Sunday, February 17, 2019

Physicians

Physicians
The doctor is in ...

Sermo, malpractice, and Howard Dean

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Sermo’s Daniel Palestrant got on TV with Howard Dean. It was an amusing (and short) little debate which you can find here.

The best moment was at the start when Dean claimed that Sermo was just a poll. Palestrant pointed out that Dean spent last week explaining how reflective online communities were about what their members thought. Given how Dean rose to national prominence I’m a little surprised that he’s trashing the Internet!

The Look

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“He gave me the look,” the patient said to my nurse as he walked out of the exam room.

My nurse laughed and said, “I had a feeling you’d get it today.”

What were they talking about?  ”What look?  I didn’t know I had a look!” I asked my nurse.

The patient tipped his chin down and looked at me over his glasses.  My nurse laughed, pointing at the patient, “That one!  Exactly!  You give that look to me too!”

I was mystified.  I don’t like lecturing people or acting like their parent.  Patients do no harm to me when they gain weight, don’t take their medications, or eat a lot of Little Debbies.  My job is not to get them to do everything I say, it is to give them enough information and motivation to do it for themself.  I am the coach; they are the ones who have to go out on the field and play.  I may be disappointed when they mess up, but it’s not my job to patronize them and wag my finger.

So I was vexed when I learned about “the look.”  I’m honestly not sure how much of it is just a product of a guilty conscience on the parts of my nurse and the patient, but there is usually at least a grain of truth in this kind of revelation. I do know that I mysteriously intimidate new employees at our office.  The longer-standing ones think this is funny – realizing the softie I really am.

I’m also not sure if it is so bad that they don’t want me to look at them over my glasses.  I have had patients (and probably employees) assume my silence on an issue was a tacit approval.  ”He never told me I shouldn’t smoke,”  ”He never said I needed to lose weight.”  I’ve had people use my lack of lecturing as an excuse to continue behavior they already know is bad for them.

I also never told them it was bad to hit themselves in the head with a hammer.  I hope that omission isn’t resulting in head trauma.

I saw another patient recently, who said to me before I could sit, “I am sure you noticed I gained 6 pounds.  Christmas and Valentine’s Day were bad for me.”  I hadn’t had the chance to check the chart, but returned a remark about how there is a clear correlation between eating too much and gaining weight.  I could tell he had a guilty conscience, so I didn’t say anything more.

As I wrapped up the visit he asked me, “Aren’t you going to say something about the six pounds I gained?”

I smiled, realizing that he was expecting “the look” from me.  I told him that it was not good to gain weight and then looked at him over my glasses.

We’ll see how much power it has.

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

Rebuilding The Medical Home: What Walgreens Surely Sees

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Walgreens_logo Though it probably went mostly unnoticed in the cacophony of health care stories, last week’s news that Walgreen’s had bought the two largest and most well-established worksite clinic firms, iTrax and Whole Health Management, was a harbinger of very big changes in health care. Walgreens, the ubiquitous drugstore company that, with Wal-Mart and CVS, has already leveraged its pharmacy platform to establish a strong footprint in retail clinics, undoubtedly startled many health care observers with its announcement. After all, isn’t the company doctor a relic?

Actually, no. The worksite clinic – and by way of disclosure for the better part of the last year I have
worked closely with a small, very innovative, Orlando-based startup worksite clinic
firm, WeCare TLC  – has been
reinvented and refitted with 21st century tools, and offers the promise
of nothing less than a paradigm shift toward dramatically better care
at significantly lower cost. Understanding how these structures work and how they differ from both old-fashioned medical practices and retail clinics provides clues into what Walgreens likely sees and why that matters to American health care.

Who Cares About the Doctor-Patient Relationship? A Review of “Next In Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health”

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By KIP SULLIVAN, JD

A mere two decades ago, the headlines were filled with stories about the “HMO backlash.” HMOs (which in the popular media meant most insurance companies) were the subject of cartoons, the butt of jokes by comedians, and the target of numerous critical stories in the media. They were even the bad guys in some movies and novels. Some defenders of the insurance industry claimed the cause of the backlash was the negative publicity and doctors whispering falsehoods about managed care into the ears of their patients. That was nonsense. The industry had itself to blame.

The primary cause of the backlash was the heavy-handed use of utilization review in all its forms –prior, concurrent, and retrospective. There were other irritants, including limitations on choice of doctor and hospital, the occasional killing or injuring of patients by forcing them to seek treatment from in-network hospitals, and attempts by insurance companies to get doctors not to tell patients about all available treatments. But utilization review was far and away the most visible irritant.

The insurance industry understood this and, in the early 2000s, with the encouragement of the health policy establishment, rolled out an ostensibly kinder and gentler version of managed care, a version I and a few others call Managed Care 2.0. What distinguished Managed Care 2.0 from Managed Care 1.0 was less reliance on utilization review and greater reliance on methods of controlling doctors and hospitals that patients and reporters couldn’t see. “Pay for performance” was the first of these methods out of the chute. By 2004 the phrase had become so ubiquitous in the health policy literature it had its own acronym – P4P. By the late 2000s, the invisible “accountable care organization” and “medical home” had replaced the HMO as the entities that were expected to achieve what HMOs had failed to achieve, and “value-based payment” had supplanted “managed care” as the managed care movement’s favorite label for MC 2.0.

Bad Medicine: How The AMA Undermined Primary Care in America – Brian Klepper

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On Tuesday’s Wall Street Journal website, Dr. Benjamin Brewer describes
physicians’ reactions
to the 10.1% cut in Medicare physician payments
that will take effect January 1. He argues that the onus will fall,
once again, disproportionately on primary care physicians, who are
already losing the struggle to keep their heads above water.

