PHCAs 

In an earlier version of this website, I postulated that patients (desperate for advocates) would express the need for a new kind of healthcare service; and that doctors (frustrated by their inability to be advocates) would find a new way to fill that need. The doctors would eventually create a new kind of healthcare professional, which I named the Personal Health Care Advocate (PHCA).

In the intervening years, the appearance of retainer practitioners has given physicians frustrated with "traditional" medical practice a much less radical approach toward regaining their role as patients' advocates. Maybe it is for this reason that PHCAs have not yet made an appearance in a big way.

There are still two reasons you should keep PHCAs in mind, however.  The first is that there is at least a reasonable chance that the healthcare system will succeed in making the practice of retainer medicine illegal, and then doctors will no longer have that outlet for their professional frustration.  Becoming a PHCA might then become their only remaining option, short of becoming florists, deep-sea fishermen, or authors. Second, and possibly more importantly, there is absolutely no reason to wait for doctors to invent this new profession. Experienced nurses, for instance, and even savvy non-professionals, would make fabulous PHCAs.  (Indeed, my emphasis on PHCAs being former physicians is primarily an attempt to find something useful for disaffected doctors to do.)  If patients make their needs clear enough, sooner or later somebody will step in to fulfill them, even if doctors do not.

The PHCA model

PHCAs would provide individual patients with an opportunity to retain their own personal advocates - professionals who work for them and them alone, and who place their interests above all others on matters related to their healthcare - just as they might retain an attorney on legal matters.  In fact, on the simple premise that patients have just as much right to a strong advocate as do accused felons, PHCAs would model themselves not after the medical profession, but after the legal profession.  

Accordingly, PHCAs would not practice medicine.  Instead, they would practice medical advocacy, doing whatever is necessary to guard the rights and welfare of their clients in all their interactions with a hostile healthcare system.  

A mission statement for PHCAs

Their mission statement might read something like this: As PHCAs, we will perform the same service within the healthcare system that attorneys perform within the legal system. We will become our clients' advocates and advisors, assuring that a dedicated and knowledgeable professional is representing them, protecting them, and advancing their rights and welfare within the healthcare system.  Our relationships with our clients will be built on trust; we will hold their confidences in private, will assiduously avoid conflicts of interest, and will work directly for them, and for no one else.

This mission statement establishes several things. It establishes that PHCAs serve in an advisory and advocacy role aimed solely at protecting the rights and welfare of their clients. It establishes that PHCAs will model themselves after lawyers, rather than doctors. (For instance, "client" is used instead of "patient," both to reinforce the "attorney-client" paradigm, and specifically to reinforce the notion that PHCAs do not practice medicine.)  It establishes a fiduciary relationship between the PHCA and the client, assuring that the PHCA will always act with the client's best interests in mind.

Why PHCAs?

For doctors to opt to become PHCAs, it will mean, in all probability, that the opponents of retainer practices will have won, and that it finally will have become illegal for doctors to work directly for their patients.  Doctors who insist on providing unimpeded advocacy services for patients - the kind that are supposed to be provided by an intact doctor-patient relationship - will then have no choice but to abandon the practice of medicine altogether, thereby shedding the guidelines, regulations, laws and constraints with which "real doctors" will have been burdened.  

Will doctors actually do this? It is entirely likely that some will. Doctors like me - the older kind, the kind who once were able to practice medicine relatively unencumbered by MBAs, intimidating federal regulators, and high-school graduates reading from lists of covered services - are ready to leave the practice of medicine in droves. There are lots of reasons for this, including all the ones you've heard - the drop in income, the mounting paperwork, the oppressive regulations, and the loss of control over their practices.  They're all good reasons, too.  The main reason doctors are frustrated, though, is that they can no longer practice medicine the way they know they should.  They cannot truly be their patient's advisors and advocates. This is really why so many doctors are at least talking seriously about leaving medial practice.  

It is at least reasonable to suppose that some doctors will be attracted to such a thing as the PHCA profession. As PHCAs, doctors will be able to shed all the encumbrances of modern medical practice, and concentrate on the one thing doctors ought to be concentrating on but cannot - advocating.  Many conscientious doctors will find this prospect attractive, even at a substantially lower income, and especially if they are otherwise considering leaving medicine altogether.

What will PHCAs do?

I have already had the audacity to propose a new medical profession. Why not extend that audacity to suggesting particular services this new profession might perform?

