There is a rumor out there. And it says that primary care practicioners are running up the cost of medicine. That they have been squeezed so tightly by busy schedules, paperwork, and short visit times that they have become careless. More on this in a moment.....But first a story.
A young lady enetered my office 6 months ago for a physicial. Among other things she was having trouble swallowing. She felt food would get stuck. She was healthy. No weight loss, her symptoms were intermittent. So I questioned her, examined her, and carefully explained my thought process. Given that there were no alarm symptoms we decided to start with an acid reducer for possible reflux and a promise that if she was no better after two weeks she would call and I would send her for a barium swallow.
Months passed and I heard nothing. Then last week she walked into my office crying. She did not try the acid reducer. Instead she went to see an ENT (Her PPO allowed her to go without a referral). The ENT did a scope and sent her to a speech therapist for a swallow evaluation. The speech therapist did a video assisted swallow study and was convinced the patient had a mass in her pharynx. She then sent the patient to another ENT. Who scoped her again and sent her for a ct of the neck. When those were both negative he scoped her one last time for God knows what reason.
So she returned to me, crying, anxious, and having even more frequent difficulty swallowing. So I again suggested an acid reducer (which she promised she would take) and an anti anxiety medication and hopefully she will see me again in a few weeks. And if that doesn't work I'll either do a barium swallow or send her to gi for an egd. The right workup that should have been done in the first place. I bet, however, she won't need it. I bet her symptoms will be gone by the next time she sees me.
So back to that rumor. You can argue that internists consult too much. That they send patients for too many tests. But as my story illustrates....specialists do the same thing. You see...good doctors treat disease expediently and cost efficiently. Bad doctors don't. It has nothing to do with a percieved time crunch. Give primary care doctors more time....the good ones will still do a good job, the bad ones will still do poorly. Period!
It's not a time issue ias much as a quality issue. The harder question is how do we reward quality!
By the way...I think PCP's could benefit from more time with each patient. I just don't think economic ramifications will be as drastic as most think.
Monday, December 1, 2008
Saturday, November 29, 2008
I'm Rebranding
That's it. I'm taking a tip from the hospitalist movement. I'm rebranding. I'm no longer a primary care physician. "PCP" now seems to be synonymous with overworked, underpaid "loser" who at least by some people's opinions aren't carrying their weight. That's not me.
So starting today I will be known as a "PREHOSPITALIST". That my ticket. I see patient's before they get to the hospital and try to divert them before they get sick enough to be admitted. I see the sickest of the sick. End stage renal disease, transplant patients, double transplant patients, end stage copd, end stage chf, end stage anything, and frequent fliers.
Send them all to me. Send me your hardest patients. And I will bend over backward to keep them out of the hospital. I will see them weekly. Daily if I have to. I'll manage them aggressively. I'll return their phone calls promptly. I'll fit them into my schedule at a moments notice.
And I will manage them. Comanage them with their specialists. In fact I will call the specialists so often to discuss management that they will be sick of me. But I will cut their hospitalization rate down by 75 percent. And they will get better. And utilize less resources, and thrive.
Yet I will still see healthy people. And do annual screenings. And make unexpected diagnosis. And while I may not be an expert in any field I will still know enough about most fileds. And when death comes I will be there to comfort. And to advise. A jack of all trades.
And I will be what used to be known as an internist. Or a pcp. Back in the days when those titles garnered respect. But don't you dare call me that now! I am a "prehospitalist" to you bucko. And don't you forget it!
So starting today I will be known as a "PREHOSPITALIST". That my ticket. I see patient's before they get to the hospital and try to divert them before they get sick enough to be admitted. I see the sickest of the sick. End stage renal disease, transplant patients, double transplant patients, end stage copd, end stage chf, end stage anything, and frequent fliers.
Send them all to me. Send me your hardest patients. And I will bend over backward to keep them out of the hospital. I will see them weekly. Daily if I have to. I'll manage them aggressively. I'll return their phone calls promptly. I'll fit them into my schedule at a moments notice.
