Recently in response to a post (somewhat tongue in cheek) about renaming primary care physicians "prehospitalists" Mathew Mintz commented:
Don't like it. Pre-hospitalist implies that everyone will eventually go to the hospital. Though we certainly do our best to prevent patients from needing hospitalization, this doesn't capture the bulk of what we do: screening, prevention, counselling, chronic disease management,etc.
Mathew's comment really made me think. While he is right....keeping people out of the hospital does not describe the bulk of what we do. He misses the point. Our ability as primary care physicians to cut down on admissions may be the single best indicator of physician quality.
The physician who keeps his patients out of the hospital probably:
Is an excellent diagnostician
Manages chronic disease states well
Is timely
Calls his patients back promptly
Likely is highly active in screening and prevention
Sees urgent appointments on the same day
The list goes on and on. Sure there has to be an adjustment for patient age, socioeconomic status, and overall health of the patient population (a clinician who treats esrd, end stage copd, end stage cad...will have a higher hospitalization rate then others).
But I like hospitalization rate as an overall indicator. It certainly is hard to game this one...unlike the other quality indicators that have been used (a1c, colonoscopies, etc.).
So what do you think?
Tuesday, December 9, 2008
Sunday, December 7, 2008
When Passion Meets Talent
There is a moment in some peoples lives were god given talent and passion mesh to create something beautiful and unique. Those who are lucky enough to experience this rare gift have a special power. The power to change the world.
I was born thinking medicine was my passion. From the earliest ages I can remember wanting to be a Doctor. I have no idea where it came from. I have no idea how it grew. But it was my goal. It was my dream. Most of my waking moments were consumed by it. It didn't matter that I had a learning disability. It didn't matter that I almost had to stay back a grade. All hurdles were temporary. All surpassable.
And so I spent my youth on this goal. I expended countless sums of money. Studied for hours without reprieve. Worked excessively long shifts without sleep. I did whatever it took.
And I succeeded. I finished medical school and residency and began living my dream. But something was missing. Maybe it was the paperwork. Maybe the sadness of watching people die and being helpless. Maybe the anger so commonly directed towards physicians which often felt unjustified.
Being a physician no longer ignited me...no longer set my heart on fire. But something did. Strangely and unexpectedly it was writing. First poetry and then stories. It would wake me up in the middle of the night and force me to turn on the light and jot down a word or phrase so that I wouldn't forget in the morning. And I was happy...at least sort of.
Friday was a perfect example. In the morning waiting for me in my in basket were rejections from four publications refusing my poetry. They all came on the same day. I can't say it was unexpected. Anyone who has submitted poetry for consideration knows that rejection is just part of the process. You have to develop a thick skin they say.
So I was down as I made my way to the hospital. One of my partner's patients had been in and out of the inpatient service for months. She was a mystery. Several hospitalizations, and specialists, and cat scans later my partner still wasn't sure what to do with her. As I reviewed the data and finished my examination everything clicked. I knew that I caught something that everyone else had missed. So I made a few changes and added a key medication and within 24 hours she was better. It might take some time but I know she will recover.
On my way home yesterday it hit me like a ton of bricks. I always say that each person has a gift and if we are lucky we find it while there is still time to act. For years I have been searching for my gift. I was hoping it would be poetry. In reality it isn't. It's medicine....medicine is the one thing I am truly gifted at. Medicine is what I was meant to spend my life doing.
I am the luckiest man on earth. I have a wonderful wife and children. I have a job and enough money to live. And now I have found my calling. My one offering to humanity. But sadly....somewhere in the process after all those years of yearning, and striving, and working...I've lost my passion for it.
Gift and passion. Passion and gift. Somehow they've missed each other so far in my life. But what if....what if for just a moment I could realign them again.
Oh the the things I could accomplish!
I was born thinking medicine was my passion. From the earliest ages I can remember wanting to be a Doctor. I have no idea where it came from. I have no idea how it grew. But it was my goal. It was my dream. Most of my waking moments were consumed by it. It didn't matter that I had a learning disability. It didn't matter that I almost had to stay back a grade. All hurdles were temporary. All surpassable.
And so I spent my youth on this goal. I expended countless sums of money. Studied for hours without reprieve. Worked excessively long shifts without sleep. I did whatever it took.
And I succeeded. I finished medical school and residency and began living my dream. But something was missing. Maybe it was the paperwork. Maybe the sadness of watching people die and being helpless. Maybe the anger so commonly directed towards physicians which often felt unjustified.
Being a physician no longer ignited me...no longer set my heart on fire. But something did. Strangely and unexpectedly it was writing. First poetry and then stories. It would wake me up in the middle of the night and force me to turn on the light and jot down a word or phrase so that I wouldn't forget in the morning. And I was happy...at least sort of.
Friday was a perfect example. In the morning waiting for me in my in basket were rejections from four publications refusing my poetry. They all came on the same day. I can't say it was unexpected. Anyone who has submitted poetry for consideration knows that rejection is just part of the process. You have to develop a thick skin they say.
