HLOL Podcast Transcripts

Health Literacy

Patients as Consumers: Physician Conflict of Interest (HLOL #145)

Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations about health literacy with some really remarkable people.

Today, I’m talking with Dr. James Rickert, who is a practicing orthopedic surgeon. He also serves on the clinical faculty of Indiana University School of Medicine.

Jim Rickert founded and is President of the Society for Patient Centered Orthopedics, a group of orthopedists advocating for the interest of patients in the US Healthcare Reform Debate. Jim has published many articles on this topic, too.

I met Jim when we were attending a conference about over-diagnosis. We had such an interesting conversation about so many aspects of healthcare reform and patient engagement that I invited him to be a guest on Health Literacy Out Loud.

Welcome, Jim.

James Rickert: Thank you for having me.

Helen Osborne: Orthopedists and healthcare reform? Candidly, that doesn’t seem like quite the natural match. Do tell, what’s that overlapping interest in healthcare reform and how orthopedists can make a difference?

James Rickert: I think there are many things that orthopedists or any doctor can do that make a difference. I think that often healthcare reform debates center around issues of primary care, that they are more engaged in it than specialists, for instance, but orthopedists, like any specialty physicians, can do a lot within our own profession to improve healthcare of our patients and improve the system that our patients seek care through.

I would point out that the most common complaint that a patient sees their doctor for is some sort of musculoskeletal ache or pain. What we’re doing, I believe, is useful to a wide variety of patients.

Helen Osborne: As you speak of this, I still have vivid memories of shoulder surgery that I needed, so I’m very interested how they come together.

You see a lot of patients. You are a specialist, not primary care. What’s that intersection with healthcare reform and changing the system?

James Rickert: I became interested in that myself. I’ve always had some interest in it, but then I became sick. I had non-Hodgkin’s lymphoma and I was in the hospital on two separate occasions for these different transplants for a month each time.

Then I was seeing my doctors continually, so I did get a great deal better understanding of a patient’s experience visiting doctors and accessing our healthcare system.

Especially through that, I realized that the way doctors visualize healthcare and see quality in healthcare can be very different than the experience of the average patient.

Helen Osborne: How are you? Are you okay?

James Rickert: Yes, I’ve been in remission for over five years now, so I feel like I’m doing very well at this point.

Helen Osborne: The lessons that you learned I think many of us can learn from our experience, not only as professionals but as patients. What is healthcare like from both perspectives and how can we make it better?

When we talk about the whole system of healthcare reform, it’s a gigormous issue. I can’t even fathom all the different components.

I know one interest you particularly have has to do with payments and the financial parts, specifically conflict of interest. Can you talk about that a bit?

James Rickert: I am interested in that and I think it’s very useful for the average patient to have some knowledge of it.

I think ideally I would like it to be an issue of health literacy, meaning that it would be something that patients or the average healthcare consumer would learn about and feel free to talk about with their physicians because of being a health-literate consumer.

Helen Osborne: Let’s start from the beginning then, because I know you’ve written a paper about it. You and I had a conversation about this, but until you started talking about physicians’ conflict of interest, it’s a concept I really had never thought about.

Explain this to all our listeners please. When you say that, what are you talking about? Help us be more health literate about that concept.

James Rickert: I think that it’s important to realize that the majority of physicians practicing in the United States are small business owners. Typically, that is not a big problem, but I do believe that there are situations where the physicians become more entrepreneurial and they grow their businesses to incorporate many different facets of patient care.

Helen Osborne: What would an example be? I think of a really nice doctor, I like to go to her, she seems so caring and all of that. Tell me how might she really be an entrepreneur?

James Rickert: For instance, many doctors own imaging centers where MRI or CT scans are done. Many doctors own surgical hospitals or surgery centers where they perform their surgery. For instance, many neurologists own radiation therapy centers.

Finally, more and more doctors own a company that sells hospitals the devices that we implant in people, whether it’s a pacemaker, a total knee replacement or a total hip replacement.

Sometimes the ownership of these different companies that provide healthcare can conflict I think with exactly what’s best for the patient.

Helen Osborne: Do you mean if I’m told I need a hip replacement, or if my friend just had one, does that mean there’s a range of choices and that it could be Hip Replacement A, B or C? Does she need to ask, “Doctor, why are you putting that hip in?”

James Rickert: All doctors at this point I believe have some sort of business office within their practice, and patients will go there if they want to set up a payment plan or they’re not exactly sure they can afford the surgery. The doctor’s staff is trained to work with the patient in order to help them work out some financial arrangement.

Many of us already talk to our doctors about finances, and I think the number will increase as we have the nation switching more and more to high-deductible health plans where the average person is spending more of their own money.

Doctor’s recognize this and we have these business offices within our practices where we help patients make arrangements for paying.

Doctors have no problem with patients coming to their offices and talking about finances. I would like patients to feel empowered to ask a couple of questions when they’re talking to their doctors or their representatives in their business offices about the finances of all this.

Helen Osborne: You’re in pain and you know you need a new hip, or in my case I just needed shoulder surgery. I not only need to understand my anatomy and my physiology about what’s wrong and how to make that informed choice about whether I need surgery or therapy or it can just wait awhile, but when we get further in that conversation, I also need to be savvy about what exactly they are doing. Is that right?