The primary mission of the PHCA will be to supplement (or even replace if need be) the advocacy role traditionally provided by an individual's physician.  This goal implies an ongoing relationship between the client and the PHCA.

Thus, PHCA services are likely to be provided, whenever possible, on a subscription basis. Subscription services might generally fall into two categories - intake services and ongoing services.  In addition, special ad hoc services will be available.  In all instances, the emphasis of the PHCA should be to educate, to advise, and to advocate for their client.

Subscription services

Intake services

Intake services might include:

-  introduction to and interview with the PHCA (for local clients, in-person interviews are preferable; on-line or telephone interviews can be used for long-distance clients)

-  complete medical history by the PHCA

-  critique of client's health insurance plan

-  develop a list of the client's overt and potential health problems, and a set of overall healthcare goals

-  PHCA begins coaching client on how to become a more effective patient

-  with specific healthcare goals in mind, PHCA develops specific recommendations on how the client can optimize the care he/she is receiving

-  initiate formal discussions on living wills and organ donor options

-  instructions on accessing ongoing services

-  assistance in obtaining client's medical records, to build an ongoing centralized medical record that can be controlled and accessed (i.e., owned) by the client

Ongoing services

Ongoing services might include:

-    develop ongoing relationship between client and PHCA

-   "coaching" service before key doctor's appointments (strategy session prior to doctors visit: decide what medical issues need to be resolved, what information will be needed in order to make decisions, what questions to ask the doctor to gain that information)

-   "debriefing" service after key doctor's appointments (critique of what transpired during visit to doctor, assessment of adequacy of the plan developed by the doctor and client, assessment of whether there is a need for follow-up contact with doctor prior to next scheduled visit)

-    timely revision of client's medical problem list and goals

-    continual updating of client's computerized medical records

-    secure access to computerized medical records by client 24 hours/day

-    with client's permission, providing doctors with data from client's computerized medical records

-    replying by phone or e-mail to any non-emergency healthcare questions within 24 hours

Ad hoc services

Ad hoc services will be more active and more direct than intake or ongoing services. Whereas intake and ongoing services take place outside of the traditional healthcare setting (i.e., in an office or on-line), and at a time other than when the client is actively undergoing a healthcare episode, ad hoc generally will take place during the healthcare episode itself, and may occur on-site if necessary (and if possible).

-  assessment during healthcare episode (such as hospitalization) of client's healthcare status, needs and appropriateness of care

-  ongoing monitoring of client's condition/status during healthcare episode

- directly communicating or negotiating on client's behalf with physicians, hospitals or insurers, to clarify issues of care (such as definition of the medical problem(s), defining the diagnostic and therapeutic options, defining the risks and benefits of various options, clarifying the physicians recommendations, assessment as to the adequacy of care).

Again, the opposition

Since the healthcare system is entirely geared up to covertly ration healthcare, since covert rationing requires destruction of the doctor-patient relationship, and since PHCAs are a sneaky way of re-establishing that relationship outside the present system, then there is only one way for the healthcare system to respond. The threat posed by PHCAs will be recognized immediately, and everything possible will be done to stifle this new profession. Those attacking PHCAs will be the usual suspects - the insurance industry, the government, activist groups striving for a centralized healthcare system - and in addition, this time, organized medicine.

Attempts will be made to declare PHCAs' activities illegal, and to block PHCAs from having access to their client's medical records and from maintaining a bedside presence.  PHCAs will be threatened with liability suits. Attempts will be made to assert that PHCAs are actually practicing medicine after all, and therefore their activities must fall under the same constraints as "real doctors."  If any of these attempts take root, the PHCA movement will likely die on the vine.

The ultimate outcome will depend on one thing.  It will depend on whether patients finally understand what is going on.  It will be much more difficult to publicly attack PHCAs than it is to attack retainer practices.  It will be, much more blatantly, a naked assault on a patient's right to hire a private, personal consultant on healthcare matters. The whole point of creating this new profession, of course, is to move the doctor-patient relationship - rather, the PHCA-client relationship - to a new realm, outside of the current stifling system, there to allow that relationship to flourish again, unencumbered by all the things designed to encumber it where it resides today. When all the great powers argue that such a thing is bad, at the very least they will be finally tipping their hand, and revealing who they really are.

If patients at last understand the stakes, and if they become sufficiently outraged at a crass attempt to eliminate what ought to be a simple consumer's right (not to mention a simple patient's right), then all those powerful forces will be vanquished.  For an aroused public will be invincible.