So I was down as I made my way to the hospital. One of my partner's patients had been in and out of the inpatient service for months. She was a mystery. Several hospitalizations, and specialists, and cat scans later my partner still wasn't sure what to do with her. As I reviewed the data and finished my examination everything clicked. I knew that I caught something that everyone else had missed. So I made a few changes and added a key medication and within 24 hours she was better. It might take some time but I know she will recover.
On my way home yesterday it hit me like a ton of bricks. I always say that each person has a gift and if we are lucky we find it while there is still time to act. For years I have been searching for my gift. I was hoping it would be poetry. In reality it isn't. It's medicine....medicine is the one thing I am truly gifted at. Medicine is what I was meant to spend my life doing.
I am the luckiest man on earth. I have a wonderful wife and children. I have a job and enough money to live. And now I have found my calling. My one offering to humanity. But sadly....somewhere in the process after all those years of yearning, and striving, and working...I've lost my passion for it.
Gift and passion. Passion and gift. Somehow they've missed each other so far in my life. But what if....what if for just a moment I could realign them again.
Oh the the things I could accomplish!
Wednesday, December 3, 2008
The Slow Down
Its happening again. I'm entering my second year of practive in my new location. And strangely....unexpectedly...I'm finding myself not very busy. In fact if I look back at my schedule I was busier six months ago then today. This really worries me. Surely I have more patients now then I had six months ago. In fact I usually see at least one new patient every day if not 2-3. So what gives?
At first I thought maybe its just the economic slow down. Maybe people don't want to pay their copays. I guess thats possible. But at least 50 percent of my patient population is medicare. They don't have copays. Then I thought maybe people are leaving me. That I am being ineffective. But we haven't recieved any record transfer forms. In fact a number of patients have moved considerable distances but still come back in town to see me.
Now that I think about it the same thing happened in my last practice. Coming out of residency I joined an internal medicine group that I stayed at for five years. Over time I accumulated about 2000 patients and was one of the busiest doctors in the office. But the truth is....the same thing happened there also. 2-3 years into it my numbers went down. My hospital census plummeted to one patient a week (after maybe having 2-3 patients in the hospital on a given day).
So what to make of all this? Previously I made up for low numbers by covering the other docs in the office. Although I saw more patients then any of them, I also would see most of their overflow. There were 5 more senior doctors in the same office who provided a steady stream of acute visits.
In my current practice there is only one physician more senior then I. So I really don't get much overflow. I still see my partners patients in the hospital...this keeps me a little busy. And for the first time in my life I am going to nursing homes and have taken on a medical directorship.
Maybe my patients just aren't that sick. I guess thats possible...but I have a huge medicare population. In fact....occasionally I have days where I see 4-5 patients in the office on the same day who are in their nineties. One of my biggest referal sources is the local nephrology group...so I have more then average number of dialysis patients.
I guess in my heart of hearts my hope is that I am slowing down because I am taking good care of people. Because I am catching disease earlier, treating it more aggressively, and keeping them out of the hospital. Becuase I am getting my dying patients enrolled in hospice so they can die at home.
In other words....I think my patients are needing me less and less each day. Gratifying...but bad for the bottom line.
But who knows...I could be wrong....maybe I am just pissing people off and they are leaving me!
At first I thought maybe its just the economic slow down. Maybe people don't want to pay their copays. I guess thats possible. But at least 50 percent of my patient population is medicare. They don't have copays. Then I thought maybe people are leaving me. That I am being ineffective. But we haven't recieved any record transfer forms. In fact a number of patients have moved considerable distances but still come back in town to see me.
Now that I think about it the same thing happened in my last practice. Coming out of residency I joined an internal medicine group that I stayed at for five years. Over time I accumulated about 2000 patients and was one of the busiest doctors in the office. But the truth is....the same thing happened there also. 2-3 years into it my numbers went down. My hospital census plummeted to one patient a week (after maybe having 2-3 patients in the hospital on a given day).
So what to make of all this? Previously I made up for low numbers by covering the other docs in the office. Although I saw more patients then any of them, I also would see most of their overflow. There were 5 more senior doctors in the same office who provided a steady stream of acute visits.
In my current practice there is only one physician more senior then I. So I really don't get much overflow. I still see my partners patients in the hospital...this keeps me a little busy. And for the first time in my life I am going to nursing homes and have taken on a medical directorship.
Maybe my patients just aren't that sick. I guess thats possible...but I have a huge medicare population. In fact....occasionally I have days where I see 4-5 patients in the office on the same day who are in their nineties. One of my biggest referal sources is the local nephrology group...so I have more then average number of dialysis patients.
I guess in my heart of hearts my hope is that I am slowing down because I am taking good care of people. Because I am catching disease earlier, treating it more aggressively, and keeping them out of the hospital. Becuase I am getting my dying patients enrolled in hospice so they can die at home.
In other words....I think my patients are needing me less and less each day. Gratifying...but bad for the bottom line.
But who knows...I could be wrong....maybe I am just pissing people off and they are leaving me!
Monday, December 1, 2008
A Dirty Rumor
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.
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.
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.
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