The Importance of Getting a Diagnosis, Yet Another Case for Good Primary Care

A new book called “When Doctors Dont Listen” was recently published and takes aim directly at Physicians and our listening skills, or seemingly lack of.  I personally find the book as rubbish that is pandering to a commercially popular idea of bashing doctors and blaming doctors for the sad state of healthcare in this country.  Certainly, MANY doctors out there have terrible bedside manner and poor listening skills, but I truly believe (which may be naive) that most doctors go into medicine with altruistic  intentions and generally work hard to “hear” their patients.  It is the “Healthcare System” that has created a “hearing” problem in the exam room, having pushed the typical primary care visit down to about 7 minutes.

But I am not going to whine and complain about that.  Diane Rheem Interviewed the authors in Jan 2013.  I listened to the whole interview and I seem to have taken a COMPLETELY different message away from the interview than Ms Rheem or her guest.   They talked at great length about the importance of getting the “right” diagnosis with the doctor.  I couldn’t agree more!

Am I the only one that listened to this and thought, “what a perfect argument for why we need good primary care?”   It seems to me that if we bolstered primary care physicians and gave them the TIME to actually do this wonderful thing of “listening”, then YES patients would get much better diagnosis and it would certainly lower healthcare cost and improve healthcare quality.

A real, “well duh!!!” moment.  But sadly… is anyone listening in the the “System?”

My Kids Dont Want to Stay with Me

I came home from work one night and sat down to dinner with the family.  Usual chaos, flying food, giggles, and squeals.

My wife promptly informed me that she would like to run to the store and do some shopping before the stores close.  I have no problem with this, I have the troops on a regimented bedtime routine and should be able to clean the monsters up and march them straight to bed with maybe a little prebedtime rasslin match.  No problem.

So she stands, rapidly grabs her purse and bolts for the door.  At which point my 7yr old proclaims, “your leaving us with HIM??!! Really?!”

I wasn’t sure how to take this.

The more I thought about it, the more it was clear.  It is a typical good cop, bad cop scenario in our house.  Most nights, I start calling for them to get ready for bed and they typically scurry in the general direction of mom.  I say general, because kids have no concept of straight lines unless cookies are involved.  Mom, of course cuddles and coos with them, the kids stall, I push further to start getting ready for bed and they scatter again.  However, I tend to find them again  back at mom.  Mom, of course tells them to get ready for bed, but somehow lacks the real “umph” of commitment and she cant resist the many child stall tactics of, “im thirsty”, “read us another story”, “can we cuddle”, and “I gotta cocka!”

I on the other hand tend to be the enforcer, ultimately I drag them to bed against repeated objections giving them the, “life’s not fair” speech.

It was clear, without momma around the kids would have much fewer viable stall tactics.

Maybe, I’m a little to harsh.  So I decided to use this opportunity to “soften” my image.

I gave into several of their stall tactics and even spent extra time doing one of their favorite nighttime activities, rasslin.  I sang them a song and then put them to bed.  It was a good night and we were all feeling close and loving.

As I turned out the light, the same 7yr old who had exclaimed worry about being left with me, quietly asked, “daddy, when is mommy coming home?  I want to cuddle.”

“Son, I can cuddle with you.”

“But Daddy your hard and spiky.”  He then laughed and said he was kidding…. but deep down, I don’t think he was.

No matter how “soft” i ever try to be.  I will never be mommy.

Thank goodness I don’t have to be.

Mommy, You Said That Five “Soons” Ago! How Many More “Soons?”

My 4yr olds response when Mommy answered his “When are we leaving” question for the tenth time.

Now, he just cuts straight to the chase and asks, “How many Soons until we leave?”

The anticipations and sense of time of a child is an amazing thing.  My dad once taught me that children were the best negotiators.  They have what it takes.  Will and TIME.  These fluttering minds bouncing from thought to thought and subject to subject often seem chaotic and with no attention span, but don’t be fooled.  Once locked in, the child’s mind has deadly laser focus and devastating power of deployment.  Once they set their mind to the negotiation, they have nothing but time on their side and constant will.  You can say “no” ten thousand times yet a child only sees an opportunity to restate or re-purpose their request once again.

