Focusing On Patients, Not Paychecks

Elyas Bakhtiari, for HealthLeaders Media, March 20, 2008
Many of the solutions being offered to address problems of quality and efficiency in healthcare are based on the notion that physicians will change their behavior if you target their paychecks. Want to improve quality? Pay physicians for their performance. Want to reduce costs? Set up gainsharing arrangements that split cost savings with physicians. Want to address the primary care physician shortage? Increase compensation to attract more medical students into the field.

Not that financial incentives aren't effective or necessary; we're all responsive to financial rewards, and many of these programs have produced measureable results. But the dialogue is so heavily centered on changing physician behavior with monetary incentives that I wonder how many doctors are growing tired of being poked, prodded, and led around by a financial carrot.

Most physicians want to focus on their patients, not their pocketbooks, says Jose Greer, MD, assistant dean of academic affairs at Florida International University College of Medicine. His approach to improving healthcare delivery begins the first day prospective physicians begin medical school--he's developing an innovative pilot program based on what he refers to as outcomes-based education. "We set the competencies we expected our students to have upon graduation and worked our way backwards."

The goal is to produce well-rounded, socially conscious physicians; it's like a liberal arts education for medical students. Some of the more interesting classes cover the ethical and moral foundations of medicine, the role of medicine in society, and training in cultural competency, which includes not just race and ethnicity, but age, gender, lifestyle, socioeconomics, and other social determinants that often correlate to health factors.

From there, students venture out into the local community to work with interdisciplinary teams--nursing, public health, education, and law students--to track and manage the health of an underserved population. With medicine trending toward increased specialization and focusing on specific procedures or organs, a trend driven largely by financial incentives, Greer wants future physicians to take a step back and proactively treat patients in the context of their larger community by incorporating social determinants, epidemiology, and biostatistics as diagnostic tools.

Cheryl Holder, MD, medical director of North Dade Health Center, who is coordinating the community outreach program through her practice, thinks refocusing medical training can restore the connection with the community and the broad understanding of the patient that characterized old-style family doctors. "Hopefully we can take the students back to where the physician understood the community, understood factors playing in the community that cause what we diagnose. We hope to get a little more understanding, and through understanding more empathy to make us better physicians."

That last line might elicit some eye rolls from hard-nosed pragmatists, but Greer and Holder may be onto something when it comes to rethinking medical education. A study in this month's Academic Medicine found a dramatic "hardening of the heart" during medical school. Researchers saw a measurable drop in vicarious empathy, which not only affected how physicians interact with and treat patients, but can also determine which specialty a student chooses after training (i.e., students with higher empathy levels were more likely to choose primary care).

Greer plans to demonstrate a return on investment for the FIU program by reducing emergency room visits, improving health literacy, and increasing preventative care. If successful, the program will help address the challenges of providing medical care--improving quality, reducing costs, and maybe even alleviating primary care shortages--by allowing doctors to focus on patients, not paychecks.

Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at
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