Thursday, April 28, 2011
Monday, April 25, 2011
They've Got It All Wrong
I mean...they've got it all wrong.
Health reform....the silly alphabetical soup...ACO, PCMH, PQRI.
These things don't mean quality. Not even close. They don't mean economical. They are not about giving good care, or even about being cost effective. They are just that....a bunch of letters. Standing for obscure, unproven concepts being passed off by academics, politicians, medical societies. It's about political expediency. Ask any practicing physician. And were killing primary care.
Because what I do is not about community health. It is not about how many of my patients A1c's are below 7 or how many of my hypertensives meet certain "goals". That's all good...but it's not how I save lives, or how I cut down on hospitalizations, or how I provide economical care. I do that a different way. I use my years of training, experience, intuition, deep knowledge of my patients, and understanding of medicine to hash out a plan that sometimes works. I strive to:
-quickly separate the various causes of both common and uncommon symptoms. I try to be king of the differential diagnosis. Defining whether the 50 year old with chest pain has coronary disease, gerd, anxiety or a pulmonary embolism. Primary care is uniquely situated better then any specialty to do this because we have the broadest knowledge base and experience.
-manage chronic illnesses and titrate medications sometimes on a daily basis. Diabetes, Chf, Copd...the patients often have specialists but unless they want to speak to a nurse practitioner they call me for day to day management.
-Have end of life discussions. Every day. Over and over. When the cards are on the table the oncologist, or cardiologist, or pulmonologist have disappeared. I am the the one left talking about hospice.
And when it works...I save lives, keep people out of the hospital, and allow them to die in peace.
But now there is the collective. Soon we (not I) will be an ACO. We will be a PCMH. Swallowed into a large group and no independence. Tethered to quality indicators that mean nothing to actual patient care. Incentivized to think less about people as individuals and more about groups. Patients will be shuttled from provider to provider to meet some type of quality goal about physician availability. The paperwork will expand..and expand...and expand. And I will expend...expend more energy thinking about everything but clinical care.
Businessmen will siphon off profits to meet the needs of the whole...expensive administrative salaries. Expensive facilities to maintain...you have to feed the hospital....you have to feed the mri machine...you have to feed our specialists.
You see ACO doesn't equal ethical. The majority of hospitals and medical groups are not going to become one because its the right thing to do.....they are adapting to meet the market. The market changes and they adapt. But these are businesses...they need to make money.
They will use us...just as the government is going to use as. We will help them sell their wares.
Good old primary care is going to save the day. But not the primary care that was proven in all those studies to cut down on the cost of care and lead to better outcomes. No...we've created a new shiny primary care. All sorts of new bells and whistles. Nothing like that old antiquated...doctor and patient...primary care thing.
The death knell is sounding.
Adapt and become a shadow of what we used to be....
Or stubbornly maintain...
And be eaten alive.
Health reform....the silly alphabetical soup...ACO, PCMH, PQRI.
These things don't mean quality. Not even close. They don't mean economical. They are not about giving good care, or even about being cost effective. They are just that....a bunch of letters. Standing for obscure, unproven concepts being passed off by academics, politicians, medical societies. It's about political expediency. Ask any practicing physician. And were killing primary care.
Because what I do is not about community health. It is not about how many of my patients A1c's are below 7 or how many of my hypertensives meet certain "goals". That's all good...but it's not how I save lives, or how I cut down on hospitalizations, or how I provide economical care. I do that a different way. I use my years of training, experience, intuition, deep knowledge of my patients, and understanding of medicine to hash out a plan that sometimes works. I strive to:
-quickly separate the various causes of both common and uncommon symptoms. I try to be king of the differential diagnosis. Defining whether the 50 year old with chest pain has coronary disease, gerd, anxiety or a pulmonary embolism. Primary care is uniquely situated better then any specialty to do this because we have the broadest knowledge base and experience.
-manage chronic illnesses and titrate medications sometimes on a daily basis. Diabetes, Chf, Copd...the patients often have specialists but unless they want to speak to a nurse practitioner they call me for day to day management.
-Have end of life discussions. Every day. Over and over. When the cards are on the table the oncologist, or cardiologist, or pulmonologist have disappeared. I am the the one left talking about hospice.
And when it works...I save lives, keep people out of the hospital, and allow them to die in peace.
