Category Archives: Medicine

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?”

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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.


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!!!


Why I never got on the Hamster wheel in the first place.

My father always taught me, “If your not going to do it right, then dont do it at all.”

In residency, I was scheduled patients every 10mins because i had to “learn how to maintain a practice”.

I hated it. My patients hated it. At the end of the day my care sucked. not because I was a poor doctor but simply because I had no where near enough time to “Do it right!”

That was almost 10yrs ago, I now have a housecall practice where I see 8-10 patients a day giving each my undivided attention.

I work my butt off and have full days, but at the end of the day my patients are happy and I am proud of the work I have done. I love what I do.

I’m a little tired of hearing this argument of how “If Primary care docs start only seeing 10-15 patients a day, then who’s going to see everybody else?” This argument always seem to come from academics who have rather cushy pay and benefits with no real worries of malpractice or billing issues as they are shielded by their institutions. Quite disingenuous for such academics to bemoan how “WE all suffer” because some physicians (who don’t have institutional protections and benefits) have decided to practice in a simpler more full filling way. Which, by the way, as Dr Drummond noted does not have to be cost prohibitive…. Why when we talk about PCPs making a little more money we are somehow demonized for it?

Why should I be forced to see increasing numbers of patients with worsening reimbursement simply because the “system” has done a wonderful job of discouraging people from going into primary care?
Why is that my problem?
I love my patients. I love what I do and at the end of the day, if i’m forced to give mediocre care to 20-40 patients a day, well then,

I just wont do it.