It’s not what you do, it’s why you do it.
In the past few months we’ve successfully renamed and relocated my practice, Innova Primary Care. We have a space that is 8,750 square feet larger than our previous space and the ability to use that space to best suite our guests’ needs. It has not been without challenges of course but we did it!!!
After a few weeks in our space, a patient in our lobby was upset about a balance due to their insurance deductible. This patient then claimed to our other guests waiting in the lobby that now we were "charging more" to pay for our new, nice building. Besides this being grossly inaccurate since medicine is not a free market and there is a fixed fee-for-service price (which by the way, is the whole problem with healthcare), it was also fascinating that this was such an unrealistic idea in her mind. People are okay with paying more money for better service and ambiance at restaurants – why not their healthcare? I’ve long realized I can’t control what others will say about me. However, it did remind me how important it is to continue to share the “why” of what we are doing at Innova.
I believe it IS possible to have exceptional quality healthcare in our country at an affordable cost.
I believe we CAN do this in Alabama.
I believe it will take people coming together who also believe this with their mind, body, and heart to get there.
I believe I am here to help restore this world closer to the creation that was intended for us as God’s children.
I believe healthcare is where I have been guided to bring renewal and restoration.
Hence the new name for our practice – Innova Primary Care. Innova is the Latin word for “renew.” As in Romans 12:2, “Do not be confirmed to the patterns of this world, but be transformed by the renewing of your mind, so that you may prove what the will of God is that which is good and acceptable and perfect.”
These beliefs are what fuel me every day. I am a burned out physician mom that does not have to do this job. BUT, I do! I do because I believe in what I am doing. My husband and I do this together for our children to show them that we are all here for a purpose. I do this for my patients whom I love.
I’ve learned over and over that those who do not share your beliefs will draw you further from your goals. So at Innova, just know that my team and I are here every day because we believe in continually striving to re-think, re-imagine and re-invent healthcare in our state. It needs to be renewed and we believe it can be. We are Innova and we are here to make your world better.
A few Friday's ago was an average day in my office. We had 60 guests come through our door for medical services. 60 guests whose ages ranged from 6 years old to 85 years old on that particular day. We took care of their needs ranging from ear infections, high blood pressure, cholesterol and diabetes management, infected wounds, anxiety, depression, pain and performed annual physicals. We established 8 new patients into our practice. Over lunch my staff took a two hour break to do our monthly volunteer work at Lincoln Village. We communicated with over 35 patients who had called in that day with questions for us. We completed multiple referrals for guests needing specialists' care. I went to the hospital for a family meeting with a patient's family. We also met with the architect for our new building currently being designed. Like I said, just an average Friday in our clinic.
Let me explain why this letter was sent to me...
With said Insurer providing plans on the exchange through the Affordable Care Act, they are trying to limit their costs on plans that have proven, as expected, to be too costly. Thus, said Insurer has made an agreement with the laboratory who will give them the best cost for lab services, Quest Diagnostics, and deemed them their "Preferred Laboratory" for certain plans offered through the exchange. And, they have previously mandated that physicians within said Insurer's network can only refer Members (our patients) to the "Preferred Laboratory...,as they may be defined, in the network of providers described in the Member's Benefit Agreement." So, apparently this Insurer's data (which in my experience with this company is on average 12-18 months old) indicates that probably a year ago (I don't know when they are actually referring to because of course it is not included in the letter), patients of mine went to their Oncology clinic to have labs and to Labcorp, which is the lab in our office when they should have gone to Quest.
And the other scenario, where labs were drawn in our office when they should have been drawn at Quest...well, I can tell you what happened there. Not many of our patients know that their insurance plan requires them to use only certain labs. So, within the past year we have spent hours of multiple staff members time setting up our Electronic Medical Record System to notify us at the point of lab order entry which lab you need to go to based on your insurance. We've learned that patients are not usually aware of these details about their plans and we cannot rely on their information. That method tended to result in angry patients calling us about a lab not being covered because "you ordered it wrong." I suspect this letter is from lab orders that occurred before we invested the time into our system to try to help us with this issue, and of course, it's not 100% correct. The sad thing is, our representative for said Insurer is actually aware that we have already gone to great lengths to resolve this within our system yet still I receive a letter from her Manager threatening my termination.
So, I know some of you are thinking there is an easy solution here. Just change the lab in our office to the Preferred Laboratory so none of this will be an issue. Of course, that still doesn't resolve my poor patients who are trying to combine lab draws with their oncologist office who can draw from their port. But even so, we have already tried this! We have tried to have Quest lab integrate with our EMR system so that we can electronically order labs and electronically receive labs back. (Without this integration, patients are sent with a paper order to the lab, blood is drawn and processed and the results are faxed back to us to be added to your electronic chart as a pdf, not as data within our system. This process results in many, many errors that I've seen over and over and thus do not prefer to order labs from a Laboratory that is not integrated.) But we did try, only to find out that Quest refused to integrate with us because our volume with their lab would be too low for it to be worth their cost. Beyond that, for other patients in our practice, Labcorp remains their preferred laboratory.
We continue to look for laboratory options that will work for at least the majority of our patient population and are committed to finding the best option. Why I am really writing is to inform you, as a healthcare consumer, that YOU need to be aware of those little details about your healthcare plan. Please for heaven's sake, don't assume that you can have your labs drawn anywhere, as reasonable as that sounds, because your insurance company is all about limiting your options if it means they can limit their cost. When doctors and patients don't work together, we have no chance of working together with your insurance company. I need you to be informed healthcare consumers! As you can see, not doing so, may result in your doctor being threatened by said Insurer.