But now there is the collective. Soon we (not I) will be an ACO. We will be a PCMH. Swallowed into a large group and no independence. Tethered to quality indicators that mean nothing to actual patient care. Incentivized to think less about people as individuals and more about groups. Patients will be shuttled from provider to provider to meet some type of quality goal about physician availability. The paperwork will expand..and expand...and expand. And I will expend...expend more energy thinking about everything but clinical care.
Businessmen will siphon off profits to meet the needs of the whole...expensive administrative salaries. Expensive facilities to maintain...you have to feed the hospital....you have to feed the mri machine...you have to feed our specialists.
You see ACO doesn't equal ethical. The majority of hospitals and medical groups are not going to become one because its the right thing to do.....they are adapting to meet the market. The market changes and they adapt. But these are businesses...they need to make money.
They will use us...just as the government is going to use as. We will help them sell their wares.
Good old primary care is going to save the day. But not the primary care that was proven in all those studies to cut down on the cost of care and lead to better outcomes. No...we've created a new shiny primary care. All sorts of new bells and whistles. Nothing like that old antiquated...doctor and patient...primary care thing.
The death knell is sounding.
Adapt and become a shadow of what we used to be....
Or stubbornly maintain...
And be eaten alive.
Tuesday, April 12, 2011
Today....I felt like a doctor
I felt like a doctor today as I awoke from a restless night on call. My shoulders and neck hurt as I arched out of the bed and toward the shower. The rest of the house was asleep and the streets were dark. I gently placed my pager and telephone on top of the toilet as I disrobed to get in the shower. The face of the pager showing 5 messages. I had cleared it the night before laying down for sleep.
I felt like a doctor today as I raced through traffic on the expressway. My pager beeping incessantly as I adjusted my blue tooth and answered phone calls. It has been so long since I could drive to work without being interrupted. I briefly caught a look at myself in the rear view mirror. My eyes tired and my head balding.
I felt like a doctor today as I dashed up the hospital stairs. My long gray coat bumping against my knees and my stethoscope almost falling out of the deep pockets. The secretaries at the nursing stations nod as I pass by. "Good morning doctor!". As if there was no place they would rather be at six in the morning.
I felt like a doctor today. Entering the quiet room. The sun starting to peak through the hospital windows. My patent's last sunrise. His eyes rolled back and breathing long drawn out breaths with uncomfortable pauses in between.
I felt like a doctor as I stood at his side. My stethoscope useless. My knowledge impotent. And waited sadly for death from an uncertain disease.
I felt like a doctor today....helpless
Because in medical school no ever taught me that every battle is lost in the end...
You just hope for a few small victories to keep you going...
From time to time
I felt like a doctor today as I raced through traffic on the expressway. My pager beeping incessantly as I adjusted my blue tooth and answered phone calls. It has been so long since I could drive to work without being interrupted. I briefly caught a look at myself in the rear view mirror. My eyes tired and my head balding.
I felt like a doctor today as I dashed up the hospital stairs. My long gray coat bumping against my knees and my stethoscope almost falling out of the deep pockets. The secretaries at the nursing stations nod as I pass by. "Good morning doctor!". As if there was no place they would rather be at six in the morning.
I felt like a doctor today. Entering the quiet room. The sun starting to peak through the hospital windows. My patent's last sunrise. His eyes rolled back and breathing long drawn out breaths with uncomfortable pauses in between.
I felt like a doctor as I stood at his side. My stethoscope useless. My knowledge impotent. And waited sadly for death from an uncertain disease.
I felt like a doctor today....helpless
Because in medical school no ever taught me that every battle is lost in the end...
You just hope for a few small victories to keep you going...
From time to time
Sunday, April 10, 2011
Tuesday, March 29, 2011
"I need to go"
"I need to go...Joe and the boys are waiting for me"
I looked up from the computer as one of my nursing home patients zoomed past with a veteran nurse running behind her. The nurse's brow was sweaty and she was huffing to keep pace. Her barely perceptible limp a remnant from a distant ankle fracture she suffered one late night while on duty.
"Sarah....Sarah...Joe is gone, he died long ago."
Sarah stopped in her tracks as her face momentarily hardened and then became blank.
"The boys...I have to get to the boys!"
The nurse was now sitting. She sat with her ankle up on a chair and looked over with both sadness and exasperation.
"They're dead...they all died before you came here".
Again Sarah paused. For a moment you could see the realization enter her face. She lifted both arms and gently cradled her own head as if in slow motion.
"OK then.....where's Mary?"
Mary, her sister who had lived with her in the nursing home until just a few weeks prior, had died quietly in her sleep.
