Sunday, September 26, 2010

Why (Single) Family Practice is Dying

There have been many articles written by family doctors in medical magazines about the present difficulties in the profession, the "good old days", and reasons for retiring early, but few, if any written for the patients, so they can understand the problem. The following is an attempt to remedy that lack. (And please feel free to forward this blog to your local Congressman, Senator, and legislators in your state's capital.) I was stimulated to write this blog by a friend of mine who has recently retired from the solo practice of internal medicine, because (a) he was spending more time on the phone with insurers and with paperwork than he does on patient care, and (b) because his net income was dropping each year so that his retirement annuity now exceeds his net income, even though he still enjoys the practice of internal/family medicine.

The main problem revolves about the amount of time that he needs to spend in non-patient care, and time is his least fungible resource. For instance, he now has to certify the need for home visits by a nurse weekly rather than monthly, and name stamps or his secretary's signature is not accepted.
This is an additional 23 pieces of paper he had to sign every Monday.

If a deaf MCR patient requires a sign language interpreter, the doctor must pay for it out of his own pocket, which costs more than what MCR pays him for the visit.

The HMO's such as Oxford keep on writing him letters to fulfill their HEDIS requirements to the government asking him why his diabetic patients have not received their yearly eye exam or his female patients their yearly mammogram. He then has to take time to explain to Oxford that the patient saw a non-Oxford ophthalmologist or radiologist, and since he was not the referring doctor he does not have a copy of the report.

He continually has to get permission for a MRI rather than a CT scan (HMO, not MCR), or explain to MCR part D that the generic medicine does not work, and the patient needs the brand name, or explain to the HMO that OTC Claritin does not work in this patient, so he/she needs Rx. Allegra or Xyzal.

He gets paid much more for doing than for thinking: MCR pays more for a 10 minute pulmonary function test than for a 30 minute visit. This is because MCR and HMO's can't measure thinking and diagnosing, but they can ask for a copy of the test.

The hospital now has an electronic order system. It used to take him 5 minutes with pen and paper to admit the patient, and now it takes 25 minutes to go through all the templates, including the birth date of the doctor (and how does that help patient care?) and whether or not his private patient should get a flu shot at discharge. Again, all this takes time, time, and time.

But if he wants to give a Botox or Restalen injection, which HMO's and MCR don't pay for, he needs supply them no proof, get no permission, and charge whatever the local traffic will bear.

A few years ago, MCR asked him why he did more flexible sigmoidoscopies than any other internist in his county. He wrote back to MCR asking them why more internists didn't look for colon cancer in their patients. He never heard from them again. Clearly MCR was more interested in reducing the number of (more expensive) financial outliers than in ensuring the good health of MCR patients.

If I write you a prescription for a sleeping pill, I make it PRN, i.e. take it if you can't fall asleep. That has been an illegal order for any MCR patient in a nursing home since 1996. MCR decided that the nursing home nurses on the night shift would be tempted to drug their patients so the nurses could have a quiet night. So I either have to write for a sleeping pill every night, which is bad medicine, or come in to the nursing home on the same day I want a patient to have a sleeping pill. The answer: I stopped seeing all nursing home patients, and let the assigned nursing home doctor worry about the problem. Once again, I didn't have the extra time.

And if I saw two nursing home patients in a nursing home the same day, I got paid less for the second one, because MCR claimed I was there already, so maybe I didn't really have to see the second patient. This was another reason to stop seeing nursing home patients, because again it took up extra time that I didn't have.

Federal MCR rules require that the rear doors of nursing homes be locked during the night, so demented patients can't wander off, but state laws forbid the locking or rear fire escape doors at any time while the building is occupied.

HMO's have their preferred list of brand name drugs, and it takes a lot of arguing with them to convince them that Prevacid works and Prilosec does not in my particular patient, or that I want my diabetic hypertensive patient to have Coreg as a beta-blocker because it is the only beta-blocker that has been shown to reduce microalbuminuria in these patients.

If I had my way, no insurance company, HMO, or MCR outfit would be allowed to challenge any Rx, Xray or blood test ordered by a doctor, and we would really save a lot of time.