Here is where parent’s steely resolve is tested.  Remember, if you say no 10,000 times and cave to the child’s request on the 10,001st time.  You have only taught them that they have to ask 10,001 times, and that certainly is no problem for them.

Ultimately we parents will lose to these negotiation masters, but hopefully will hold fast when it comes to the critical battles that teach our children character and truth about our world.  Allowing them enough success for good self esteem without allowing them to run a foul without any sense of boundary or rule.

I personally want my children to push boundaries and bend the rules, but they have to firmly know the boundaries and rules as well as the consequences before this can be successfully done.

Now… I have to stop this post.  The 7yr old has asked to use the computer 20 times since I started typing and I cant hold out any further.

Saving Primary Care? It’s Not All About Money.

I read many healthcare blogs and of course follow healthcare news.  It is bewildering and stupefying the (seemingly) thousands of different directions it’s all going.  Honestly, our politicians and leaders really seem to be clueless.  Driven by so many “fingers” in the pot and ultimately they continue to make one fatal flaw.

Politicians are to busy telling people what they WANT to hear and not what they NEED to hear.  Where are the real leaders?  Alas, that is a different blog entry.

One common (albeit thin) thread is the reoccurring theme that primary care needs to be more of a central focus in healthcare.  It seems so obvious and is supported by many as the way to improve not only cost and efficiency but also the quality of healthcare.  The healthcare system was meant to be a pyramid with the majority of physicians as primary doctors at the base and supported by a much fewer specialist at the top.  Our system however, has turned this upside down and the pyramid is rapidly growing at the top while the primary care base dwindles.  I dare anyone to argue that this is not a calamity in the making.  The pyramid standing on it’s point will collapse.  Yet, our politicians continue to ignore this issue or throw small bones at it in passing that are laughable.

So, what does it take to reverse this trend and fix Primary care?  In one word, time.

Many have articulated this in so many different ways, my blog today seems redundant, but I think the point is still missed.  Most want and feel that primary care needs to be payed better.  I wont argue with that and it would certainly be a quick and efficient way to solve the problem.  However, in this economic and political climate that doesn’t seem feasible or likely (thus the growth of Direct practices where physicians have taken matters into their own hands.)  In a nonscientific survey of my colleagues, I think most primary care docs are actually happy with their income (mostly), but they are not happy with what they have to do and the liability they assume for that income.

So, let me make this clear.  We don’t have to focus on money as the only panacea to fix Primary care.  There is a whole other side to this equation that needs to be dealt with. Let us “fix” the job.  Do away with countless unfunded mandates and meaningless bureaucracies and suddenly, hours of wasted physician time can be used for…. dare I say it, actual care!  Not to mention the enormous amount of wasted staff time and expense that will disappear and… dare I say it, the practice will make more money.

So many of these “little task” have been invented and created with the sole purpose of “slowing” down physicians and to artificially lower cost.  Since most fall squarely on primary care they have completely missed the boat.  Primary care is not  the source of massive spending problems in healthcare.  So why do they still exist?

In an attempt to be constructive, I offer these suggestions.

1. Outlaw prior approvals.  How convenient for the insurance company, “of course we would pay your benefits, but YOUR doctor hasn’t done the prior approval.”    I’m not sure how these are legal in the first place.  Insurance is a contract between patients and the insurance company.  How does the Insurance company get away with “forcing” physicians to waste time and energy to complete this process without paying them for that time?  If insurance really thinks that need a “checks and balance” on doctors, then I suggest implementing a “second opinion requirement” for certain high dollar healthcare expenses.  If the insurance doesn’t want to pay for an MRI, fine, then require 2 different physicians agreeing that an MRI is needed before they will pay.  At least then, the insurance company would have to pay for 2 evaluations to get the professional consensus that they think they need.  that extra expense would be nothing for slowing actual “waste” but it would prevent the insurance from abusing the process.  I once was told to get a prior approval for atenolol.  Really?? Atenolol is about as cheap as it comes…

Another great example: Medical Necessity « Musings of a Dinosaur.

