Tag: primary care

Letting the Data Flow, Part One

Making clinical data liquid permeated a series of events I attended last week during Health Innovation Week in San Francisco.  Monday and Tuesday found me at the HIE/REC conference. Wednesday was HealthCamp at Kaiser-Permanente’s Garfield Research Center (KP was extremely gracious in hosting this event and the opportunity to get a tour of the facilities prior to event kick-off was great). The week concluded with the annual and well-orchestrated Health 2.0 conference.

This first post will focus on the HIE/REC event as it was quite distinct from the other events: smaller audience, more staid, dominated by government officials and tied at the hip, for good and bad, to the existing healthcare system infrastructure.

The HIE/REC conference was an odd event with attendance hovering around 200 or so attendees.  The event was focused almost entirely on what the States are doing with the federal funds coming their way to establish Regional Extension Centers (RECs) whose main objective is to get priority primary care physicians (PPCPs) to adopt and meaningfully use a certified EHR. Now, having been to this event and heard many of the State REC initiatives that are now underway via this program, sad to say that my original opinion has not changed. Rather than picking preferred EHRs and assisting with deployment, these RECs may be better off just helping to these PPCPs understand exactly what the HITECH Act is, what are their options, what questions to ask of a vendor or service provider and leave it to EHR consultants and vendors to take it from there.

Continue reading…

What is a Patient?

What is a patient?  What do they do?  What’s their role in the doctor’s office?  Are they chassis on a conveyor belt?  Are they puzzles for doctors to solve?  Are they diseases?  Are they demographics?  Are they a repository for applied science?

Or are they consumers?  Are they paying customers?  Are they the ones in charge?  Are they employing physicians for their own needs?

It depends.  It depends on the situation.  It depends on perspective.

Some physicians are very offended when the “consumer” and “customer” labels are applied to patients.  They see this as the industrialization of healthcare.  We are no longer professionals, we are made into “providers” – a sort of smart vending-machine made out of flesh.

Continue reading…

Sickening People


I found the discussion around my recent post about treating colds very interesting.  Sick people come to the office to find out how sick they are.  Most people don’t want to be sick, and when they are sick they want doctors to make them better.

Most people.

Some people want to be sick, and some doctors want to make people sick.  I am not talking about hypochondriacs – people who worry that they may have disease and become fixated on being sick.  I am not talking about malingerers – people who pretend to be sick so they can get medications.  I am talking about the slippery slope of defining disease.

“I lost my job and have felt depressed ever since.”

“My son won’t obey me.”

“I’m just tired and have no motivation.”

“My daughter’s having trouble in school.”

The definition of disease versus normal has become a big issue recently.  A recent study found that over 50% of Americans are taking regular medications.  In the eye of the hurricane of this controversy is the DSM-5, the new manual for the definition of mental illness.  John Gever, of MedPage Today explained in a recent article on KevinMD that the criteria seem, in the eyes of many, to shrink the definition of a “normal” person.  The motivation to put a label on normal people, he explains, has various motivating forces:

It’s true that drug companies often do little to discourage off-label use of psychiatric drugs and sometimes encourage it. It’s also true that many doctors throw medications at patients who might do better with other treatments or no treatments. (That’s true for many somatic conditions too, let’s not forget.)Continue reading…

Primary Care is Not a Panacea: It Takes a Team


The emphasis on primary care as the “key” to lifting the quality of U.S. healthcare may be exaggerated according to a report, released today, by Dartmouth’s Institute for Health Policy & Clinical Practice.

“Primary care forms the bedrock of a well-functioning, effective health care system,” the researchers observe. But– and this is an important caveat- “simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage, may not be enough to improve the quality of care or lead to better outcomes.”

Wait a minute. In past reports, didn’t Dartmouth’s researchers tell us that patients fare better if they see fewer specialists and more internists?

No. Dartmouth’s earlier studies have shown that when patients see more specialists, care is more aggressive and more expensive, but, on average, outcomes are no better—and sometimes they are worse. This, however, doesn’t mean that primary care, by itself, ensures better care, even if a patient sees her PCP on a regular basis.

As the report points out: “Primary care is most effective when it is embedded in a high-functioning system, where care is coordinated, where physicians communicate with one another about their patients, and where feedback is available about performance that allows physicians and local hospitals to continually improve.”

Policy should “focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals,” says Dr. David C. Goodman, lead author and co-principal investigator for the Dartmouth Atlas Project.

Continue reading…

To Med Students Considering Primary Care


Dear Student:

Thank you for your consideration of my profession for your career. I am a primary care physician and have practiced for the past 16 years in a privately-owned practice. (At some point I intend to stop practicing and start doing the real thing. It amazes me at how many patients let me practice on them.)

Anyhow, I thought I’d give you some advice as you go through what is perhaps your biggest decision regarding your career. Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices. It is the final choice that is, well, final. What are you going to do with your life? ”Being a doctor” covers so much range, that it really has little meaning. Dr. Oz is a doctor, and he has a very different life from mine (for one, he’s not the target of Oprah’s contempt like I am – but that’s a whole other story).

Here are the things to consider when thinking about primary care:

1. Do you like talking to people who are not like you?

Primary care doctors spend time with humans – normal humans. This is both good and bad, as you see all sides of people, the good, bad , crazy, annoying, funny, and vulnerable sides. If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don’t do it. The single most important thing I have with my patients that most non-pcp’s don’t have is relationship. I see people over their lifetime, and that gives me a unique perspective.

Continue reading…

Why I Don’t Accept E-mail From Patients

Dr. Wes (a cardiology blogger who all should read) wrote a very compelling post about technology and the bondage it can create for doctors.:

The devaluation of doctors’ time continues unabated.

