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Cultural anthropology today is a very different enterprise from the almost romantic pursuit of the exotic and strange suggested by its
early practitioners. When Margaret Mead set off for Samoa and returned home to capsize American notions of "normal" adolescent sexual behavior, or when the British social anthropologists like Evans-Pritchard and
Malinowski published their monographs describing Nuer religion or the kinship systems of the Trobriand Islanders, they opened up new worlds and new possibilities for the ordering of society to the audiences in their
native countries. Today there are no unknown tribes waiting to be "discovered" by those intrepid men and women in their solar topis
and canvas tennis shoes equipped with nothing more than a notebook and pencil, a camera, and maybe some mosquito repellant. Anthropologists have learned to switch their ethnographic lenses to focus on their own societies. In doing so they have discovered that because modern life is so complex, there are a host of possibilities for isolating different pockets of it just as if they were small villages or cities with their own laws, traditions, myths, and rules of behavior. They have shown that an anthropological perspective trained on virtually any area of our daily lives-–the family, the home, the community, the school, the workplace, the religious meeting, the sports arena, and yes, the doctor's office (!)-–is possibly the most enlightened and useful way to understand how such "cultures" originate, how they function, how they change.
When the first issue of the Chronicles
came out we put forth as a kind of office credo that because we ourselves were grappling with so many changes in the practice of medicine in this country, we wanted to enlist you as partners in bringing about whatever transformations we had to, as painlessly as possible. Like every tribal group or small community we, i.e. the doctors, staff, and patients, had a collective image of ourselves that was distinctive and in a way immutable – the bustling energy, the personal touch, the combined medical knowledge and skills of the staff, the huge and interesting variety of people who became part of the practice. It gave us, we think, a unique place in the city's life. Just a place to go when you were sick. But yet much more than that.
Since the advent of Managed Care and since our own expansion in the new space, it has not been easy to make sure we don't lose sight of this core sense of who we are and what we are about. As we stumble and try to
find our bearings in the maze of rules and constraints that Managed Care especially has placed upon us, we realize that many patients are unhappy about some of the changes, and sometimes feel as if their complaints are
not being addressed or taken seriously. The most common pejorative terms we have heard, expressing the subjective impressions of patients in describing their experience with us, have been words like "factory," "clinic,"
"Grand Central Station at rush hour" etc. We must admit in all honesty that sometimes these descriptors are not unfair. But we also want you to know that we ARE listening. We DO understand how you feel. We DO want to
correct the mistakes we've made. And above all, if you have had some not-so-pleasant experiences in dealing with the office, we DON'T want you to be discouraged from coming back. Because whether it is always apparent or
not, we are constantly engaged in a critique of our own practices and constantly looking for ways to learn from past mistakes and improve. Through our Web Site and on the pages of these Chronicles
we want you to understand that these are not just empty statements proclaiming good intentions. Every week we wrestle with nitty gritty issues such as how to make the voice mail more efficient in directing your calls to the right department, how to not put you on interminable hold but at the same time not build up a mountain of calls to get back to at the end of the day, how to cut down on waiting time, how to process your referral requests more quickly, how to accommodate your special work or family schedules in order to get you in for an appointment, how to get your lab results to you as soon as possible after your appointment. From talking to you over the phone and elsewhere, and conducting actual "interviews" with you to get your feedback on the office, we know that one of your prime concerns regarding the nature of your relationship to your primary care doctor has to do with the amount of time you actually see him or her. We know that you are sometimes disconcerted by what seem to you like too many interruptions, by being given appointments in which you spend more time with a Physician's Assistant than with the Physician.
