`Most women are the entry point for their families into health care,” says Dr. Nancy Dickey. “For themselves, for their spouse and children, and more and more for their elderly parents or dependent siblings. The health care issues today are huge, and for the most part, women are the decision-makers. They pick the doctors, they make the appointments, they fill the prescriptions, and they do most of the health care at home.”
A family practitioner for more than 20 years, Dickey believes her perspective as a woman is important in her efforts to change the health-care system when she takes over June 17 as the first woman president of the American Medical Association.
“Because I bring a different vision — literal (female) vision — when I come to a podium to speak,” Dickey says, “hopefully there will be a few more people who will stay and listen.”
Dickey believes increased communication between women and their doctors is crucial to improving the quality of health care.
“The day when a patient walked into a doctor’s office and the doctor went, `Hmm, ahh. Here’s a prescription. This ought to take care of it,’ are gone,” Dickey says. “We’re partners. My patients want to know what’s wrong. If I don’t know, they want me to tell them I’m not sure, and this is what I recommend we do. But for that to work, (patients) have to trust their doctor. And that trust has been seriously challenged by the huge changes with managed care and headlines asking, `Is your doctor doing what he or she thinks is best for you, or following (insurance companies’) contract regulation?’ “
She believes physicians have become discouraged by the cost-cutting measures of managed care and need to regain their sense of commitment and ethics.
Dickey believes that as the costs of health care continue to rise, employers, which pay for most of the care, are going to say, “Wait a minute! We’ve got to do something.” And in that window, she feels, “We (the AMA) need to be proactive, not reactive.”
She believes there will be another opportunity to reassess the health-care system, and she wants the AMA and physicians ready with a plan.
“It’s imperative that we look at the foundation of our profession,” Dickey says, “and the ethics and things we revere and are committed to, because that’s what gives us credibility when we try to tell you why you should let us operate on you or try to make health-care decisions with you. And frankly, I think that has been in question. What we can do now is spectacular. We just need to make sure we do it with care and compassion. We get caught up in being good scientists and forget there is a person on the other end.”
In addition to doctors’ becoming more proactive in communicating with their patients, Dickey believes patients need to become more assertive in asking questions and making good choices within their health-care plans.
“If patients invested as much time, energy and thoughtfulness in selecting their partner in health care — their doctor — as they do in buying a car, they’d ask a lot different questions. They’d get a lot more comparative information. And they’d probably be more satisfied with what happens,” Dickey says.
“I’m a bit of snap shopper. But I don’t go out and buy the first car I look at. I don’t know anybody that does. I want to know what features this one has versus that one, what price you’re going to charge me, what interest rate you can give me. I want to know what colors you have. And yet I can’t tell you how shocked I’ve been over 20 years of practice that intelligent, educated, thoughtful people arrive in a local emergency room having chest pains, and you say, `Who’s your doctor?’ And they say, `Doctor? I don’t have a doctor.’
“Well, of course, I tell them how lucky they are. They got me, and that means they get a great doctor,” Dickey says. “But they didn’t pick me.”
Dickey believes patients should ask questions that are specific to their personal issues, for example pregnancy, aging or children’s health. Dickey suggests asking questions such as, “What do you do with an emergency at 10 o’clock at night? Can I get my medicines refilled, or do I have to come see you every three weeks? How long do I have to sit in your waiting room, and is that a real answer, or just what you hope (the wait) would be?
“These days, there are lots of questions a patient can ask. Like what’s your immunization rate? What’s your C-section rate? How many women between the ages of 40 and 60 get mammograms? What hospitals do you use? How do you feel about breast-feeding? How do you feel about going home after 24 hours instead of 72? Do you make house calls? Do you work on Saturdays or are you here late in the evenings?
“It’s kind of like when you buy that car. After you’ve talked to three different sales reps, there might be one of them where you felt if you had a real serious problem, they just might listen to you. And if you had that conversation with your doctor, then you’d feel a little better when you got sick. You’d have some concept of who’s going to show up at your bedside, and you wouldn’t have to start building the trust at a time when every answer counts.
“And just like you would in going to buy a car, where you’d say, `I don’t think this sales person is listening to me, I don’t think I’ll stay here,’ you need to have the same courage to do that in a doctor’s office. My patients used to say to me, `No doctor’s going to give me 15 minutes to ask these questions without charging me.’ And I’d say, `Well maybe that’s not a doctor you want to go see.’ It’s important that your questions get answered, so first of all, pick a doctor you can talk to.”
Even as Dickey urges patients to take charge of their health care, she admits that this is becoming more difficult because of “the ethical dilemmas of the changing fee-for-service structure,” in which insurers encourage doctors to cut costs.
“It was reasonably easy,” she says, “to teach my patients how to protect themselves against the conflicts in fee-for-service. If I said to you, `You need to do this, you need to get that, you need to buy this,’ you could say, `What if I don’t? What if I don’t get the chest X-ray, or the blood count or that prescription?
“But with the managed-care incentives of doing less, it’s much harder to teach your patients to say, `What are you not telling me? Which treatments didn’t you tell me about? Which specialists didn’t you refer me to?’ I think it’s much harder for patients to protect themselves against those ethical dilemmas.”
Dickey considers universal health care the optimal solution.
“It’s time for the physicians in this country to advocate for access for all Americans to the care they need and a way to pay for it,” she says. “An honest commitment by a fairly powerful advocacy voice — medicine — for a group that doesn’t have much of a voice — largely the poor and the uninsured — for something that needs to happen. It’s time to move this up on the priority list.
“We think patients ought to have the right to pick the insurance that they want. Some people love HMOs, and other people don’t want to be limited to the doctors on the list.”
Dickey, 47, lives in College Station, Texas, with her basketball coach husband and three teenage children.
After excelling in science at her Texas high school, Dickey says, she went to college as a psychology/sociology major because her high school counselor told her she could be a doctor or a mother, but not both.
Most of the men she dated in college agreed with that assessment, until she met the man who would become her husband, Franklin “Champ” Dickey. “He told me, `If that’s what you want to do, go for it!’ ” Dickey says. “He’s been an extraordinary partner.”
Dickey decided to become a family practitioner rather than a specialist because she enjoys caring for different generations of patients.
“I like being a decision-maker,” she says. “I like a variety of challenges, mysteries and solving puzzles.”
But the direct interaction with patients and the relationships she develops with them have proven to be the most rewarding for Dickey. The hardest part of leaving her private practice, she says, was the people.
“I like small towns,” Dickey says. “I like to meet people when I go to the grocery store. I used to have a handful of people who’d drive 100 miles to come and see me. And that’s great fun, to see someone that you’ve been caring for for 20 years.
“The baseline reward of medicine is the people you get to know. It’s an extraordinary honor that patients come in and share a great deal of who they are, what they’re concerned about, what’s going on in their lives. (Doctors) should not take that lightly.”