And I will manage them. Comanage them with their specialists. In fact I will call the specialists so often to discuss management that they will be sick of me. But I will cut their hospitalization rate down by 75 percent. And they will get better. And utilize less resources, and thrive.
Yet I will still see healthy people. And do annual screenings. And make unexpected diagnosis. And while I may not be an expert in any field I will still know enough about most fileds. And when death comes I will be there to comfort. And to advise. A jack of all trades.
And I will be what used to be known as an internist. Or a pcp. Back in the days when those titles garnered respect. But don't you dare call me that now! I am a "prehospitalist" to you bucko. And don't you forget it!
Wednesday, November 26, 2008
Monday, November 24, 2008
My Weekend
It was another weekend on call. Filled with the usual phone calls, hospital work, and Saturday clinic. I dread weekend's on call. Mostly because they take me away from my family. There is also, ofcourse, the lack of sleep. Getting up at 5am on Saturday is no fun. But this is what I do. Every third week. It is what it is.
My call, at least, this time was brightened by the morning clinic. I was a little bit less busy then usual so had more time to talk with my patients. A rare luxury, I like to take advantage of extra time when I get it. My first two patients were a man and a wife in their eighties who live in a local nursing home. After going into the regular littany of medical questions I started my exam. While taking blood pressure, stethoscoping, pushing and pulling.... curiosity got the best of me. I started in with the personal questions.
"So how long have youy been married?....How many kids to do you have? Grandkids? Great Grandkids? where did you both grow up?". I am always amazed at how much I learn from people by asking these type of questions. And as usual this couple surprised me.
I would have never guessed it from looking at them...but they had been only married for fifteen years! Apparently they had met in their teens and at the tender age of twenty she had refused his marriage proposal. Years passsed. They both married other people and had kids, they both got divorced. And forty years later after minimal contact he picked up the phone and called her and they realized that they lived blocks away. The rest was history.
A little later in the day I saw another patient who was relatively new to me. I had seen her only a few times for minor problems. Each time she came in accompanied by her daughter. And each time I kept thinking that I somehow had met her daughter before. But I just couldn't place her. As my patient was preparing to leave her daughter mentioned that, "oh by the way mom will be on TV next week!" And that's when it dawned on me. Her daughter looked familiar becuase I had seen her before...many times in fact, she is on a TV show I occasionally watch. How funny! I didn't even recognize her.
I guess it just goes to show that even a monotonous, boring, weekend on call can turn out to have some surprises.
My call, at least, this time was brightened by the morning clinic. I was a little bit less busy then usual so had more time to talk with my patients. A rare luxury, I like to take advantage of extra time when I get it. My first two patients were a man and a wife in their eighties who live in a local nursing home. After going into the regular littany of medical questions I started my exam. While taking blood pressure, stethoscoping, pushing and pulling.... curiosity got the best of me. I started in with the personal questions.
"So how long have youy been married?....How many kids to do you have? Grandkids? Great Grandkids? where did you both grow up?". I am always amazed at how much I learn from people by asking these type of questions. And as usual this couple surprised me.
I would have never guessed it from looking at them...but they had been only married for fifteen years! Apparently they had met in their teens and at the tender age of twenty she had refused his marriage proposal. Years passsed. They both married other people and had kids, they both got divorced. And forty years later after minimal contact he picked up the phone and called her and they realized that they lived blocks away. The rest was history.
A little later in the day I saw another patient who was relatively new to me. I had seen her only a few times for minor problems. Each time she came in accompanied by her daughter. And each time I kept thinking that I somehow had met her daughter before. But I just couldn't place her. As my patient was preparing to leave her daughter mentioned that, "oh by the way mom will be on TV next week!" And that's when it dawned on me. Her daughter looked familiar becuase I had seen her before...many times in fact, she is on a TV show I occasionally watch. How funny! I didn't even recognize her.
I guess it just goes to show that even a monotonous, boring, weekend on call can turn out to have some surprises.
Friday, November 21, 2008
Smile
It all starts with a sparkle.