 

2. Require companies to pay physicians for FMLA, disability, and long term care forms.  yes, I know that physicians can charge patients for these forms but why do we need to drive even more of a wedge between patient and doctor when it is the companies that are benefiting from the bureaucracy of the forms?  Most docs don’t charge for the forms yet we should be paid for our time.  Companies create their own forms and then demand physicians to fill them out, often 4-5 pages long and filled with nonsense.  Simply, more wasted time and an attempt to prevent people from being able to get their benefits.  How convenient for the insurance company, “of course we would pay your benefits, but YOUR doctor hasn’t properly filled out the forms.”

 

3. Pay primary care doctors for time, not for encounters.  Current system encourages volume of patients and not quality.  Patient comes in with chest pain that looks, smells, and sounds like reflux, the PCP gets the same amount of money to write “consult to GI” in 5mins that they get paid to spend 45mins educating the patient and explaining why a trial of PPI is worthwhile.  Amazingly, the 5 minute “consult to GI” visit also has a lot less liability for the physician.  This McMedicine approach is a major reason for the chaos we have in medicine now.

 

4. Offer real malpractice reform (at least for primary care if the politicians can’t stomach it for all healthcare.)  Reality is that Primary care already has lower liability than most in healthcare, but that doesn’t stop us from having ridiculously high premiums.  I personally don’t know a single primary care doctor that honestly feels they don’t practice defensive medicine.  This often includes many of those 5 minute “consult to so and so” visits that I mentioned above.  Without the constant threat of liability, Primary care doctors wouldn’t be so crabby about their relatively low pay and they certainly would be less likely to order unnecessary consults and test.

Ultimately, we have to give PCPs more time to do their job, or we have to pay them better.  My Guess is the right answer is somewhere in the middle.

If we want a return to a high quality primary care centric model of medicine in this country, then we have to improve primary care.  More money helps, but it is not the only answer.  Simply making the job better would go a long way to improve attractiveness of primary care for young doctors.

The Adoption Talk I Wasn’t Prepared to Have

I recently was working in the yard when my 4 year old son came to my side and declared, “My real dad was awesome.”  This of course perked my ears up.  “real dad?”  “Yeah, my real dad, you know the one before you were my dad?”  I said, “son, what are you talking about?”  He chirped up, “you know, my dad before I was adopted.”

My son then proceeded to edify his case and tell me in great detail about his life “before” he lived with me and how great his “real” mom and dad was.

As an adoptive father, I knew this conversation was coming.  My wife and I have been preparing for it ever since that fateful day we first held our two beautiful adopted boys in our arms.  As matter of fact, we have never hid our boys adoption and have always tried to talk to our boys openly about it.  Maybe that was the problem.  You see, Our adopted boys are now 9 and 7 years old.  Their four year old brother standing before me now is actually my own flesh in blood.  Looks so much like me that he once looked at an old picture of me with Santa Claus and declared that it was him.  Honestly… it vary well could have been him as he is my little clone.

I must admit, it hurt more than I expected.  I was initially stung by the words when he declared that I was not his “real dad.”  He said it so matter of factually and with a gleefulness and excitement.  How could this little man be so happy and proud to pronounce that I’m not his “real dad,”  And where in the world did he hear this anyway?

Of course I know where.  He adores his older brothers and wants to be like them in so many ways.

I have always expected and been prepared to “defend” my rightful place as “dad” with my older boys.   I stand confident in my roll as “heavy object mover”, “rasslin king” , and “professional hook baiter.”  I even occasionally turn into the terrible “Zombie Dad” from time to time that is always good for squeals of delight.  I constantly work extra hard to be at my kids school events and even volunteered to lead their Cub scouts group, and when they have an injury, I am there to wash it, tell them to suck it up and walk it off.  

I am DAD.

come to think of it…. It doesn’t really matter which of my kids want to challenge my status.  What makes me their father is the same.

