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Tag: Medical Practice

I Have a Strong Relationship with my Bank but I Almost Never Go There. How Could this Translate to Primary Care?

By HANS DUVEFELT, MD

Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch – and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.

Of course that’s not how banks operate. There are small ongoing charges (or margins off the interest they pay you) for keeping your money and for making it possible to do almost everything from your iPhone these days. Yes, there may be additional charges for things that can’t be done without the bank’s personalized assistance, but those things happen at your request, not by the bank’s insistence.

Compare that with primary care. The bulk of our income is “patient revenue”, what patients and their insurance companies pay us for services we provide “face to face”. We may also have grants if we are Federally Qualified Health Centers, mostly meant to cover sliding fee discounts and what we call “enabling services” – care coordination, loosely speaking.

Only a small fraction of our income comes from meeting quality or compliance “targets”, and those monies only come to us after we have reached those goals – they don’t help us create the needed infrastructure to get there.

Then look at how medical providers are scheduled and paid. We all have productivity targets, RVUs (Relative Value Units – number and complexity of visits combined) if our employer is paid that way and usually just straight visit counts in FQHCs (because all visits are reimbursed at the same rate there). Sometimes we have quality bonuses or incentives, which truthfully may be the combined result of both our own AND other staff members’ efforts.

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Everybody Seems to be an Expert, Except Your Family Doctor?

By HANS DUVEFELT, MD

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.

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Cultivating Charisma in the Clinical Encounter (and emulating Marcus Welby, M.D.)

By HANS DUVEFELT, MD

If medical journals are the religious texts that guide me as a physician, the New York Times has become the secular source of illumination for my relationship to my country and the world I live in.

That doesn’t exactly mean that I feel like a citizen of the world. Quite the opposite, particularly now, with just me and my horses sharing our existence on a peaceful plot of land within walking distance of the Canadian border; my physical world seems quite small even though I am aware, sometimes painfully but with an obvious distance, of the calamity of our planet.

Early Sunday morning, drinking coffee in bed as the gray morning light revealed the outline of the trees and pasture outside my window, I read the Times on my iPad as usual and came across an article titled “What makes people charismatic and how you can be too”.

The article claims that charisma can be learned and cultivated, and that thought resonated with me as I think often about how we as physicians have roles to fill in the stories of diseases and transitions in our patients lives. I try to be the kind of doctor each patient needs as I walk into each exam room.

The article mentions three pillars of charisma: Presence, Power and Warmth.

As I think of my current third guiding light in addition to my medical journals and the New York Times, my DVD collection of the Marcus Welby, M.D. shows, which is shorthand for his character and all the other role models I carry mental images and video clips of, Charisma is definitely something we need to consider and cultivate in our careers.

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Are Radiologists Prepared for The Future?

By ALEX LOGSDON, MD

Leave your bias aside and take a look into the healthcare future with me. No, artificial intelligence, augmented intelligence and machine learning will not replace the radiologist. It will allow clinicians to.

The year is 2035 (plus or minus 5 years), the world is waking up after a few years of economic hardship and maybe even some dreaded stagflation. This is an important accelerant to where we are going, economic hardship, because it will destroy most radiology AI startups that have thrived on quantitative easing polices and excessive liquidity of the last decade creating a bubble in this space. When the bubble pops, few small to midsize AI companies will survive but the ones who remain will consolidate and reap the rewards. This will almost certainly be big tech who can purchase assets/algorithms across a wide breadth of radiology and integrate/standardize them better than anyone. When the burst happens some of the best algorithms for pulmonary embolism, stroke, knee MRI, intracranial hemorrhage etc. etc. will become available to consolidate, on the “cheap”.

Hospitals can now purchase AI equipment that is highly effective both in cost and function, and its only getting better for them. It doesn’t make sense to do so now but soon it will. Consolidation in healthcare has led to greater purchasing power from groups and hospitals. The “roads and bridges” that would be needed to connect such systems are being built and deals will soon be struck with GE, Google, IBM etc., powerhouse hundred-billion-dollar companies, that will provide AI cloud-based services. RadPartners is already starting to provide natural language processing and imaging data to partners; that’s right, you speak into the Dictaphone and it is recorded, synced with the image you dictated, processed with everyone else to find all the commonalities in descriptors to eventually replace you. It is like the transcriptionists ghost of the past has come back to haunt us and no one cried for them. Prices will be competitive, and adoption will be fast, much faster than most believe.