As if the devil himself had placed just enough mischieviousness in your eyes to be bitter sweet. The sparkle evolves into a comet of bright white light sweetening your beautiful brown skin soft and smooth. Your lips part. The lower hiding your teeth while the other curls upward. Your face and body radiate, brightening the room and releasing all unwanted thoughts that dwell in my mind. And those word return. Filling my soul. Over and over again....
I love your smile
As if the devil himself had placed just enough mischieviousness in your eyes to be bitter sweet. The sparkle evolves into a comet of bright white light sweetening your beautiful brown skin soft and smooth. Your lips part. The lower hiding your teeth while the other curls upward. Your face and body radiate, brightening the room and releasing all unwanted thoughts that dwell in my mind. And those word return. Filling my soul. Over and over again....
I love your smile
Tuesday, November 18, 2008
Primary....Care
Early morning
The exam room.....
When I look in the mirror
A stranger stares back at me
How so?
The face is not mine
The eyes are too far apart
The left higher then the right
and the lips are too close to the nose
Could it be that you no longer recognize yourself?
And when I walk
Everything is leaning...
roads, sidewalks, people
Has your life lost balance?
And my chest
Every time I think
or worry
Pain
Is it your heart that hurts? Has the sadness consumed you?
And sometimes
sometimes
when I'm alone
I talk to myself
Like you have not a friend in the world?
Silence
And then a knock on the door
"Doctor....doctor?"
"Yes?" I respond awaking from my reverie
"Your first patient is here....
shall I send her in?"
From the chapbook Primary Care, The Lives You Touch Publications
The exam room.....
When I look in the mirror
A stranger stares back at me
How so?
The face is not mine
The eyes are too far apart
The left higher then the right
and the lips are too close to the nose
Could it be that you no longer recognize yourself?
And when I walk
Everything is leaning...
roads, sidewalks, people
Has your life lost balance?
And my chest
Every time I think
or worry
Pain
Is it your heart that hurts? Has the sadness consumed you?
And sometimes
sometimes
when I'm alone
I talk to myself
Like you have not a friend in the world?
Silence
And then a knock on the door
"Doctor....doctor?"
"Yes?" I respond awaking from my reverie
"Your first patient is here....
shall I send her in?"
From the chapbook Primary Care, The Lives You Touch Publications
Hospitals
Here's something you won't here your physician say everyday.....I hate hospitals!. I hate emergency rooms! I hate when my patients are sick enough to need emergency care. I hate when they get admitted.
Why...because hospitals are dangerous places where bad things can potentially happen and bad bugs hang out. It's a place for sick people...really sick people...deathly ill people. And I don't want to ever let my pateints get that way.
As I am fond of saying in my office...If you find yourself in a hospital you better be one of a few things....either really ill, visiting a friend, or at work. Because it's not the place for the kinda ill or sorta ill. Only bad things can happen to these people.
So if you call me in the middle of the night and expect that I'll tell you to go the the emergency room for your cold...you got another thing coming. Or if your an emergency room doctor and you want to admit my 50 year old patient with bronchitis....I'll probably give you a hard time.
It is my responsibility to protect my patients from the harms that they don't recognize. And let me repeat this to make it clear....the hospital is a great place if your on the cusp of dying.....but incredibly risky for everybody else.
Why...because hospitals are dangerous places where bad things can potentially happen and bad bugs hang out. It's a place for sick people...really sick people...deathly ill people. And I don't want to ever let my pateints get that way.
As I am fond of saying in my office...If you find yourself in a hospital you better be one of a few things....either really ill, visiting a friend, or at work. Because it's not the place for the kinda ill or sorta ill. Only bad things can happen to these people.
So if you call me in the middle of the night and expect that I'll tell you to go the the emergency room for your cold...you got another thing coming. Or if your an emergency room doctor and you want to admit my 50 year old patient with bronchitis....I'll probably give you a hard time.
It is my responsibility to protect my patients from the harms that they don't recognize. And let me repeat this to make it clear....the hospital is a great place if your on the cusp of dying.....but incredibly risky for everybody else.
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