I love my children.  I will always be there for them.  They can never do anything that would prevent that.

I am their DAD.

so if my biological son wants to fantasize about being adopted.  Who cares.  I know where he will always end up when he has a scrapped knee.

Probably running to his mother….

As Some try to Capitalize on the Terrible

I’m sick to my stomach. As any decent human being would be at the cowardly assault on children.

But I’m mad at the despicable onslaught of people trying to capitalize on the issue.

the Media: for selling commercials. They should donate every penny they have made selling commercials for the past week to the people of Newtown.

Politicians: for seizing on the issue to push their agendas. Once again calling for covenants and restrictions that would likely have very little effect on criminals and would only serve to give the “illusion” of safety.

And anyone else who has even remotely profited from the fear and anxiety caused by this horrible act.

If you want a political response, how about this.
Bless our Teachers!
If any “major changes” should occur as a result of this, it should be how we treat our teachers and schools!
Instead of “beefing up security” or “putting guns in schools” or “taking guns away from everyone”, why don’t we start with praising the amazing and selfless sacrifice, love, and passion that was shown by these amazing adults in the face or pure evil.
Where are the politicians calling for a huge boost in education funding and teacher pay as a results of the remarkable job they do!?!?

you want to honor the children, then let’s EDUCATE THEM!!!

Let’s Talk About Your “Rights”…

Nothing gets me more in a tizzy than to hear politician say, “it’s your right” or “you deserve. ”

We have so many problems and issues in our country.  Problems that are not new or somehow unique to our country or even our particular generation.  What is unique however is our social dialogue.  No time in the history of man have we been more connected and more free to speak our mind.  A freedom that I fear is wasted by most and is incessantly driven by a mindless and commercially driven media.  In a world that is FULL of EASILY AVAILABLE information, yet we are still horribly ignorant and still allow a few loud and verbose among us to tell us what to think.

Well, I would like a chance to move thought a little.

“Rights” is where I think we have to start.  Our society has spiraled into relative chaos due to this simple but contentious concept.  Rights, as described by our forefathers, started simply.  Life, liberty, and the pursuit of happiness.  They knew that true Rights are rare, small but highly treasured things.  The basic belief that humans control their own destiny and must be allowed the opportunity to pursue that destiny.  Without outside interference whenever possible.  Those simple Rights are the cornerstone of our great nation and must be protected.  Problem is,  recently we decided to expand those “rights.”

Creating one after another (through social dialogue) rights that we “deserve” and are “owed” by society.  This was with the noblest of intentions but has led to a degenerate society.  One question epitomizes the issue, “What happens when your Rights, conflict with my Rights?”

The definition of Right should never allow this to happen because a Right should be self determined.  If a Right is infringing on another person, then it is no longer a Right, it’s a privilege.

I will offer this definition to simplify Rights: anything you can have or do that does not require another living soul to have or accomplish.

If it requires another person, for any reason, then it can not be considered a Right.  It has required that living soul to give (even the smallest amount) then it is a gift, therefore a privilege.

If you are honest with yourself, you will see that it is almost impossible to claim many of our so called Rights, as true Rights.  The late great George Carlin said it best, “There are no such things as Rights, just temporary privileges.”  He also said,” it’s only a Right until it is inconvenient for the government.”  So True.

So if I could have one dream.  One wish, it would be that we would change our national dialogue of “our Rights” and what we “deserve.”  Instead, could we please talk about what privileges we as a nation want?

Talk of Rights is full of selfishness.  As the most powerful, wealthy , and advanced country in the world…. What privileges would we want for each other?  We want good roads, police, and fire fighters (as someone who has traveled to the 3rd world, these are defiantly privileges) so we are willing to pay for it.  We want social welfare and medical care for our elderly, and so, we REALLY pay for it.  We have decided we want the biggest, baddest army in the world, and boy do we ever pay for it.  We even once wanted to be the first nation to the moon, we payed for it and then celebrated and shared in the privilege that showed our strength and determination to the world.

