The myth of provider preference

The leadership where I work likes to claim that our local hospital and I have the same goals. Well, they are wrong.

My job is patient care, and my goal is to provide the best possible care to my patients. The hospital’s job is to maintain resources and an environment where care can occur, and its goal is to support those who actually provide care to patients. Different jobs. Different goals.

Most of my day is spent in 1:1 interactions with patients, in an exam room or on the phone. The next largest chunk is spent doing things on behalf of an individual patient: filling out a form, reviewing test results, finishing a note about a visit. My focus during all these activities is on the individual patient: what diagnoses should be considered, what testing might be useful, what treatment options are available, what additional resources might be helpful, and how can I help the patient understand and participate? The blood pressure cuff, the stethescope, and the exam table are all useful tools. I need them to varying degrees as part of the care process, but they are just tools. Similarly, the physical therapy office, x-ray facility, and available consultants can be useful - even essential - components of the care I provide. But they are just that, components to be selected and used based exclusively on the needs of individual patients. It would be unethical – and should be unthinkable – to order an unnecessary MRI because a local radiology office is having a budget shortfall, or to send a patient to a consultant for an unnecessary procedure because that consultant needs money to pay college tuition for her twins. Yet I am routinely admonished to keep referrals ‘within the family’ to support the organization that writes my pay check. My ‘out of family’ referrals are tracked and reported (with numeric targets) as part of my annual evaluation. Out-of-family referrals are ‘excused’ if they are part of a pre-existing patient relationship (to preserve continuity of care) or at the direct request of a patient (patient centered care) but not acceptable if they are based on what leadership calls provider preference (an offensively tone deaf term that implies decision making based on a golf partners or shared paces of worship). The gulf between leadership and clinicians is nowhere so clearly shown as the choice of the term provider preference, reflecting a complete failure to understand the process of clinical decision making.

(It would be legitimate and useful to monitor out-of-family referrals to determine where and how to improve referral resources.) 

I recognize that what is best for my patient may not always be best for me. It may not be best for my practice, or for my hospital. When these needs conflict, my first responsibility is to my patient. Always. No. Questions. Asked.

I may send a patient to a physical therapy center or laboratory near their work, or I may refer to a urologist who does laser or robotic surgery - not available locally - in neighboring town. Or to a consultant who is familiar with their culture or language of origin. Or whose conversational style I think will make a difficult illness more tolerable. Or who reliably follows up with me about the long term care of the patient. None of these reflect provider preference. These are clinical decisions aimed at ensuring high quality patient centered care. That’s my job. Their job is to make sure the organization is in a position to support me, not erect barriers to quality care.



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