He is right, of course. There is no question that Medicare must rein in
cost.
But the cuts are approximately the same across specialties and
therefore regressive. Insensitive to its distinct role, its lower
revenues and its high operational costs, they hit primary care harder
than they do specialties. Given its already battered status, the cuts’
impact on primary care could translate to real consequences this time.

INTERNATIONAL/PHYSICIANS: Canadian doctors going home means the US sucks, n’est-ce pas?

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This one I find hilarious and gives me great deal of personal satisfaction. The pro-American health care system, "it’s the finest on earth crowd" goes on and on about how terrible the Canadian system is and how all the doctors are leaving. In fact it was that sentiment especially from the wonderful, but confused, Sydney Smith over at Medpundit that inspired my "Oh Canada" tome.  (Actually I re-read "Oh Canada" the other day and it’s a pretty damn good piece of analysis if I say so myself).

Syd was basically saying that all the doctors were leaving cos they hated the clinical restrictions of the single payer system and wanted to move to the glorious homeland of free-choice medical practice and CABGs for 97 year olds. I showed pretty conclusively using actual real life data that a) very few doctors were leaving Canada for the US, and that b) if they were leaving it wasn’t that surprising as they get paid about twice as much by sneaking below the 49th parallel.

Well now we have more actual statistics and real data that shows that more Canadian doctors are heading back to Canada than are leaving — and this was in 2004 when hockey was on strike so there was no real reason to go to Canada! The numbers are:

Canada has seen more doctors returning than leaving for the first time in 30 years, a report by the Canadian Institute for Health Information (CIHI) shows. The report, released Wednesday, says that between 2000 and 2004,the number of physicians leaving Canada declined by 38 percent. In 2004, 317 physicians returned to Canada and 262 left. That was a drop from 2000, when 420 doctors left the country and a significant decrease from the peak of 771 physicians who moved abroad in 1994.

I’m looking forward to the barrage of articles from the know-it all alleged "free-market" crowd who get spoon-fed rubbish by Frasier, PRI, Manhattan et al offering their apologies to the Canadians and admitting that their system is better than the one down here.  After all the alleged rush of Canadian doctors to the US was absolute proof in their mind that the reverse was true.

I’m waiting, I’m waiting….

Using virtual reasoning to redefine health care

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is the CEO of Enhanced Medical Decisions, which is the company behind DoubleCheckMD.com.

The Internet is redefining the health care industry. Major transformations can be expected because Internet-based technology will deliver certain health care services more effectively and at lower costs. In the near future, much of the information that is currently imparted to consumers by clinicians will be delivered through and by web-based technology. If the web-based tools that deliver this information mature to the point of becoming reimbursable, beyond their current usefulness as value add-ons, the health care industry could experience a dramatic shift.

A Prescription For Doctors

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Enough about patients: What is a doctor to do?

Picture 42In the past few months, since The Decision Tree book came out, I’ve had the privilege to talk with many doctors about the opportunity and challenge of engaging patients in their own health. Some physicians, not surprisingly, have been suspicious, and even hostile to the idea that patients have a role to play. But thankfully, those have been rare exceptions. Most doctors I’ve spent time with have been eager to hear about new tools that might engage their patients, and they’ve been eager to share well-earned advice on where there’s work to be done. It has been a delight and an education to talk about the potential of healthcare with these physicians who are, after all, doing the hard work of providing medical care every day.

A high point in my continuing education came a couple weeks ago, when I was invited to speak at the Minneapolis Heart Institute Foundation‘s Fall Nursing Conference, where I met a number of nurses who are eager to help patients gain some control over their health. A few days later I gave a lecture on patient engagement at the University of Minnesota Medical Center. The invitation came from Dr. David Rothenberger, an esteemed surgeon who has consistently emphasized the importance of innovative thinking in medicine. Dr. Rothenberger also runs a program for physicians with promising leadership potential, and part of my day involved talking with them about the changing nature of clinical medicine, and the challenge of engaging patients in their healthcare.

These were good doctors, deeply motivated to help their patients, and there was scant resistance to the notion of an empowered patient who might seek to engage in their care and treatment. Indeed, they seemed to relish the opportunity to work with such patients.

The Doctor Is In and Logged On.

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Wow. I’ve just taken care of three patients in 12 minutes, and I didn’t do it by “churning” them through my office as if it’s some sort of factory assembly line. Rather, those patients (their parents, more specifically — I’m a pediatrician), e-mailed me over a secure network with questions and descriptions of signs and symptoms.

One mother attached a digital photo of a rash on her 3-month-old daughter’s face; it turned out be nothing more serious than baby acne (it’ll go away in a month or so). Another mom had noticed that her son was missing one of his pre-kindergarten immunizations (she had pulled up his shot records online) and requested that I order it. And the father of a 5-month-old boy told me that his son has been constipated off and on for the last month. I e-mailed him a questionnaire so I could determine whether the family should try something at home or bring the child to the office.

JAMA EHR Study: Misdiagnosis Poses Significant Potential for Harm

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An important study in the Journal of the American Medical Association finds that misdiagnosis is more common than you might think.  According to the study, almost 40% of patients who unexpectedly returned after an initial primary care visit had been misdiagnosed.  Almost 80% of the misdiagnoses were tied to problems in doctor-patient communication, and more than half of those problems had to do with things that were missed in the patient’s medical history.

The results of this study shouldn’t be surprising if you’re a regular reader here – they are another example of a system that isn’t working as well as it could for patients, and doctors.  Doctors – and the medical professionals who help them in their work – are the best educated and best trained than they have ever been.  They have more access to medical information and technology than at any time in our history.  And yet, U.S. government data show that the typical doctor visit involves 15 minutes or less with your doctor.  Medical records are kept in fragmented, uncoordinated ways.