Sunday, March 25, 2012
Saturday, October 9, 2010
Sunday, September 19, 2010
I wanted to talk today about this because I see so many of my patients and their families struggle through these difficult times, often making it worse; adding insult to injury.
Often I see patients and/or their family fall into what I like to call the “Why Me” trap. It goes something like this:
Consider for example, a 45 year old mother of 3 being diagnosed with breast cancer. After the initial shock wears off and some of the preliminary testing is done it’s not unusual for patients to dwell on the situation. And often times, obsess. They begin, in earnest, asking Why Me? I lived a good clean life why did I get cancer? What about so and so that drinks, smokes or is a mean person? I have kids that depend on me, why me? I go to church regularly, why me? No one in my family got cancer, why me?
Families do the same thing. How can my son/daughter have cancer? It’s not fair? I wish I could trade places with him/her. How could my sister or brother have cancer? How could my mom/dad have cancer? Why? They’re good people. They didn’t do anything wrong. And on and on.
Some go so far as to curse religion and God. I had a patient that swore off church 25 years prior after his daughter was born mentally challenged. He wallowed in Why Me land. He liked to joke that the only church he would attend from now on was St. Mattress with Sr. Sheet and Fr. Pillow.
It is frustrating as a doctor to watch the patients and their families literally torture themselves. I know it’s perfectly natural to ask these questions but it needs to be controlled. Go ahead, ask these questions, get it out of your system but only for a short while then move on.
The bottom line is that the endless conundrum of Why Me serves no useful purpose. Literally, no good will come of it unless there’s closure. If you ask it for a short while and conclude correctly, there really is no answer then it was cathartic, good. But, if like so many, you continue to beat yourself up over it all you really do is end up ruining what precious time you have.
Think about that. You or your loved one has just been faced with major mortality issues; they’re staring at the real possibility of a life that may be much shorter/differerent than they had planned. And what do they do? They waist time worrying about why it happened. Asking questions that can’t be answered. I’m not saying you shouldn’t pursue therapy; or ask if there are ways to improve things, prevent things in the future. I’m talking about the endless barrage of unanswerable questions I outlined earlier.
Acceptance, that’s what is needed. The truth is that cancer and disease don’t discriminate. They’re the result of a complex interplay of genetics and environment. The sooner you accept that fact, the sooner you can move on.
Therefore, in conclusion, my advice is to punch up the famous country music song, “Live Like You Were Dying” on your ipod and blow out the speakers.
Do like he says: live each and every minute to the fullest; give thanks for every beautiful day.
Saturday, July 10, 2010
It strikes fear in the hearts of doctors across the country; it is not the deadly Ebola virus or a new strain of cancer, but its malignancy is equally apparent. It is the dreaded “PA”, which is insurance-speak for “prior authorization” and it seems that no matter which way we turn it appears, standing between our patients and the care they need.
Tuesday, May 18, 2010
He turned down the radio and called out loudly, “Who is it?”
“Kenny. Kenny Sparks.”
“Be right there.”
Mark tossed the form aside with a feeling of relief. Not relief that his work was done but the relief of knowing that the evening’s monotony would be interrupted. He undid the lock and opened to door to find a young Kenny Spears grinning back at him.
“Well look at you. You’re the spitting image of your old man, you know that?”
“Everyone says that.”
“The last time I saw you, you were yeah high.” Mark held his hand about 3 feet off the ground. “Well come on in.” He paused a moment then commented, “The bounty you seek my good boy is over here.” He pointed to a late model refrigerator in the corner then walked over to it.
“Never had any trouble with it. It’s only about 5 years old. Your dad says you need it for the frat house?
“Sure do. We can always use an extra refrigerator if you know what I mean.”
“Do I ever. Live it up son. One day you’re going to wake up with a houseful of kids and a full time job.
“That’s what everyone keeps telling me.”
“Well it’s true.” Mark went around to the side table and motioned for Kenny to grab the other end. “Here help me move this so we can get at the fridge.”
They moved the table up and over into the hall, then loaded the fridge onto a dolly. They then wheeled it outside and hoisted it into the back of the truck Kenny came over in.
Slamming the tailgate Mark said, “Well that ought to do it. Want some water or something?”
They went inside and moved the table back. Mark poured out two glasses of water and sat down across from Kenny.
“Can I interest you in anything else around this place? A table, some chairs? How about a gently used microwave?”
“Really? You’re just gonna just give it all away?”
“Yep. Like I told your dad. I’m closing the whole place down. Don’t want any of it. Take what you want, seriously.”
“Well since you’re asking I’m sure the guys could find a use for this stuff. So why are you closing down? I never heard anyone in your line of work going out of business.”
