Saturday, April 30, 2011

Was Hank a Dinosaur?

I have to say I'm absolutely struck by the heartfelt comments on my post about Hank. So I'm wondering, was Hank a dinosaur?

That is, he was in private solo practice. He was with a couple of groups before he went solo - don't know what the story was there, but he finally found himself in a small office by himself and had never been happier. Nothing between him and his patients, except insurance, but he didn't grouse about that.

Medical sociology, mostly Eliot Friedson in his great tome Profession of Medicine, looked at groups of doctors, mostly large groups in New York. He said that the more you are in a group, the more you look for consensual validation from your peers - that is, other doctors - and the less you look to your patients to validate your work and you as a person. I would imagine that the more administration there is, the more you look for validation from the administrators, the more you want to be like them (every doctor I know thinks that administrators have a sweet deal - little do they know). So with larger institutions patients are less patients and the more customers or even consumers.

Maybe I'm wrong. Maybe when a Kaiser doctor leaves the scene for whatever reason, patients feel bereft. Or maybe they shouldn't feel bereft, so personally deserted. Maybe they should feel that there is another one just behind him or her, waiting to take their place. I remember in Sweden when I would talk to people about the impersonality of the polyclinics, some of them said, but isn't that what you want, objective opinions?

But for myself I can't think that medicine should be anything but a real person to person enterprise. Our group, Bayside, is large by Bay Area standards - about 35 clinicians in 10 offices. But the offices are small, intentionally, not one stop shopping but rather pearls on a string. I think my job is to make sure we retain the ideals that Hank personified. We'll see if it's possible - I think it is. The culture comes from the top, they say, and I think everyone knows where I stand. With the dinosaurs.

Budd Shenkin

Monday, April 11, 2011

Welcome Back Budd

I have been neglecting my readers, and myself, by not posting lo these many weeks. Unlike a columnist, I don't have to churn them out and can lay fallow at times. I hope that's what I've been doing, fallowing. I've been distracted. Two trips to Chicago for AAP meetings, losing my wallet (and having it found) on one trip, losing my favorite belt in the scanning machine when I forgot it and discovered the fact too late when my pants were falling down. Many activities at the Goldman School of Public Policy where we hosted former Senator Bob Graham last week, and then health economist and Obama advisor David Cutler - first time I met him. Losing my Kindle. Worrying about good friend Bob with two heart attacks, my good friend and neighbor obstetrician Hank, who delivered my step-granddaughter with a midnight house call, with recurrent melanoma. As my friend Michael says, as you get older, there is no Yellow Brick Road, you just keep doing what you have always done, coping. Sigh.

Also, there is the tyranny of success. I have been so pleased to get positive responses about my blog from people I respect that I don't want to pollute my product with mediocre posts. Easy enough to do. It can be a killer. One of our employees, after years of underproduction, met with our new Administrator and began to do really well. They then went out with anxiety, and their stupid doctor recommended rest - like a pill, rest. Idiot! The employee finally does well and collapses with anxiety? What about some counseling to make it possible for them to continue to do well, and not worry if they can keep it up? Doctors. Kaiser. Idiots.

OK, so with this prolonged intro, here's my post on health care, my now and forever topic.

Our system of health care sucks. Everyone knows that. Here is another detailed complaint from a primary care doc at the Mass General (sine she is at Mecca, anything that happens must be someone else’s fault.) Then a comment from my friend pediatrician Jon Caine, and finally trenchant comments from me.

A Waste of Money

By Katharine Treadway

Last week, a patient I have known for several years called my office and spoke to my nurse. She said that while she was driving, her vision had gone blank for one second and then she was fine. My schedule was already overbooked: almost all of the slots were filled with patients with the usual array of multiple chronic medical problems for follow up and management of what were, for the most part, stable conditions. Thus my nurse sent her to Urgent Care, a unit set up so that patients can be seen quickly for acute medical problems rather than being sent to the emergency room. The necessity for such a system has developed gradually as the burden of prevention, chronic care, documentation, and paperwork has eroded the flexibility of many internists to squeeze in the extra patient who has an acute problem. The result of this system is that paradoxically, I see my patients when they are well or stable and urgent care sees them when they are sick; the reverse of what should happen. The cost of such a system can be significant, as this story illustrates.
The nurse practitioner who saw my patient in Urgent Care sent her to the emergency room for evaluation of a transient ischemic attack (TIA, characterized by passing stroke-like symptoms) despite the fact that a symptom lasting 1-2 seconds does not fit any definition of a TIA. Once in the emergency room, she was seen by the medical service and then the neurology service who, not surprisingly, ordered magnetic resonance imaging tests which, also not surprisingly, were entirely normal. She was sent home after several hours with instructions to follow up with her primary care physician.
I saw her a few days later and carefully reviewed her history which confirmed the story of a 1-2 second white-out of her entire visual field bilaterally which resolved with complete visual clarity in the time it took to blink. She had no preceding symptoms: no heart palpitations, no lightheadedness, no other focal neurological symptoms. Except for a burst of anxiety, she felt entirely well after the episode and has remained so.
I thought about the close to $10,000 that had been spent ruling out a serious cause of her symptoms. If I had been able to see her, would it have made a difference in her management? I believe it would have for two reasons. After listening to her story in detail, I was confident this was not a significant neurologic event. Because she knows and trusts me, I was able to reassure her with my opinion (which interestingly the normal scans had not been able to accomplish). But equally importantly, because I knew her well, I was willing to take responsibility for my decision. One of the hallmarks of being a primary care physician is to be comfortable with uncertainty. We learn to trust our clinical judgment and not jump to ordering expensive tests “just to be sure.” It is hard to accept the responsibility of decisions when the patient is unknown to you.
It is clear that we need to redesign primary care so that we can see our patients when they are sick, not just when they are well. The medical home is one such model and there are undoubtedly others but whatever the design, it cannot be assumed that medical personnel are interchangeable. The knowledge of a patient gained over years coupled with the trust such a relationship builds for both the doctor and the patient are essential components of cost-effective medical care.
Katharine Treadway, MD is a primary care physician at Massachusetts General Hospital who teaches at Harvard Medical School.