Some of these problems are more easily fixed than others. What we want to point out however, without trying to be either coy or immodest, is that in taking an anthropological approach to our practice, we are probably
unlike any of the more "establishment" type medical practices in the country. We want to be open about our struggles, we invite honest criticism, we try to learn from our mistakes. Through trial and error we have come
to believe that the only way to survive change is not to keep fighting it or harking back nostalgically to "the old days", but to accept and try to make the best of it. Some of you have told us of other doctors or
specialists that you see outside this practice, who choose not to belong to any HMOs, and give you more individual time and attention compared to what you receive here. For this privilege however, you also mention that
you pay ten times as much, or more, than your usual co-payment here. While for some patients in our practice, this might not constitute a hardship, we know from talking to you, that for the majority, this is not really
an affordable option. It seems that there is a pretty straightforward economic principle operating here. More money buys more time or more services. Managed Care, whether we like it or not, is a volume business. Managed
Care organizations want to keep their costs down. While they will never admit that they want the doctor to not "waste" unnecessary time with each patient, that is exactly the message they ARE giving the doctors. When
you complain about feeling rushed, treated abruptly, pushed around as if you're on an assembly line, we understand your feelings of distress. We do not want things to be this way. Doctors Jason Theodosakis
and David Feinberg have stated in their recent, very timely little volume Don't Let Your HMO Kill You: How to Wake Up Your Doctor, Take Control of Your Health and Make Managed Care Work for You (2000), that "the
old way of practicing medicine allowed costs to run away at twice the rate of inflation for decades. Most health care consumers didn't mind or even notice-as long as someone else was paying the bill." (A crash course on
the history of health insurance in the USA should probably be mandatory for us all, providers as well as consumers of health care. One fact it would point out is, it was only after World War II that it became standard
practice for employers to offer their employees, the expensive indemnity plans most of us of the baby boomer generation, got used to, when growing up.) Theodosakis and Feinberg note that "the most important difference
between the fee-for-service system and managed care is this: under a fee-for service or indemnity plan, each patient who walked through a doctor's door was a benefit. Under managed care, each patient who asks for care
is a cost." It is crucial to understand the difference because doing so will help us understand why the doctor-patient relationship has changed, how HMOs pressure doctors by asking them to save money through denying
care, and how both doctors and patients are often at the mercy of managed care administrators, who in their efforts to pinch pennies, challenge the judgement of those who should be the only ones making medical decisions.
We come back to why an anthropological approach is the only truly reasonable one to adopt given the current state of health care practice in America. First off, it is an approach that best takes account of the whole
and not just the parts. It helps us find answers to questions such as "Why is my doctor different after I started seeing him as an HMO patient?" "What sort of contract does s/he have to sign to become part of one?"
"Does joining a plan mean s/he is controlled by the bosses and medical directors of that plan?" It helps us finally to realize that change in any system, especially when it is as drastic as the change of Managed Care,
cannot just creep in unnoticed like some stranger at a dinner party arriving uninvited and thinking that every body will simply carry on their conversations and socializing as comfortably as they did before he got
there. If I sign up for a Managed Care plan that my old doctor belongs to, can I really expect to get the same service for half the cost? On the other hand, is there still a way to form a mutual trusting relationship
with my doctor? We believe there is. We believe that it is not necessary for patients to view their doctors as adversaries or money grubbing insurance agents whose every move they have to watch or question. We also
believe that doctors and their staffs should consistently respect their patients and give them the care and compassion that is the defining mark of their profession. This issue of the Chronicles
seems to have exhausted itself in discussing the trials and tribulations of life in a doctor's office under Managed Care. The only reason we have spent so much time on this subject is because it looms so large on everyone's mind any time a transaction must be conducted between a health care provider and patient. The entire healthcare system across the country is affected by it, so its no use pretending that if we bury our heads in the sand long enough, when we look up, it will go away. We, at 201 East 65
th Street want to meet the challenge head on and prove, with your help, that even if we do not embrace it uncritically, we CAN make it work for us all in the long run. We hope to move on to many other more
interesting and varied topics in the coming months. We ask again that you join us in giving your ideas and suggestions about what some of these might be.
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Vera Mehta, Ed.D. in Anthropology and Education, will spend several hours per week mining data from the office environment. She will be looking at medical attitudes in New York, from both
the physician's and patients' perspectives. She may be contacted at veramehta@yafferuden.com |
