoming the driving force in heatlh care. Cost-saving strategies not only restrict patients but contribute to the increasing fragmentation of medical care.2.12.13

GAPS IN COMMUNICATION

Repeated Giving of Medical Information

The trend toward managed health care, whether in the form of an HMO or of an insurance carrier managing or monitoring the health care of a patient, means, among other things, that the patient has to divulge his medical condition and history to several people before seeing the physician. This is problematic, because (1) most patients do not have information about their medical history readily available, and they become frustrated by the need to repeat it; (2) one’s medical history becomes less and less confidential as the information is processed; (3) the clerical or line staff, though trained and expert in their jobs, are often inexperienced in dealing with the psychosocial impact of health-care delivery; and (4) most patients feel very uncomfortable having to divulge their medical problems and history to nonmedical personnel.

Despite the increased use of HMOs, many patients do not have a primary care physician or general internist. A patient may seek medical advice or treatment from several different doctors simultaneously. When a patient gives his medical history to several physicians, he may be incon- sistent in giving vital historical and anecdotal information, because the patient may forget or may think that certain information is irrelevant. Patients are not given much time to communicate their history. In addi-


tion, a patient’s ability to articulate his condition may be influenced by the condition itself. When physicians rely heavily on modern technology to make their assessments, verbal communication between patient and doctor may become minimal. The physician’s desire to make’effective use of his time may also minimize communication with the patient, who may quickly be referred to other colleagues for highly technical care. Often a patient is left unclear as to who will give follow-up care, and medical records may not necessarily be sent to the physician who manages the patient’s care. It becomes difficult to establish a relationship with your physician when your care is so fragmented.2-5,s,12

Confidentiality of Medical Information

Not many years ago, a doctor’s office used to consist of the doctor and a nurse, with the nurse undertaking all the clerical responsibilities; or the doctor and his secretary, with the secretary.often acting as his medical assistant. The overall setup of the doctor’s office was personal. There was one-on-one contact between patient, physician, and staff. The secretary or nurse would be responsible for filing insurance claims to the guar- antor. There would be a set fee for services regardless of the complexity of the visit. A diagnosis or explanation would be placed on insurance claim forms even if the patient had come in for a routine visit. Filing forms allowed for the physician to be paid or the patient reimbursed.

Today’s doctor’s office is usually a group practice of three or more physicians, where typically there is a receptionist, secretary, billing manager, office manager, laboratory technician or clinician, medical assistant, and registered nurse. When making an appointment, you speak with the receptionist, who schedules your appointment and informs you of the fee and whether or not their group participates in your insurance plan. When you go for your visit, you meet and speak to several staff members on your way in and out of the office, reiterating the reason why you are there. There is no feeling of continuity of care when you must make an appointment with one person, negotiate a bill with another, discuss insurance matters with an office manager, and get instructions from a nurse or clinician.

In addition, throughout the patient’s visit his/her personal, private life is revealed in the presence of the staff and other patients in the waiting area. This lack of privacy is often aggravated by the architecture of the office: the staff’s work area is built into the waiting area?r4 Often other patients can overhear the conversations of the technicians and other workers pertaining to another patient’s life. The office setting does not promote satisfactory communication or confidentiality.

Through the years, the health-care field has become more and more complex. Insurance carriers or HMOs have become the authorities in


managing the care of the patient, as the direct result of their reimbursement policies. When a patient signs his name on a claim form for payment to the physician or reimbursement, he is authorizing the release of information about his medical condition and history.8J2 That information can then be reviewed and disclosed to a hospital or health-care service plan so that it may process his claim.'3 The authorization could also per- mit disclosure to the patient's employer for the purpose of utilization review or financial audit. Even though much emphasis is placed on confidentiality, the insurance filing system, like the overall office structure, does not allow for privacy.