Now we have some patients who arrive for imaging, as outpatients, ER visits, inpatients; it does not matter the premise is the same. Ms. Jones has chest pain, elevated d-dimer, history of Lupus anti-coagulant and left femoral DVT. Likely her chart has already been analyzed by a cloud-based AI (merlonintelligence.com/intelligent-screening/) and the probability of her having a PE is high, this is relayed to the clinician (PA, NP, MD, DO) and the study is ordered. She’s sent for a CT angiogram PE protocol imaging study. This is important to understand because there will be no role for the radiologist at this level. The recommendation for imaging will be a machine learning algorithm based off more data and papers than any one radiologist could ever read; and it will be instantaneous and fluid. Correct studies will be recommended and “incorrectly” ordered studies will need justifications without radiologist validation.

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“Thanks for Your Time”: Einstein’s Relativity in the Clinical Encounter

By HANS DUVEFELT, MD

In business literature I have seen the phrase “getting paid for who you are instead of what you do”. This implies that some people bring value because of the depth of their knowledge and their appreciation of all the nuances in their field, the authority with which they render their opinion or because of their ability to influence others.

This is the antithesis of commoditization. Many industries have become less commoditized in this postindustrial era, but not medicine. Who in our culture would say that a car is a car is a car, or that a meal is a meal is a meal?

The differences between services with the same CPT code for the same ICD-10 code aren’t, hopefully, quite that vast. But they’re also not always the same or of the same value. There is a huge difference between “I don’t know what that spot is, but it looks harmless” and “It’s a dermatofibroma, a harmless clump of scar tissue that, even though it’s not cancerous, sometimes grows back if you remove it, so we leave them alone if they don’t get in your way”.

I always feel a twinge of dissatisfaction when, after a visit, a patient says “Thanks for your time”. It always makes me wonder, on some level, “did my patient not get anything out of this other than the passage of time, did we not accomplish anything”?

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Zeev Neuwirth Reframes Primary Care…Brilliantly

By AL LEWIS

I would urge THCB-ers to read Reframing Healthcare by Dr. Zeev Neuwirth. While much of the territory he covers will be familiar to those of us with an interest in healthcare reform (meaning just about everyone reading this blog), Chapter 5 breaks new ground in the field of primary care.

Primary care is perhaps the sorest spot in healthcare, the sorest of industries. Primary care providers (PCPs) are underpaid, dissatisfied, and in short supply. (The supply issue could be solved in part if employers didn’t pay employees bonuses to get useless annual checkups or fine them if they don’t, of course.) 

They are also expected to stay up to date on a myriad of topics, but lack the time in which to do that and typically don’t get compensated for it. Plus, there are a million other “asks” that have nothing to do with seeing actual patients.

For instance, I’ve gone back and forth three times with my PCP as she tries to get Optum to cover 60 5-milligram zolpidems (Ambien) instead of 30 10-milligram pills. (I already cut the 5 mg. pills in half. Not fair or good medicine to ask patients to try to slice those tiny 10 mg pills into quarters. And not sure why Optum would incentivize patients to take more of this habit-forming medicine instead of less.)

This can’t be fun for her. No wonder PCPs burn out and leave the practice faster than other specialties. What some of my physician colleagues call the “joy of practice” is simply not there.

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A Patient in the Lobby Refuses to Leave: Medical Emergency, Unhappy Customer or Active Shooter?

By HANS DUVEFELT, MD

The receptionist interrupted me in the middle of my dictation.

“There’s a woman and her husband at the front desk. She’s already been seen by Dr. Kim for chest pain, but refuses to leave and her husband seems really agitated. They’re demanding to speak with you.”

I didn’t take the time to look up the woman’s chart. This could be a medical emergency, I figured. Something may have developed in just the last few minutes.

I hurried down the hall and unlocked the door to the lobby. I had already noticed the man and the woman standing at the glassed-in reception desk.

“I’m Dr. Duvefelt, can I help you?” I began, one hand on the still partway open door behind me.

The husband did the talking.

“My wife just saw Dr. Kim for chest pain and he thought it was nothing. He didn’t have any of her old records, so how could he know?”

While I quickly considered my response, knowing that Dr. Kim is a very thorough and conscientious physician, the man continued:

“Can we get out of here, and step inside for some privacy?”

My mind raced. This was either a medical emergency or an unhappy customer situation. We had the door locks installed not long ago on the advice of the police and many other sources of guidance for clinics like ours. It was a decision made by our Board of Directors. In this age of school, workplace and church shootings, everyone is preparing for such scenarios. We are always reminded not to bring people inside the “secure” areas of our clinics who don’t have an appointment or a true medical emergency.

I figured I had to find out more about this woman’s chest pain in order to make my decision whether to let her inside again; after all, she had just been evaluated.