Accept it folks.  We have very few Rights.  Almost none.  But, we have more opportunity than almost anyone else in the entire world…. please let us not squander it.

We must look long and hard at ourselves and decide what privileges we want and what we are willing to pay for.  The pot of gold is not infinite but it is huge and if managed well, could give us (and does give us) privileges beyond our wildest dreams.

We must earn privileges. We must all contribute and work to make our country great so that we can enjoy even more privileges.  The Rights you think you deserve, just don’t exist.

The world and society owes us nothing but the opportunity to succeed, it is up to us to take this privilege and be thankful for it.

Why My Son Doesn’t Want to Sleep in His Bed.

I have 5 children.  My wife and I have seen a little of everything when it comes to raising kids, but everyday they still surprise me.  That’s the fun of kids, right?  right?  Kids are supposed to be fun, right?

I’m kidding…. a little. 🙂

Kids are amazing.  Amazingly hard, amazingly exhausting, and amazingly awesome.  Even if I do threaten to eat them on a daily basis.

Our latest battle (one of several, as the war to raise children has many fronts) is our four your old son.  Nightly, he comes to our bedroom and crawls into our bed.  We have been terribly inconsistent.  Which is the worst thing to do but, we are to tired to fight it most nights.  Some nights we take him back to is bed and others we just let him stay.  The problem really is that he is a kicker.  Squirming, nesting, kicker.  He likes to take his feet and bury them and kick them (usually under me.)  I think he probably has restless leg syndrome.  It doesn’t seem to bother him one bit, but me… no chance of sleeping.

On one particular morning, we had enough.  My wife and I decided we would do the grown up thing and “reason” with our four year old.  We are highly educated people, we can do that, right?

Had it all figured out.  I certainly could out debate and circle a four your old.  I would dismantle each of his excuses and reasons for coming to our bed and he would have NO CHOICE but to understand and stay in his own bed.

Scared of the dark? check, we would leave a night light on.

I’m thirsty? check, leave a small glass of water at his bedside.

Want to sleep with someone? check, he ha his teddy that he has always slept with just fine.

 

so, sat my son down.  Looked him straight in the eye and was ready to go.

“Son, why do you keep coming to our bed every night?”

He looked at me, calm, without an ounce of fear.  “There’s no mommy in my bed.”

In a single phrase, I was stunned and horribly defeated with absolutely no response.

I stood up, looked at my wife who was looking for me to say something. “Well, I cant argue with that.”

So all three of us are sleeping together.  I really hope he out grows this…..

Doctors are Just Glorified Theatre Ushers

I’ve made this contention on several occasions and always get the same head cocked confused half nervous chuckle.  “Dr Brian, how do you figure?”

In my practice I see all ages but mainly geriatric patients.  There  is no end to the amazing diversity of discussions, questions, and odd request that I get from my patients and I attentively try to manage each and every one.  I love tackling the enigmatic diagnosis and the satisfaction of relieving someone’s acute symptoms.  The challenges of dealing with family dynamics and patient insight is always interesting.  I take special pride and honor that Patients trust me and often will call me first with problems and extremely personal issues.  They give me the most intimate insight into their lives.  A trust and honor that will always make being a doctor a most sacred of professions.  After all, doctors are the nosiest people I know.

But day in and day out, my job is pretty routine and basic.  I rarely heal people (that’s patients and nature), I just keep them busy while their bodies do all the real work.  I have thought this for a long time but have really never known how to say it just right.  However, at the blog Musings of a Dinosaur (http://dinosaurmusings.blogspot.com/) I think she said it better than I with her 1st Law:

“The art of medicine consists of amusing the patient while nature takes its course.”