Increased Direct Involvement of Clerical and Line Staf with Patients

Clerical and line staff are becoming increasingly involved in patient care. Staff members who assist physicians or health-care practitioners are often not equipped to handle the emotional demands of the situation. Rather than being formally taught how to handle stressful situations, they learn through day-to-day experience. This may have serious repercus- sions for both patient and workers. When patients are ill or in pain, it is quite normal for them to behave irrationally. They may become impa- tient, nervous, annoyed, demanding, even hysterical. They may become uncooperative, aggressive, or hostile toward the physician or staff. It is the duty and responsibility of the clerical staff not only to maintain and manage the office, but also to defuse any difficult situations that may develop, always treating the patient with dignity and respect. When con- fronted with an aggressive or hostile patient or family member, the health-care worker may feel that in some way he/she provoked the patient and blame him/herself for not having been better able to prevent an embarrassing s ~ e n e . ~ - ~

A staff worker who is not experienced in handling difficult situations may worsen a situation by inadvertently disclosing confidential information. I vividly recall a situation in which I was involved some years ago that was very troublesome to me. I was working for the chief of service in an internal medicine department. He was an older doctor, an expert in his area who was able quickly to diagnose his patients. He maintained a heavy patient schedule and generally spent little time with his patients.

A well-groomed, well-spoken twenty-year-old man came in for a con- sultation because of a dry cough. He had swollen lymph nodes in his neck. As he was leaving the office after his visit with the doctor, I was given his chart and was asked to schedule an appointment for a CT scan. This test was routinely used to rule out lymphoma. The young man became annoyed because he did not want to make the appointment. I tried to convince him that it was necessary, that the doctor needed the test


in order to make an accurate diagnosis. The patient adamantly told me that he had not wanted to come in to see the doctor in the first place; that he came only because his mother had urged him to. He felt the test was unnecessary because he felt fine. He told me that I should contact his mother and forward the bill to her. The young man spoke condescend- ingly to me, as he refused to make the appointment. He placed me in awk- ward position.

Once again, I tried to explain that it was important to schedule the CT scan appointment. Assuming that the doctor had given him a thorough exam and had already explained the need for the test, I told him that the test was necessary because if there was a tumor surrounding the medi- astina, the CT scan would be the only way it could be detected. I did not intend to alarm the patient but to help him understand the importance of the test. Needless to say, he then scheduled the appointment without fur- ther hesitation.

Later that afternoon, just before the office closed, I received a telephone call from his mother. She was extremely upset and anxious and asked me in a concerned voice, "Does he really have a tumor? Does he have cancer?"

I was terribly upset because I realized I had caused the mother unnecessary grief. My responsibility was to schedule the CT appointment. Had this young man left without making the appointment, I knew there would be no follow-up. I knew I needed to convey the importance of the CT scan. I was disappointed in myself for not having known a better way of dealing with the situation. I then realized how important effective communication skills are for front line workers.

The next day, I told a senior co-worker of the incident. She was an older women and had been working with the doctor for more than ten years. I thought that she would have understood my position, but instead she reprimanded me for mentioning the "T word." I had innocently made a mistake.

Although I blamed myself, I felt strongly that had I been trained to deal with such a situation, I would have been better able to handle it. I also felt that the doctor should have spent more time with his patient and explained to him the importance of having the CT scan. I know from experience that a patient may behave differently with a doctor than with staff members: he may be subdued with the former, but aggressive with the latter.

CONCLUSION

Communication can start at a simple level-being courteous.4 This should be incorporated into the daily routine at every level of the medical


hierarchy. In my opinion, training and development programs on communication should address such topics as compassion, understanding, and respect for each patient’s individuality-his culture, class, sexual ori- entation, education level, and religious beliefs. Training programs should also include training in crisis intervention, stress management, and ethic^.^ These programs should be geared not only to health clinicians, but also to front-line staff, such as receptionists, secretaries, and clerical personnel. Continuing education addressing communication can effec- tively lower the cost of medical care by contributing to determining and providing for patients’ needs more quickly and accurately. All partici- pants in health care should learn to view the patient as a unique individ- ual, a contributing member of their community.

ACKNOWLEDGMENTS

I would like to thank my outstanding instructor Dr. Lin Lombardi for her time and guidance. I would also like to thank many friends for their contributions and assistance, particularly Nancy Weinstock and Richard Stiefel. Mostly, I am indebted to Dr. Antonella Surbone for giving me the privilege of joining the eminent contributors to this volume and also for her help and encouragement. Finally, I ask my son’s forgiveness for the time I stole from him in order to write this.

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Health Care in the United States : A Perspective from the Front Line

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