“Ma’am, are you having chest pain right now?” I asked.

“A little”, she answered.

“How long have you had it?” I probed.

“A couple of years now.”

“And you just saw Dr. Kim?”

“Yes, and he said my EKG looked okay, but he didn’t bother to ask me about you heart valve operation three years ago in, Boston. He just said ’we’ll get those records’, and he told me I was okay today.”

The husband broke in, “It’s the same everywhere we go, everybody just says it’s not a heart attack, but we need more answers than that. we know what it isn’t, but we need to know what it is!” He added, again, “can’t we go inside for some privacy?”

“Have you been seen elsewhere for the same thing?” I said without answering the request.

“Yes, at the emergency room in Concord, New Hampshire when we lived there…”

“Did Dr. Kim have you sign a records release form so we can get the records from Boston and New Hampshire?” I asked.

“Yes”, the woman answered.

“Then that’s all we can do today,” I said. “I hear you telling me this is an ongoing problem, you’ve already been assessed today and Dr. Kim told you that you’re safe today and we’ve requested your old records. That’s what needs to happen.”

“You mean you’re not going to help us today?”

“You’ve seen Dr.Kim, your records will get here, I don’t know what more we can do for you today.”

“You’ll hear about this”, the husband said as they stormed out. Another man in the lobby introduced himself to them and said “I’ll be your witness.”

I closed the self-locking door and wished I had somehow been more skilled and more diplomatic, and I wished the world wasn’t the way it has become in just a few years, with more concern for bolted doors, gun violence and mass shootings than simple customer relations.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

The ABCs of Beginning a Clinical Encounter

By HANS DUVEFELT, MD

You’re running late and many things didn’t go right today. You knock on the door and enter the exam room with an apology. If you’re like me, you have a few papers and an iPad or a laptop in your hand. You sit down and open the patient’s chart in your device or perhaps on the big desktop, eyes not exactly locked on the patient.

Only after getting to where you need to be in the computer do you really look the patient in the eyes. Your body language has been one of hurry and distraction. Now you try to repair the damage of that, so you try to show you’re settling down now, at least for a few moments. You might sigh, move your arms in a gesture of relaxation and say something to get the history taking underway.

So far, you’re failing. I do that often, too.

Here’s what we all know we need to do, but often don’t; we should follow these ABCs:

A – Attention:

Clear your mind. It doesn’t matter what happened in the other room with the other patient, or on the phone with the insurance company or the smug specialist or ER doc who pointed out the diagnosis you missed. Open the door (I always knock first) and immediately look at the patient. Make eye contact and observe them. Pay attention to how they look, what they are signaling. The computer can wait; a few moments of focused attention will usually save you time in the end. After all, red or teary eyes, a leg cast, a big bruise or change in grooming can make the visit go in a direction you wouldn’t have expected from he listed chief complaint. How many times have we heard a patient comment about another doctor: He didn’t pay attention to me. Do we always do that ourselves if we’re rushed or preoccupied?

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The Folly of Self Referral

By HANS DUVEFELT, MD

A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.

This “system” often doesn’t work, because of the way medical specialties are divided up.

If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does ERCPs, and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from an ovarian cancer, best treated by a GYN-oncology surgeon, which anywhere in Maine means a drive down to Portland.

The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and another unrelated operation for a fracture in Bangor a few years ago. Then, after a non surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for EMG testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.

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A Millennial Doctor’s Experience with Industrial Medicine

By TALAL HILAL, MD

A survey of 200 physicians under the age of 35 showed that 56% reported unhappiness with the current state of medicine. That number didn’t seem surprising to me at first. I was not particularly “happy” at the time of reading this survey either.

I’ve aspired to become an oncologist for as long as I can remember. In oncology, despite my inability to cure, I can always try to heal. I form connections with patients and their families as they embark on a journey that is quite often their last. I learn from my patients as much as, and at times more than, they learn from me.

But all of this is overshadowed by a sense of heaviness that I frequently encounter as I enter the clinic room. That sense of heaviness hits when a patient tells me of the time when they were placed on a “brief hold” for more than half an hour in order to reach someone to get a prescription refilled or reschedule an appointment. Or when their insurance refused to cover the drug that I had prescribed to them. It is when I hear that clinic visits or treatments are not scheduled due to insurance authorization delays. Or when I’m asked about the cost of drugs and end up having to explain how nobody really knows.

By the time I hear these stories, the “allotted time” for the clinic visit is coming to an end. The emotional burden and physical symptoms of my patient’s cancer diagnosis or chemotherapy side effects often not adequately addressed.

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