The nurse was now back on her feet and held Sarah's waist and started to walk her back to her room. Her voice almost a whisper.
"Mary....Mary," you could see her take a moment to think it through, "Mary died".
Sarah's stooped posture jerked upright. A look of anger entering her face as she shrieked,
"Mary is not dead!"
A certified nursing assistant hearing the commotion jumped from an adjacent chair and lunged forward as the nurse began to talk again.
"Of course she's dead...I took you to the funeral!"
Sarah was now thrashing..pushing away restraining hands.
"You lie...I did not go to her funeral...I did not go to her funeral!"
Multiple nursing home staff closed in and gently guided Sarah back to her room.
The nurse came out a few minutes later and limped toward me. As I stared I felt both annoyance and great compassion . She was now sweating profusely and her gait abnormalities had become more prominent.
She crumpled into the chair next to mine and sighed loudly. A few moments later we both shuddered as the door flew open and Sarah burst out of the room in full sprint and ran toward the door...
"I need to go....Joe and the boys are waiting for me!"
Sunday, March 20, 2011
On Being A Doctor/Father
It takes its toll on me...this being a doctor....I think as I wait in the Indian restaurant buffet. My son is curled on my lap. Uncharacteristically tired...later he will develop a fever and I will realize why he is so warn out.
It takes it toll on me. I wouldn't say I am a stressed out person but I certainly live with stress. Most of it is self inflicted.
It's just that I can't help feeling responsible. For those few thousand people who have placed their lives in my hands. I know I am not god. I know that Doctors can only do so much. But that doesn't stop me from worrying.
It doesn't stop my mind from racing at night as I pour over the problems of the day. And it doesn't stop the guilt. Every time someone gets sicker then expected. Every time someone dies. And boy do they die. All the time.
I guess that's what happens when you take care of people in their eighties...and nineties...and hundreds. And when you spend a lot of time in nursing homes.
I always ask myself what could I have done different. How could I have been better. Was I enough?
Mostly the answer is yes. Occasionally the answer is no. But I always ask the question.
It takes a toll on me.....the stress. The sadness. And sometimes I wonder what this is doing to my mind. My body. Am I causing in myself that which I spend so much time fighting in others. Will the stress raise my blood pressure. Clog my coronaries. Herald in a major depressive episode....uncontrollable anxiety.
But how can I complain. My life has meaning. I struggle daily with the essence of life. And I get paid a comfortable salary to do so. I get to help people....at least when things are working at their best. I get to reach out to my fellow man.
And I get to do it on my own terms. I work when I want to work....and rest when I want to rest. Sure I spend my share of weekends and nights. But I am usually home by 4pm...no later then 5.
I can count the number of times I have missed dinner with my children on one maybe two hands...ever. I am present. I put them to sleep at night. I see them on the weekends. They know me. They love me.
And maybe that's worth it. The stress...the worry. The physical and emotional burdens of this lifestyle. Maybe its worth it because it has afforded the ability to be there. For my children. For my wife. Such that my son will walk over to me when he is hurting.
He will climb up on my lap. And place his head on my chest. And he will feel safe.
Because I am always here.
Of all the things this profession has allowed....
It allows me to be present.....
In my families life.
It takes it toll on me. I wouldn't say I am a stressed out person but I certainly live with stress. Most of it is self inflicted.
It's just that I can't help feeling responsible. For those few thousand people who have placed their lives in my hands. I know I am not god. I know that Doctors can only do so much. But that doesn't stop me from worrying.
It doesn't stop my mind from racing at night as I pour over the problems of the day. And it doesn't stop the guilt. Every time someone gets sicker then expected. Every time someone dies. And boy do they die. All the time.
I guess that's what happens when you take care of people in their eighties...and nineties...and hundreds. And when you spend a lot of time in nursing homes.
I always ask myself what could I have done different. How could I have been better. Was I enough?
Mostly the answer is yes. Occasionally the answer is no. But I always ask the question.
It takes a toll on me.....the stress. The sadness. And sometimes I wonder what this is doing to my mind. My body. Am I causing in myself that which I spend so much time fighting in others. Will the stress raise my blood pressure. Clog my coronaries. Herald in a major depressive episode....uncontrollable anxiety.
But how can I complain. My life has meaning. I struggle daily with the essence of life. And I get paid a comfortable salary to do so. I get to help people....at least when things are working at their best. I get to reach out to my fellow man.