I’m always  just buying time and trying to keep the patient comfortable and calm.  Following my own personal 1st rule: DON’T PANIC.  No matter what you do, that is ALWAYS the first rule.  I believe this so much that my kids, when asked what’s the first rule will always respond in a monotone unison,” Don’t Panic, dad…”  Keep people calm and comfortable and more importantly, distracted. 🙂

I digress and must get back to the reason of this blog.  How is a doctor like a theatre usher?  All this day to day care of patients is not the most important and satisfying part of my job.  That position is firmly held by two things, Birth and Death.  Nothing in all of medicine is more fulfilling, amazing, or spiritual than helping to bring a life into the world or to leave it.  I do not mean euthanasia before anyone sends me hate mail.  I mean the process of comforting physically and emotionally the dying.  Standing there at the bedside as someone drifts to eternity and pulls the last bits of air from this world.  Due to a malicious and unreasonable malpractice system, I have been robed of delivering babies.  Something I just have to accept.  Thank heavens I’m still allowed to help the dying.  It is the greatest of honors to share in a patients death, especially when it is a good death.  Every human dies and only once.  When done well, the experience is out of this world.

So, how are doctors like theatre ushers?

My job is to usher people into the show.   Help them find their seat and to keep order and calm so they can hopefully enjoy their show.  I don’t have anything to do with what show they see.  It may be a short film or a marathon epic.  It may be a comedy, horror, or amazing love story, but in the end I just try to keep people comfortable during the show.  I cant stop them from leaving early, I cant stop others from ruining their experience.  I simply use my little flashlight to look for signs of problems and deal with them as best I can.  More importantly, when the show is over I gently show them the door and clean up the mess afterwards.  After all, we have many more showings to do.

So please remember, the doctor cant fix your life.  They can only help make it more tolerable.  They can not save your life, they can only allow you to stay till the end of the credits.  You eventually will still have to leave the theatre when the lights come up.

Enjoy it and above all…. Dont Panic.

 

Zombies!!!

Zombies are real.

We create them everyday in hospitals and medical facilities all across this country.  Not in sinister basement labs or secret government facilities.

But they are real.  Dead humans, brought back to life to be brainless, rotting, eating machines.

For as much horror as Zombies invoke, I am amazed at how easily people often allow this Zombification to be performed on their own loved ones.

Now let me be clear.  Doctors, nurses, and other healthcare providers try to warn people and often work hard to avoid the zombification procedure from being done but it is often futile as families ignore this professional advise and will even insist that the procedure be done at all cost.  In some cases, when families and patients are not satisfied with the first zombie procedure, they will insist that it be repeated over and over again.  With each procedure the chance of full fledged zombiehood  increases to the point that it is an almost certainty.

Certainty that the patient will be left a brainless existence and lay rotting, moaning, and wallowing in their own filth with nothing more to do than feed.

At this point in the post I am certain I have lost a few readers (either in disgust or in contempt for my ridiculous notion) but hear me out.

The way Americans approach end of life care is atrocious.  Our society is immature and uneducated about one of the most basic truths of life.  The truth that we all die.  Also the truth that we are meant to die and pass this world on to our children and grandchildren (hopefully better than when we got here but that’s debatable and a whole different post.)  Modern medicine has given us remarkable tools to improve and sustain life but often these tools are used excessively with little real benefit to quality of human life and existence.

Dr Ken Murray recently posted an excellent blog, Zócalo Public Square :: How Doctors Die. In which he explains that doctors themselves rarely use the full extent of modern medical capabilities toward end of life.  Why is this?  Doctors have spent a life time in the study of life and with this, they are comfortable with death.  Not only are physicians comfortable with death, we know that people can (and often do) die BADLY.  Doctors want to have “The Good Death.”

When they see that time of death approaching and if given the opportunity, they will usually welcome the good death and refuse aggressive medical care.  Medical care that will only lead to complications, pain, and suffering in the last days.

So if this is what most doctors want for themselves and recommend for their families, then why not for their patients?  I can go into a long soapbox of how lawyers, politicians, doctors, patients, etc. etc. have all poisoned the system and the doctor patient relationship, but I wont.  The answer is in each and every one of us.  The whole U.S.A society.  We all share the blame that we have glorified life and demonized death to the point that accepting death under any circumstance is a sin.

And what do we have to show for it?

GGggrrUgghhh….. Brains!!!