Jonathan Caine MD says:

The sequence of events you describe was completely predictable once you made the decision to “turf” the patient to the Urgent Care Center. What your patient experienced was a sequence of defensive medicine decisions. First, the NP was not able to correctly diagnose the patient was not having a TIA. (Those bureaucrats who believe that NPs will save the “system” money because they are paid less for providing services, please take note.) She in turn “turfed” the patient to the ED, who then “turfed” her to neurology. Neurology did what neurology consultants do, that is, order MRIs (and occasionally EEGs). The fact is no one gets sued for ordering too many tests. The number one cause of malpractice suits these days – failure to diagnose. Would the medical home model have prevented this as you surmised? Doubtful. You could have had the highest level of NCQA Certified Medical Home, but if you were fully booked and couldn’t see the patient that day the same outcome would have occurred. If you were truly confident in your impression that she did not have a TIA, you never would have referred her to the Urgent Care Center in the first place. So, your decision was defensive medicine as well. Until we have legitimate tort reform in this state these types of cases will continue to occur on a daily basis in Massachusetts.
Jonathan Caine MD, Pediatrician

• Kate Treadway says:
You are absolutely correct about the problem of defensive decision making and that is the point of my blog – that, as primary care doctors who know our patients, we are much more willing to accept responsibility for these types of decisions. My nurse sent the patient to urgent care without my input so I was not part of that decison making process. However, I also heartily agree that tort reform is absolutely necessary if we are to change medical care and medical costs. Thanks so much

And now, breathless reader, my own comments:

She thinks the problem is "the system," a vague designation. You, Jon, think the problem is defensive medicine. I agree. But although both are correct, I think we should look further.

First, let's not forget incompetence. Was the NP generically over-matched -- that is, no NP could make this diagnosis, and only a doctor could -- or was she as a professional not up to the job?

Then the ER - why could they not deal with this? Not sharp enough?

Then the neurologist. Is the primary care doc smarter than the neurologist in his or her own specialty? Or were they mindless?

So, yes, certainly defensive medicine and the fear of lawsuits pressure all of us in practice. But then there is competence or the lack thereof and courage of convictions.

However -- having said that -- the "system" will not reward any of these professionals who saw the patient for their abstemiousness. No way. So why try if your only reward will be your own knowledge of what you have done? It's not enough.

But then, why has this primary care doctor so overbooked her day that she does not have the capacity to see an acutely ill patient? Why has she set up her practice this way? She blames others, but why? We have the same mix of pre-scheduled and acute patients in pediatrics, and we make sure we have enough capacity every day to see anyone who calls in.

Perhaps the issue is payment. Because we build in the capacity to see patients who might or might not call, we sometimes have unused capacity. We therefore make less money than we might otherwise. If primary care adult doctors had higher payments and thus had more money to play with, perhaps they could do the same thing.

But one still has to ask, why is her practice set up this way, with an urgent care center somewhere else? Wouldn't it make sense for her to have a group practice where they had an urgent care center right on their premises? Wouldn't it make sense for her to employ some nurse practitioners or physician assistants to see some of her regular patients for some of their visits, allowing her to see some of the more difficult patients -- our patient in question -- when warranted? It would be better medicine, and the partners in the practice would make a little more money.

Our physician corps does have many entrepreneurial members, and being entrepreneurs, they often look for the biggest payoff, which is available in areas other than primary care. The entrepreneurs thrive in areas with surgical interventions, or radiological interventions, or some such -- that's what our system pays for. But still, our primary care physicians can build systems that serve patients better and make themselves a little bit of money in the process.

So, yes, it's the system. But this primary care doc let's herself off too easily. Better to ask, "Why have I not set up my practice so that I can serve my patients better?"

And finally from Jon:

“I agree completely that the problem lies with the doctor herself and the way she is scheduling her office visits. I sort of implied that with the term "turf". I didn't want to continue to bash her so as not be accused of assault.”

Budd Shenkin