And I get to do it on my own terms. I work when I want to work....and rest when I want to rest. Sure I spend my share of weekends and nights. But I am usually home by 4pm...no later then 5.
I can count the number of times I have missed dinner with my children on one maybe two hands...ever. I am present. I put them to sleep at night. I see them on the weekends. They know me. They love me.
And maybe that's worth it. The stress...the worry. The physical and emotional burdens of this lifestyle. Maybe its worth it because it has afforded the ability to be there. For my children. For my wife. Such that my son will walk over to me when he is hurting.
He will climb up on my lap. And place his head on my chest. And he will feel safe.
Because I am always here.
Of all the things this profession has allowed....
It allows me to be present.....
In my families life.
Saturday, March 12, 2011
Why I Feel Shame
Why I feel shame:
1)Because every damn health care article I read somehow finds a way to quote "To ERR Is Human"
2)Because every discussion about torte reform ends up being a soliloquy about those "Bad Doctors".
3)Because every year a new governmental regulation adds a new piece of paper I have to fill out or a new computer screen I have to click through to do my job. Now to discharge a patient I have to fill out three separate forms. Last year it was two. The year before I could give a verbal order (the quality of care has not changed).
4)Because the government gives lip service to improving primary care but just doesn't get it. Now to get home health for my patients I have to fill out even more paperwork....this is not stopping people from using home health inappropriately.....it is just taking up more of my time.
5)Because when I send my patient to have a swallow eval, the speech therapist sends them to a pulmonologist for their cough, and then the pulmonologist sends them to a neurologist for their dizziness. And after thousands of dollars of workup the specialists come to conclusions that I had already told the patient and documented in the chart but no one took the time to ask me because what does a primary care doc know anyway?
6)Because for some reason when patients get sick and die the first question society asks is....Who messed up?
7)Because sometimes I get so involved in using my emr, figuring out eprescribe, or making sure that I have documented correctly for billing purposes that I don't "hear" what my patient is so desperately trying to tell me.
8)Because sometimes, god forbid, I am having a bad day and may not perform to my peak level....somehow that doesn't feel OK anymore.
9)Because I am deathly afraid of my government...breaking down my doors, looking at my records, and asking for money back. Even though certified coders themselves rarely agree with each others findings.
10)Because I used to practice under the assumption that I was being look at under a microscope...now I feel like I am practicing under the gun.
11)Because I secretly worry....that with all the doctor bashing and painting us as knaves in the media...one day a disgruntled patient will walk into my office with a gun and start shooting.
12)Because I went into this profession with such pure and innocent motives...
I wonder how it all became so convoluted!
1)Because every damn health care article I read somehow finds a way to quote "To ERR Is Human"
2)Because every discussion about torte reform ends up being a soliloquy about those "Bad Doctors".
3)Because every year a new governmental regulation adds a new piece of paper I have to fill out or a new computer screen I have to click through to do my job. Now to discharge a patient I have to fill out three separate forms. Last year it was two. The year before I could give a verbal order (the quality of care has not changed).
4)Because the government gives lip service to improving primary care but just doesn't get it. Now to get home health for my patients I have to fill out even more paperwork....this is not stopping people from using home health inappropriately.....it is just taking up more of my time.
5)Because when I send my patient to have a swallow eval, the speech therapist sends them to a pulmonologist for their cough, and then the pulmonologist sends them to a neurologist for their dizziness. And after thousands of dollars of workup the specialists come to conclusions that I had already told the patient and documented in the chart but no one took the time to ask me because what does a primary care doc know anyway?
6)Because for some reason when patients get sick and die the first question society asks is....Who messed up?
7)Because sometimes I get so involved in using my emr, figuring out eprescribe, or making sure that I have documented correctly for billing purposes that I don't "hear" what my patient is so desperately trying to tell me.
8)Because sometimes, god forbid, I am having a bad day and may not perform to my peak level....somehow that doesn't feel OK anymore.
9)Because I am deathly afraid of my government...breaking down my doors, looking at my records, and asking for money back. Even though certified coders themselves rarely agree with each others findings.
10)Because I used to practice under the assumption that I was being look at under a microscope...now I feel like I am practicing under the gun.
11)Because I secretly worry....that with all the doctor bashing and painting us as knaves in the media...one day a disgruntled patient will walk into my office with a gun and start shooting.
12)Because I went into this profession with such pure and innocent motives...
I wonder how it all became so convoluted!
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