James Rickert: I would recommend it. I don’t believe that it’s one of those things where we have to be scrutinizing our physicians, their business practices and their books or anything like that, but I do believe it’s useful to ask a couple of simple questions.

If the doctor is recommending to you a surgery or some sort of treatment and it all sounds good and you like the doctor, then you could either have a conversation with the physician himself or with one of their associates that are in their business office.

Just say, “My doctor is talking to me about doing this knee replacement and I would just like to know for my own peace of mind if the doctor owns the company that will be selling this particular replacement.”

You also could say, “My doctor really is interested in me getting this MRI. I know I have many places to go and choose from, but he wants me to go to Doctor’s MRI and I’m just curious as to whether he owns that.”

I think the listeners at this point might be saying, “Gee, why does this really matter?” I can tell you that this has been looked at carefully.

For instance, the Government Accountability Office did several studies on physician self-referral, and over the course of time they studied, which I think was 2004 to 2010, the likelihood of an MRI being ordered by a physician who owned an imaging center grew seven times faster than that of physicians who didn’t own these kinds of things.

The likelihood of an MRI being prescribed is somewhat dependent on whether or not the doctor owns the imaging center.

Helen Osborne: Yikes. I just am thinking as you’re talking about this. I haven’t had a knee or hip replaced. It must hurt a lot and I’m sure you want it done as quickly as you need to, but in other situations you don’t even have that much time.

In your situation, for what you were going through, it seemed much more critical. Are we supposed to go through all of this for even those life-sustaining interventions as well as those where we have a little bit more time?

James Rickert: I have two comments about that. First of all, obviously, if something is an emergency or you’re just overwhelmed and a person feels they just need care, then I can totally understand people just wanting to move ahead and not get bogged down in a lot of extraneous discussions.

The other important thing to recognize is that often, even with things like what I had, cancer, there is time to think a little bit.

It’s not as if the system is designed to diagnose a person, have you see the specialist and then have you start your treatment all within a day. I think a person knows you have this cancer, but still you’re being told you have to wait for your appointment. The system isn’t thriving as to make instant decisions usually.

An example in cancer is prostate cancer. That’s a slow-growing cancer. Typically, patients are presented with several options.

I do want to let you know that, again, this was a Government Accountability Office study, and they found that doctors who owned their own radiation therapy centers were much more likely to prescribe radiation therapy for their patients than doctors who didn’t own it.

Helen Osborne: Just knowing that, what does that do to the doctor-patient relationship, that one of trust and caring and putting my life in somebody else’s hands?

James Rickert: I think it’s difficult, and I’ve been through this. I had cancer myself.

All of us want to feel, especially when we have these very significant illnesses or we’re undergoing something serious like a surgery, that the decision was entirely made out of a sense of beneficence and the doctor just is only thinking about what’s best for me.

I think the best way to start helping to achieve that is by asking people these kinds of questions so that we can then gravitate toward doctors who shun these kinds of arrangements.

Helen Osborne: It sounds like, Jim, that you’re almost talking about, in addition to being the patient with something not going right right now, we also have to be pretty savvy consumers.

It sounds like a big burden there, but is this a burden just for patients? Does the provider community or your fellow doctors bear any responsibility in this conversation?

James Rickert: I think with the average doctor, obviously, their responsibility should be to always acknowledge up front when they have ownership interest in different financial arrangements, but that often doesn’t happen.

I do believe the provider has the burden, but I’m not sure at this point that providers are really giving the information necessary to let patients know about this kind of thing.

I think at this point it is patients who have to start taking it more upon themselves.

Helen Osborne: Wow, that goes so much more. We already have a big load to understand what’s wrong, why it matters and what happens if we do or do not do something.

I’m humbled and I’m awed listening to this, but I also have that sense. You’re really hitting a cord with me how important this is.

I also read your paper, “What Can Patients Do in the Face of Physician Conflict of Interest.” I’d like to put that URL on your Health Literacy Out Loud website so other people can read what you wrote. This was published in The Health Affairs blog.

I also want to thank you for what you’re doing to help move this conversation along.

James Rickert: I would like to take a moment to thank you because I don’t believe there’s anything as patients we can hardly do that’s more important than becoming literate about any of these issues. It helps us be better patients and helps make sure we get that care that is going to be best for us.

Helen Osborne: Thanks. I like that term “help us be better patients.” We not only need to be better, but we need to be better at being patients.

Jim, thank you so much for doing what you do to help advance that dialog about all the things we need to consider in health, wellness and illness. Thank you so much for being a guest on Health Literacy Out Loud.

James Rickert: Thank you very much.

Helen Osborne: As we just heard from Dr. James Rickert, there are so many facets of communicating clearly. It’s not just about what’s wrong with us, but also about understanding the context in which we communicate with our providers and understand care.

This is not always an easy challenge. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free monthly e-newsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, Stitcher Radio and the Health Literacy Out Loud website at www.HealthLiteracyOutLoud.org.

Did you like this podcast? Even more, did you learn something new? If so, tell your colleagues and tell your friends. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne

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