As we move into our new era of health care delivery with millions more needing physician time (and other health care provider’s time, for that matter) – we’re seeing a powerful force emerge – a subtle marketing of limitless physician availability facilitated by the advance of the electronic medical record, social media, and smart phones.

Doctors, you see, must be always present, always available, always giving

This sounds like dire words, but the degree to which it has resonated around the web among doctors is telling.  He continues:

Increasingly the question becomes – if we choose future doctors on their willingness to sacrifice for others without expectation of appropriate boundaries and compensation – will we be drawing from the same pool of people as the ones who will make the best technically-skilled clinicians? What type of person will enter medicine if they know that their personal life will always take second place to patient care?

Dr. Brian V (long last name, but another one who you all should read) adds his voice to this:Continue reading…

“I Like (Political) Science and I Want to Help People”

I thought I was an oddball in college. I’ve only recently learned that I was avant-garde.

Right before beginning college in 1975, I decided I wanted to be a doctor. Being the first-born son – with decent SATs – of an upwardly mobile Long Island Jewish family, I had relatively little choice in the matter. Notwithstanding this predestiny, I felt confident that medicine was a good fit for my interests and skills.

But on my med school interviews four years later, I stumbled when the time came to answer the ubiquitous, “Why do you want to be a doctor?” question. The correct (but hackneyed) response, of course, is “I like science and I want to help people.” You’ll be comforted to know that I had no problem with the helping people part. It was the science thing that threw me for a loop.

It wasn’t that I didn’t like science, mind you. I found biology interesting, and organic chem was kind of cool, in the same way that Scrabble is. But I barely tolerated Chem 101, and disliked physics.Continue reading…

What if All Americans Had at Least Catastrophic Health Care Coverage?

Picture 9I really dislike the term healthcare reform. I think our system needs to be changed not reformed. I assume that I am not the only person who suspects that the recent health care reform act is not going to be the final solution for America’shealth care problems. The cost of healthcare is not really addressed at all, and even if it works better than expected some Americans will not have even catastrophic health carecoverage.

This post is really just my first shot at suggesting a way I think makes sense to address the problem of the large number of uninsured people in America, while at the same time leaving lots of choice and personal responsibility that seems to be needed and a part of the American culture. I am certain that I have not thought through all of the gritty details, and really don’t profess to have the talent or knowledge to write legislation, but I think this basic tenant might be a starting point.First my assumptions:Continue reading…

A Permanent “Doc-Fix” Remains Elusive


For now, all those physicians who threatened to make a mass exodus from Medicare can take a breather. Last week, the House voted to once again delay the mandated 21% cut in physician fees by another six months; thereby ensuring that the fight over the sustainable growth rate (SGR) will be resurrected sometime around Thanksgiving.

So far, Congress has kicked the SGR can down the road 10 times since 2003—four times just this year alone. The targets have long been considered unobtainable and the mandated physician payment cuts are opposed in Congress by Democrats as well as Republicans and supported by nearly no one. The level of anxiety among doctors continues to escalate every time the issue is raised—even though the cuts have never gone into effect for more than a couple of weeks. Why not get rid of this devilishly frustrating formula once and for all?

The short answer is that getting rid of the SGR—even though it has never led to any savings in Medicare—is just too expensive on paper. The Congressional Budget Office establishes a “baseline” projection of future spending and revenue that takes into account that all current laws will be enforced. Legislation that eliminates the SGR targets would then be scored by the CBO as adding to the deficit—to the tune of $276 billion between 2011 and 2020 even if Medicare payment rates to doctors were frozen at 2009 levels. In the current economic climate, it will be very hard to get enough members of Congress to agree to a permanent “doc fix” that eliminates the SGR targets without also finding a way to pay for it.

Continue reading…

Are Doctors Really Boycotting Medicare?

Naomi FreundlichAs Congress once again wrestles with “the doctor fix”—yet another postponement of the 21% cut in Medicare reimbursement that went into effect this month—the media has been swirling with stories warning of a mass exodus of doctors out of the federal program. The reason: In 2008 Medicare paid doctors 78% of what they get from private insurers; with the 21% cut they fear that their income will drop even lower.

The reports hit their peak late last week—USA Today wrote that “[t]he number of doctors refusing new Medicare patients because of low government payment rates is setting a new high,” while the American Medical Association announced that 31% of primary care doctors are restricting the number of Medicare patients they take. In a recent survey, the American Academy of Family Physicians found that 13% of respondents didn’t participate in Medicare last year, up from 8% in 2008 and 6% in 2004. Chic Older, executive director of the Arizona Medical Association told the Seattle Times ; “If the 21 percent cut goes into effect, we’re going to have a very severe problem in the state of Arizona.”

The question is: Will Medicare beneficiaries really face a shortage of providers and restrictions on their access to care? Or is this a scare tactic being used for political reasons?

First off, all this is happening against the backdrop of a major political fight in Congress over how much the government should invest in economic recovery. On Friday, the Senate passed a “doc fix” that would postpone the 21% cut in Medicare payments for another six months and provides a 2% increase in reimbursement instead. Unfortunately for doctors—and the seniors they count as patients—Nancy Pelosi has signaled that she may not be willing to settle for such a short-term solution. According to Politico, Pelosi was “caught off guard last week when Reid suddenly opted to pull the Medicare issue out of a jobs and economic relief bill on which the two leaders have been working for months.” For more background on the long history of the “sustainable growth rate” formula that mandates the Medicare cuts (enacted in 1997 by a Republican administration) and the unlikelihood of it ever being instituted long-term, see Maggie’s recent post here.Continue reading…