It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word.
This has been the bread and butter of counselors for years. People will faithfully attend and pay for weeks, months and even years of therapy visits just to have an attentive and active listener and to feel like they have an ally.
We also have data that shows that adherence to treatment plans is dependent on how patients feel about their provider. One problem solved can build an ally for life
Primary care medicine is a relationship based business. I don’t know how often that basic fact is overlooked or denied. Whether you are trying to get another person to alter their lifestyle, take expensive medicines according to inconvenient schedules or even just trust and accept your diagnosis, you have to “earn” the right to do those things. Our titles and medical accoutrements give us a foot in the door, but they don’t usually get us all the way into peoples inner circles of trusted advisers.
In this age of corporate medicine, there is a belief that patients attach themselves to institutions and networks because of their trust in the organizations, and that therefore the connection with their individual providers is secondary.
It’s a funny world we live in. Lots of people make a handsome living, defining their work and setting their own fees and hours with little or no formal education or certification
There are personal and executive coaches, wealth advisers, marketing experts, closet organizers and all kinds of people offering to help us run our lives.
In each of these fields, the expectation is that the provider of such services has his or her own “take” or perspective and offers advice that is individual, unique and as far removed from cookie cutter dogma as possible. Why pay for something generic that lots of people offer everywhere you turn?
So why is it, in this day of paying lip service to “personalized medicine”, genetic mapping, the human biome and psychoneuroimmunology that we expect our healthcare to be standardized and utterly predictable?
And why is it that we are so willing to fragment our care, using convenient care clinics, health apps, specialists who don’t communicate with each other and so on? Does anybody believe it makes sense to have your life coach tell you to have a latte if you feel like it because it makes you happy and your financial adviser scorn you for wasting money, never mind your health coach talking about all those unnecessary calories?
In today’s world, almost all knowledge and information is available, for free, instantly and from anywhere on the planet. But this has not eliminated our need for “experts”. It used to be that we paid experts for knowing the facts, but now we pay them for sorting and making sense of them, because there are too many facts and too much data out there to make anything self explanatory.
Hence we have the new guidelines for PSA testing. (Given that many patients with prostate cancer have normal PSAs and lots of patients with high PSAs don’t have prostate cancer, it doesn’t seem semantically correct to call it “prostate cancer screening”.) Surprise! Turns out that not only does PSA testing not save lives, but that urologists don’t really care. Certainly not enough to stop recommending PSAs to just about everyone they can get their hands on.
Nor do breast surgeons have any intention of modifying their recommendations, not only in light of new understandings of the limitations of mammography, but even as their own treatment recommendations contract, becoming ever more targeted and less invasive. I recently heard a local surgeon speak about the progression from radical mastectomies to partial mastectomies to lumpectomies; from axillary node dissections to sentinel node sampling; from whole-breast radiation to intra-cavitary seeds. Listening to him, breast cancer therapy is becoming downright minimalist.
Yet at the end of the talk, when asked about the new recommendations for biennial mammography, his response was, “Every woman should have an annual mammogram starting at age 40. I mean, there are no downsides to mammography.” Never mind the psychological stress of extra views, ultrasounds, and false positives, not to mention the bruising and even skin tearing that I see far more often than I’d like. “No downsides”? Not for him, that’s for sure. When will they realize that mammography catches slower-growing cancers that would be treated just as easily if they were found a year later? Women die of aggressive tumors that pop up between annual mammograms, which by definition would not be detected by standard screening.
The gynecologists are no better. They all still insist on annual visits for paps to find cancers that take 10 years to grow (and then only in the presence of HPV) and pelvic exams that detect, well, nothing. Whether driven by legal concerns or patient insistence, scientifically unnecessary medical care is running rampant in this country, playing a pivotal role in bankrupting us in the Orwellian name of “the best medical care in the world”.
A long time ago, when I worked in Sweden’s Socialized health care system, there were no incentives to see more patients.
In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On-call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.
There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: most clinics took phone calls only for an hour or two in the morning.
After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.
As my father always said: “There must be a reward for working”.