The government is pushing computerized EMR's and drug ordering systems, which is another recipe for wasting time. There are a lot of (sometimes theoretical) drug conflicts listed in the PDR, and the computerized order system mindlessly follows them. The fact that the warning has been superceded by more recent research never makes it into the PDR, because it would cost the drug companies too much money. For instance, it is NOT true that beta-blockers cause depression (see, for instance, NEJM article from 3 years ago), but every time I try to add a beta-blocker to a patient on an antidepressant, my hospital's computer flashes an alert, and I have to manually put in an override command. I even got flashed for putting a young patient on a calcium channel blocker, with the warning that there were more efficient anti-hypertensives. In fact, I was using the Ca++ blocker for the well-recognized off-label use of reducing esophageal spasm, and again this explanation/override took time. And don't even think of using a tricyclic anti-depressant for stomach acid suppression----no computer has ever heard of such a use!

Unlike lawyers, doctors cannot charge for telephone advice, but we can be sued for it.

And we don't need tort reform so much as we need removal of the contingency fee from medical malpractice cases. Let it all be no-fault, similar to some states' mandatory automobile insurance policies, and let the workman's compensation fee schedule prevail for doctors and lawyers. And no, the threat of being sued for malpractice doesn't make a doctor a more careful physician. No doctor wants to harm a patient, either by omission or commission. But the threat of malpractice suits makes us order many more Xrays and specialty consults than we think the patient really needs, and in some counties (e.g. in Florida) no neurosurgeon covers the emergency room, because all automobile accident injuries end up in court. Similarly, no OB attending trains his residents in the use of forceps, because of the risk of a malpractice suit when the doctor is asked:"if there was a problem, why didn't you do a C-section?" That is why the number of C-sections has increased.

I still think that medicine is the most wonderful and rewarding profession in the world, and I also feel that internists have the most enjoyable specialty because we get to be real family physicians and take care of three generations of the same family. But all my children are educated and married, my mortgage is paid off, and I don't need that much income. I don't know if I would choose this specialty if I were starting off today.

I wish all doctors had time enough to spend more time with each patient, but I have no idea how to achieve this.

Tuesday, September 14, 2010

Basic Care by Doctors for Patients

There have been articles (and even books) written about what a patient should expect from a doctor, but I have found none of them to be of practical use. Let me tell you about the basic behavior I expect from my medical residents. Some if it is what I call "good housekeeping", some of it is common sense, and some of it is based on over 25 years of experience of taking care of ward and office patients. This list is not complete, and it is not a check list of what the doctor should do, because check lists are mechanical, and are not insightful for the doctor. Rather, if your doctor does NOT do several of my suggested actions, it may be time to find a "luckier" doctor for you, i.e. one who is more thorough with his/her patients.

Every patient should be asked about past transfusions (most usually occur during childbirth, so ask specifically). If any transfusions before 1985, do blood test for Hepatitis C antibodies, and, if positive, for Hep. C. RNA.

Ask about blood donations (immediate check for Hepatitis A,B,C, syphilis, West Nile disease, etc.).

In the appropriate neighborhood or background, skin test for TB on high risk patients. Always skin test on admission to a hospital, rehab center, assisted living, or nursing home. Patients from the Caribbean, especially the DR, have usually had BCG vaccine to protect against bovine TB, but the PPD should still be planted. Ask about prior TB skin tests, + or -.

Check on last Tetanus booster (at least one every 10 years), and Pneumovax and cervical herpes vaccine if appropriate. Offer flu vaccine.

Ask about any foreign travel in the past 5 years, and any illnesses while traveling or shortly after return home. Ask if took malaria prophylaxis, if appropriate.

Over age 50, one test for Vitamin B-12, as well as 25-OH Vitamin D. Also test for Vitamin D and Calcium after any bone fracture.

ANY patient put on steroids for longer than one month should be placed on Fosamax or its equivalent to help prevent steroid-induced bone loss.

If patient requests Viagra or its equivalent, check free and total testosterone level as swell as prolactin level. If either testosterone test is low, check the pituitary FSH/LH.

