The Things We Think But Don’t Say: The Future of Our Business

“This business is all about building relationships.” So declared Jerry Maguire’s mentor. Hopefully, some millennials may remember the old Tom Cruise movie about a highly driven sports agent who was fired from the firm he helped build and left with basically a single client who was a running back by the name of Rod Tidwell (played by Cuba Gooding Jr.), who kept telling Jerry to “Show me the money.”

Jerry’s life had become all about the monetary transaction without regard for personal relationships. Jerry’s epiphany came when one of his football clients is in the hospital with his fourth concussion. Scared about losing his father, the player’s 10-year-old son asks Jerry, “Shouldn't somebody get him to stop?” When Jerry responds that his father would never want to retire, the boy replies “F--- you” and flips him the bird.

This was Maguire’s defining moment when he realized that his life had become so transactional that he forgot the relational element of the business – these players were real people. In response, Jerry wrote a mission statement repeated as the headline of this piece.

My mentor was Dr. Walter Bradley, a giant of a man, who rose from humble beginnings, completed medical school, earned an MBA, and became an emergency-room director locally for many years. Before my first interview with Walter, my wife and I had decided that the Quad Cites was too far from our families in Chicago and that the interview was merely practice after so many years of medical school and residency. But then I met Walter.

To sum it up, Walter said, “What I want more than anything are ER physicians that will bring faith, hope, and light to the patients.” This was a relational objective rather than a financial one. Until then, I only had interviews with monolithic ER directors whose sole objective was transactional – more RVUs.

The RVU (Relative Value Unit) is the value assigned to every medical transaction coded as a CPT code (Current Procedural Terminology). Currently Medicare reimburses about $34.61 per RVU in 2022, down from $34.89 in 2021. It is a common misconception that the ER bill is calculated based on time in the ER. In reality, the bill is a collection of CPT coded actions which management makes sure are all properly documented to maximize reimbursement. The average ER bill is about 63.56 RVUs or $2,200.

In this transactional framework of medicine, there are no CPT codes for listening to the patient, informing them about treatment, researching the patient’s condition, or comforting the family of the dying, suffering, or recovering patient. These are the activities that effective patient relationships are built on. These caring acts provide “faith, hope, and light,” and are at the heart of practicing relational medicine. Because of Walter, we moved our family to the Quad Cities. I cherish every encounter I had with Walter. He led by example and mentored those who would listen in the fundamentals of relational medicine.

I frequently travel to work at other hospitals. Most encourage the transactional medicine we have become used to. I was working in another city when I cared for a patient with back pain. I remember one patient with back pain. Before I went in to see the patient, the nurse warned me that he was a “frequent flier” and here for drug seeking. He had been to the emergency department about a dozen times in the past two months. His demeanor told me in an instant that he was not a chronic addict like we see so often. His back pain was progressive over the past four months, and he had never had trauma. About 10 years earlier, he had renal cell carcinoma, but it was in remission. His primary-care doctor had retired and he was forced to come to the emergency department seeking help.

Looking back on his last 10 transactional visits, I realized that he was constantly dismissed as a drug seeker and that nobody ever bothered to even get an X-ray of his back. When I got the X-ray, it revealed metastatic cancer up and down his spine. Although he was shocked by the bad news, he was thankful that I listened to him. I talked with his urologist and oncologists so that he could get ongoing care, and wrote in bold letters on the chart that this patient had metastatic cancer so that he would not be mislabeled again.

About two months later, I saw him again. I walked into the room and he exclaimed, “Thank God it's you!” Despite his painful metastatic cancer and several ER visits, no one was willing to treat his pain, and that night, it was more than he could handle. He was a casualty of the government “crack-down” on opiate prescribing by physicians. He was referred to a pain clinic but he couldn’t get in for four months due to the backlog of untreated pain. I arranged for him to be seen immediately for his pain by referring him to palliative care. This is an example of relational medical care and just doesn’t occur in the world of transactional medicine where every action must be to maximize RVUs in the minimum time.

Two years ago, I started a clinic in Davenport in a commercial office building location known only to my patients. They all have my cell phone rather than through a receptionist which most doctors use to protect them from the patients. I get most of my patients by word of mouth. While my practice is not lucrative, it is professionally rewarding to give patients what they need: a relationship with a knowledgeable physician who cares about them. Most of my patient time is spent in the conference room where I take time to get to know the patient and their problems. I don’t take insurance, and for some, this is an impediment. But for many, the difference in care and outcome is stark.

In the end, Jerry Maguire landed a mega-deal for his pro-sports client. His marriage to his wife (played by Renée Zellweger) was transformed from transactional to relational. At the end of the day, the relationships of life inspire us rather than the transactions. Dr. Walter J Bradley III died on February 6, 2020, before the onset of COVID-19. His obituary quoted his philosophy of medicine, "Whatever the hour you may come, you will find light, hope, and human kindness.”

I think of Walter frequently, and mourn the loss of his mentoring for the future of our business.

Dr. David Hartsuch, a former Iowa State Senator, is an emergency medicine physician practicing in Iowa and operates a clinic in Davenport, Iowa.