“A lot of people say that. Truth is I never thought it could happen myself. When I went into this business it was different. There was respect, prestige and a code of honor. You paid your dues and had a job for life, to save lives. Sure it was always a demanding job but at the end of the day you went home gratified you helped people and put in an honest day’s work. And it used to be a good living.”
“And that’s not true anymore?”
“Nope. The bureaucrats have taken over. All they care about is whether or not you file the proper forms. Then they cut the pay down so much I can barely cover my expenses. By 6 in the evening I’ve barely covered my overhead and still have two hours worth of paperwork to justify my keep. “
“So what are you gonna do?”
“Don’t know. Thankfully my kids are done with college. I always thought I’d grow old here helping people out and seeing them through their ups and downs. But like I said no one cares about that anymore. “
“It’s still hard for me to believe. When I was a little kid I thought Doctors had it all.”
“So did I my friend. So did I.”
Mark took one long last swig of his water then stood up. “Well young man, let’s load up the rest of this stuff. Whatever you don’t use feel free pawn on EBAY for some beer money. I’ve got to get back to my paperwork so I can hopefully see my wife before she falls asleep.
“Thanks, I appreciate it.”
“No problem. I don’t envy you young guys. I don’t know what to make of the future for you. It’s a different world...”
Wednesday, April 7, 2010
Although my research involves an unenviable sample size of one physician (me), I think it sheds light on some of the critical issues facing the majority of PCP’s. The simple question I set out to explore was: Do I spend more of my time working with paper than with patients?
The methodology was also straight forward – I documented my daily tasks during an average day in the office, including time spent caring for patients and administrative work.
Data collection kicked off at 10:00 am when I arrived at my office after early morning rounds with my patients in the hospital. (Interestingly, I am one of only four physicians in our community, population ~45,000, that still chooses to admit and care for my own patients rather than transfer their care to a hospitalist; a topic for another day.) Data collection ended at 6:00 pm when the final paper of the day was pushed.
The raw data are somewhat interesting but tell a typical tale … patients outnumber hours in the office by roughly 4 to 1; if signatures equated to money I would be rich; and sometimes doctors fill out forms and call people on their own! Here are the numbers for your consideration:
Total hrs in office (10-6): 8
Total patients seen: 18
Number of times I signed my name: 77
Number of prescriptions (new and refills): 36
Forms completed: 7
Required telephone calls: 3
Minutes doing paper work during patient hours: 75
Minutes doing paper work during non-patient hours: 170
Total minutes seeing patients during patient hrs: 225
Although interesting in their untransformed state, when you begin parsing the numbers, they begin to tell a much more interesting story. Using advanced statistical techniques that I learned in 4th grade – addition, subtraction, and division – it appears that I spent more time with my pen and computer then with patients.
I spent eight hours at the office, which I can confirm is typical, and 47%of that time was devoted to patient care (225 min/480 min). Averaged across the 18 patients, that works out to ~12.5 minutes with each patient (range 7 to 45 min). This is right in line with the national estimates that range from 10 to 18 minutes for patient visits and 55% of total office time devoted to patient care.1-2 Yeah, I’m average! … or as scholarly-types like to say, I am consistent with my peer group.
Despite uniformity with my cohort in these categories, I wonder whether I’m on the right track if I am devoting only half of my time to patient care? In other words, if 100% efficiency is spending every minute with patients, is 50% efficiency good enough? Although it seems unreasonable to expect 100% efficiency since few systems, biological or mechanical, come close to 100% efficiency. For example, the diesel engine, which is famous for its efficiency, only approaches 50%1, so should we expect healthcare to do any better? Am I better than a diesel?
Intuitively we all know reaching 100% efficiency is beyond utopian and probably defies some law of thermodynamics. However, important questions remain: Where does rest of the time go? How productive is that time spent? How does it impact patients?
In my little study the answer to the first question is fairly simple: 35% of my time was spent doing paperwork during non-patient hours (4-6 PM), and another 15% was devoted to paperwork during patient hours. So 50% of my day – actually 51% when decimals are accounted for – went to filling out paperwork and administrative tasks, which answers the primary study question: Indeed, I spend more time pushing papers than seeing patients.
Obviously, if none of these administrative tasks were completed, I could not bring in the revenue required to pay myself, the staff, malpractice insurance or the overhead, so some of this effort is necessary. But it seems counter-intuitive that after jamming so much potentially useful information into my brain for so many years that half of my working hours should be used signing my name and ordering batteries for a scooter!
This split – 50% patients: 50% paperwork – is what frustrates so many of us. Like my colleagues, I became a doctor to care for patients and understand that documentation and paperwork are necessary but wonder if a more productive split such as 80:20 in favor of patient care (of course) couldn’t be achieved?