In irritable bowel disease, always check for lactose intolerance and celiac disease/malabsorption. Both can occur at any age.

There are only two acceptable reasons for not doing a rectal exam at the annual physical: no rectum, and no finger.

If no mammogram in the past year, examine breasts.

In hospital visit, always SIT DOWN. The patient should not feel rushed. You should always at least take the patient's pulse for physical contact and reassurance.

Ask about allergies, and request copies of written Xray reports and all past operative reports.

Ask about any veneral diseases, specifically herpes.

Last ophthalmology, dental and GYN visit, and any abnormalities. Can the patient read street signs at night when he/she drives?

Birth control used, sexual satisfaction with partner, and sex of partner.

Any stresses in life. Children or parents with mental or physical problems. Do you like your job?
When was your last vacation? Do you exercise regularly? Do you fall asleep easily? Any pets at home?

Check blood pressure in both arms. If over 50 (or 40 with certain medical conditions such as diabetes), listen for murmurs in the carotid arteries in the neck.

Do NOT tell the patient your own problems. You are wasting their time, because you are there to help them with their problems.

Keep a shadow chart in code of embarrassing facts the patient does not want released, and NEVER copy the shadow chart (OK to verbally give info to treating doctors with secrecy caution): e.g.; adultery, uses cocaine, prior pregnancy and surrender for adoption or abortion, bisexual, hole in nasal septum, lax anal sphincter.

Only try to diagnose treatable diseases (e.g. atrial fibrillation due to hyperthyroidism, and not atrial fibrillation secondary to cardiac amyloid).

The test may not be the patient's, so always repeat any abnormal blood test before you alarm the patient.

If the patient has syphilis and you suspect neurosyphilis, send the spinal fluid only for a VDRL, and never for an FTA, because no one knows what to do with a positive CSF FTA. Remember that Lyme disease is also caused by a spirochete, and is the cause of many false positive VDRL/RPR screens for syphilis.

Ask about orgasms. Ask about suicidal thoughts or attempts or plans. If sex drive low or sex with partner infrequent, ask about masturbation.

Undiagnosed Addison's disease can kill, and you won't make the diagnosis if you don't think of it.

If you have been on prednisone or other oral steroid in the past year, ask the doctor about stress doses of steroids if admitted to the hospital with an acute illness or infection, or for surgery.

If there is a dog in the house, the dog should get the monthly drop on the neck to keep Lyme ticks off.

If the patients says 2 drinks/day, ask how big the drinks are. (In some groups "two beers" means "two six-packs".)

Last menstrual period, and consider pregnancy test (must be done on every hospital admission.).

Ask the patient (1) what he/she thinks is medically wrong, and (2) if there are any other questions.

Most important: try to deduce the patient's model of disease, because any prescribed treatment that is in conflict with this model will not be properly applied.

(Trivial) if patient is low in serum potassium, check urine potassium, and serum magnesium; serum PTH usually not needed.

If kidney stone, 24 hour urine collection for Ca++, urate, and Ox-- so can treat to prevent further recurrences (if untreated, 50% have recurrent attack in 5 years).

Ask about unprotected sex (there is always some), and berate patient appropriately.

ALWAYS skin test for TB (and strongoloides as well?) when immunosuppressing with steroids, imuran, etc.

You may not be worried about lung cancer, but if you are a smoker your doctor should tell you that you are 100% guaranteed to develop emphysema, and spend the end of your life on an oxygen tank if you live long enough.

Why does the dentist go into the other room when taking dental Xrays if they are so safe?

Your doctor should never complain to you about his/her personal problems, but bitching about Medicare, HMO's and Electronic Medical Records is perfectly appropriate.

Never be afraid to leave a doctor because you don't want to "hurt his/her feelings". You should always find a doctor with whom you are gemutlich. I always tell my patients that my ego is not on the line: I give them my best professional advice, and they take it or not.

50% of our current medical knowledge will be obsolete in 5 years, but we don't know which 50%.
Leeches for high blood pressure, anyone?: (They did work , which makes it all the more surprising that the Red Cross will not let anyone with high blood pressure donate blood!)

And finally, do you feel "good" about your doctor?