But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.
A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.
So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.
But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.
“The more you learn, the more you realize you don’t know.”
You will hear this statement not just from physicians, but from lots of other folks engaged in scholarly work of all stripes. That’s because it is not merely true; it is a deep and universal truth that permeates all of mankind’s intellectual endeavors.
The implication of this for the practice of medicine is that a little knowledge can be very dangerous.
What do I, as a fully trained, extensively experienced primary care physician bring to the evaluation of patients who seek out my care that cannot be matched by so-called “mid-level providers” (PAs and NPs)? It is not (always) my knowledge, but rather the experience to know when I do not know something. In short, I know when to ask someone else’s opinion in consultation or referral.
I had a scary experience lately with a PA who didn’t even know what she didn’t know (and who still probably doesn’t realize it.)
The patient had been bit on the hand by a cat. I saw the injury approximately 9 hours after it had occurred. The patient had cleaned it thoroughly as soon as it had happened, and by the time I saw it, it was still clean, bleeding freely, not particularly red or swollen, and only a little painful. Still; cat bites are nasty, especially on the hands. Therefore I began treatment with oral amoxicillin-clavulanate, and told the patient to soak it in hot water several times a day.
Six hours later (after one oral dose of antibiotic) the patient called me back: the wound was now much more painful, red, swollen, and there were red streaks going from the hand all the way up to his elbow. Frankly, I was a little puzzled. He was already on antibiotics; the single dose probably hadn’t had enough time to make much of an impact. And yet the infection was clearly progressing. Continue reading…
“He came in and started spouting that he was busy saving someone’s life in the ER, and then he didn’t listen to what I had to say,” she told me. ”I know that he’s a good doctor and all, but he was a real jerk!”
This was a specialist that I hold in particular high esteem for his medical skill, so I was a little surprised and told her so.
“I think he holds himself in pretty high esteem, if you ask me,” she replied, still angry.
“Yes,” I agreed, “he probably does. It’s kind of hard to find a doctor who doesn’t.”
She laughed and we went on to figure out her plan.
This encounter made me wonder: was this behavior typical of this physician (something I’ve never heard about from him), or was there something else going on? I thought about the recent study which showed doctors are significantly more likely than people of other professions to suffer from burn-out.
Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both).
This is consistent with other data I’ve seen indicating higher rates of depression, alcoholism, and suicide for physicians compared to the general public. On first glance it would seem that physicians would have lower rates of problems associated with self-esteem, as the medical profession is still held in high esteem by the public, is full of opportunities to “do good” for others, and (in my experience) is one in which people are quick to express their appreciation for simply doing the job as it should be done. Yet this study not only showed burn-out, but a feeling of self-doubt few would associate with my profession.
Today I am going to write about how the US could save up to 10% on its healthcare bill.
The US spends more on health care than any other nation, $8,500 per person per year. Multiply that by 300 million people and try to grasp the vast sum of $2,5 trillion.
A lot of changes are taking place with the intent to save healthcare dollars. So far, many of those changes have involved creating new layers of middlemen, whose paychecks will come out of the same healthcare budget as MRI’s, prescription medicines and physician salaries.
Every so often physician salaries come into focus as a place where money might be saved. Some people even picture physician pay as a major driver of healthcare costs.
Now, I am just a country doctor, and I don’t have an MBA or any financial background. But I used to be pretty good at math, and I’d like to think I still am.
If the 2.5 trillion dollars this country spends on healthcare is paid to or prescribed by our 850,000 physicians, then each doctor controls 3 million dollars from our nation’s healthcare budget.
Of course, physicians aren’t the only providers or prescribers. I don’t have a figure for how much money is controlled by our 100,000 Nurse Practitioners and 70, 000 Physician Assistants. I also don’t know what portion of our 50,000 chiropractors’ work falls inside the traditional healthcare budget, but let me assume each physician on average controls only 2-2.5 million dollars worth of products or services…
Then, if every physician took a $200,000 pay cut, we could reduce our healthcare spending by up to 10%!