I hope you can understand the frustrations PCP’s are feeling now. We’re not a group prone to complaining; we are trained to endure and we do it gladly for patients, but for the sake of paper and the insurers lurking behind them, never. I have not even begun to enumerate the endless piles of paper my two staff members must read, label, fax, shred, trash, shovel, and curse on a daily basis – a moment of silence for all the trees that have sacrificed for this country, oh, I mean insurer paperwork!
The conclusions of my study are quite clear and simple, time allocation in primary care is loathsome, and those that suffer the most from the system are patients. Every 12 minutes spent with paperwork is another patient not seen or an important health question not answered.
The question is what is the solution? One place we-the-PCP’s of the country would start is lowering the administrative hurdles and barriers to getting the care our patients need. Never again should there be days that include spending 30 minutes on hold to simply speak to a human regarding a prior authorization for one patient. Never again should the fax machine that fields requests to change patients’ medicines require more reams of paper than the copy machine used for patient charts. Never again shall someone without a medical degree put up their proverbial hand through the phone or on paper and deny a patient the care they need because their manual told them so. And for the record I do not believe a single payer system or capitation would change the 50:50 split one iota. In fact, the forms Medicare requires are some of the most cumbersome.
Building checks on the paperwork required by insurers would dramatically improve the efficiency of my care and, most likely, primary care physicians across the country (since I’m such a good representation of my cohort). It’s time to re-focus our attention on taking the ‘honorary’ medical degree off insurance company walls.
Sunday, March 21, 2010
A survey going around this week projected that if President Obama’s Health Care Reform passed 46% of primary care physicians would quit. Several sites stated that the survey was reprinted in the New England Journal of Medicine though when I searched their site I’m unable to find it. I did find a survery that quotes a figure closer to 33%.
Regardless of the exact number I personally believe a large block of PCPs really would quit.
No, it’s not likely going to happen in the short run. Obviously a lot of hard work and training goes into becoming a doctor and finding a career with similar income levels is going to take some doing. So, again, in the short run most won’t quit. But what about 2, 3 or even 5 years out? Then I would say yes.
First off you have those that could retire. The 50-55+ group. Many of them could simply retire or branch off into another field. Many physicians in this group have older children that are done with college and have left home. Many have made wise investments. Therefore, I’d venture to guess many of them might simply decide it’s not worth it to practice anymore and up and quit.
Secondly, many will probably quickly look for a change such as an administrative position, an academic position or becoming a hospitalist. I’ve personally witnessed this already. There were four of us that were friends in medical school that went into primary care. Of those four I’m the only one left; albeit hanging by a thread. One went into ER and the other two are hospitalists.
Finally, many can and will find new career paths. I’ll never forget the first talent show I went to at my medical school in Cincinnati Ohio. Anyway, every year we had a talent show put on by the students. I staggered out of the auditorium. The amount of talent many of my classmates exhibited just blew me away. I remember thinking had they not wanted to be doctors they surely would have been successful in other areas. Just to name a few, there was the award winning violinist that graduated from West Point, an opera singer and a professional illusionist. This last guy had paid his way by working gigs now and then. Outside of this we had a guy in our class that quit pro-football, a pharmacist and another classmate that was a model. We had numerous engineers. These are intelligent, motivated people with means. If the rules change to the point it no longer makes sense to practice medicine, they can and will change.
This is not new or unique to primary care. I remember commenting to my wife about this very topic, way back 11 years ago in my first year of practice. I had been sitting in the doctor’s lounge at the hospital doing paperwork and was just sort of randomly listening to conversations. I remember going home and telling her that I’d never seen a profession that took so long to achieve your position yet so many were trying to get out.
Don't think it’s just about money. Quality of life has tanked also. Doctors have seen their autonomy and prestige systematically stripped away. Endless forms now need to be filled out for everything from a prior authorization for a medicine to a new set of batteries for a scooter. Rules regarding documentation keep getting ratcheted up and enforced. Medicare uses ex-IRS auditors to look over physician charts. Some insurance companies, under the rouge of increasing quality, rank physicians using dubious means. Most physicians will tell you they are spending more and more time doing paperwork and less seeing patients. EMR’s and e-prescribing are great for tracking diseases and reducing errors but they are expensive and time consuming.
And what about the money? Incomes keep going down. Medicare again has frozen reimbursement, which is in all actuality a pay cut when you factor in inflation and the rising costs to do business. And don’t forget the staggering debt loads. I’ve seen statistics that greater than ten percent of the medical students graduating from a state school today are over two hundred thousand dollars in debt. If this is paid back over 10-15 years it will typically balloon to 1.5 times the principal or three hundred thousand dollars. Do the math, that’s $1667 a month for fifteen years or $2500 a month for ten. This doesn’t include private schools or undergraduate debt.
The final straw will be on the supply side. The percentage of medical students going into primary care has already plummeted. This will only get worse and I suspect will spill over into the specialties.Medicine will cease to attract the best and brightest students. You figure out the rest