There are two ways that doctors react to receiving threats like this. 1) Ignore it, don't change anything and angrily throw the letter in the trash can. 2) Work tirelessly to try to continue to work with said Insurer for the benefit of their patients who just like all of us, need quality medical care. There are not many that fall into option #2. And let me tell you, for those of us that do fall into option #2, it is wearisome and demoralizing because still, despite the amazing care we give to our patients everyday and the personal investment of our lives to do so, we still end Fridays receiving letters like this.
“…the reason to move on really comes down to one word, courage. The courage to move on, do something new that betters all of us, and our team has tremendous courage.” – Phil Schiller
Listening to the Apple iPhone media event yesterday I was struck by Phil’s comment as our clinic strives to drive improvement and change for our patients.
In our wonderfully innovative community here in Huntsville, when we see outmoded technologies like fax machines still serving as the dominant method for sending critical health records between clinics and hospitals, it is time to move on.
As we continue to grow and serve, BrookeMD Primary Care will continue to drive innovation and efficiency. Leading innovation always encounters resistance, it always takes courage. Striving to adopt new technologies and move into the 21st century in healthcare seems even harder than eliminating the headphone-jack on an iPhone. Our clinic can’t do it all alone; it takes buy-in across our local healthcare ecosystem.
At BrookeMD we are excited about the changes already here and those yet to come. It is indeed time to do something new that betters all of us, and our team has tremendous courage!
Guest post by David Uptagrafft
As a third year medical student beginning my surgery rotation, I remember sitting in the conference room with the rest of my peers receiving our lists of what surgeons we would be working with during the rotation. For us who knew we weren't going into surgery, there was one rotation that was dreaded; the most difficult, time-consuming surgical rotation - thoracic surgery. This surgeon performed 8-10 surgeries a day in the OR, running multiple OR's at a time. He was the only surgeon in the UAB OR at the time that was allowed to even claim 3-4 Operating Rooms at the same time. He was a world renowned surgeon; very, very good at what he did and very, very aware of how good he was. I look down at my paper handed to me - General Surgery, no problem, Urology, even better, Thoracic Surgery, oh no.
And so began the rotation, getting up by at least 4 AM to begin pre-rounding on our inpatient post-surgical patients, then rounding with the resident, then to the OR's to begin assisting in prepping patients for surgery, scrubbing in and watching and learning from the master in the OR. The day was spent doing open thoracotamy's and lobectomies, removing sections of patient's lungs who had lung cancer, VATS (video assisted thorascopic surgery), cleaning out empyema's (collections of pus and infection within the pleural cavity around the lungs), and removing cavitary lesions of patient's lungs to send off specimens for analysis so we would better know how to treat the patient. Being in the OR with this surgeon was a fascinating experience. He demanded perfection of his team and himself. He came across as the most arrogant man in the universe. In the OR, he listened to certain albums and playlists he had created. His surgeries seemed to be actually timed to those playlists. If he got to a certain song and was not to a certain point in the surgery, we all knew things were off- recoverable, just off. When things were going great in the OR, he was performing surgery by an incredible muscle memory and proceeding with clockwork, and then he would make up other lyrics to the songs pertinent to the surgery he was performing. The one I most remember was Chasing Cars by Snow Patrol.
"We'll do it all
On our own
We don't need
I remember thinking how perfect this song was for this god-like surgeon dictating the entire teams of 3 Operating Rooms and acting like he was doing it all on his own.
He came up with nick names for everyone in the OR - mine was Katarina because he thought Uptagrafft was such a weird name and I should have been a German ice skater.
After at least 8 hours in the OR, it was time to round on the patients we had pre-rounded on that morning to present those patients to Dr. Cerfolio for him to evaluate how they were recovering. He would change out of his scrubs into a black suit and tie with his Dansko shoes and we would run through the hospital updating him about patients on the way to their rooms before he would go in to see them. It was here that I handed the man his chocolate milk. Everyday, out of the OR, he wanted to be handed a chocolate milk on his way to round on his patients. I don't know when the man ate during the day. I guess he did. But at this point in the day, he wanted his chocolate milk. At the beginning of the rotation, his assistant, I think she was a PA (Physician Assistant) that had been with him for years asked which of the students would get his chocolate milk everyday. We all just stared at her blankly and confused. She didn't offer much explanation except to say it had to happen so I volunteered. So, each day at the end of our OR time, I made a mad-dash to one of the units on the hospital floor stocked with items like jello, Popsicles, juice, apple sauce and chocolate milk that were intended for the patients on the floor and I would grab a chocolate milk and run back down to where we would start rounding and hand it to him as he glided through the halls. He would chug it down in about 2 sips and then toss the empty carton with 100% perfection every time into a trash can as we were passing.
At the time, I thought this was so ridiculous. I mean the whole experience felt surreal and it was almost laughable that this world renowned surgeon demanded his chocolate milk in order to make it through rounding on his patients after a day in the OR.
But looking back on it, I am so thankful to Dr. Cerfolio for this experience. I knew I wasn't going to be a surgeon. But even as a 3rd year non-surgical medical student whom he would never remember, he took minutes out of his day to teach me in and out of the OR. He could make really good use of just a few minutes; I learned more anatomy and surgical technique in that rotation than probably any other. I still learn from that experience today by thinking back on how he demanded peak performance out of himself and his teams. He was the best. What he did all day long was incredible - cutting open people's chests and figuring out ways to do less and less invasive surgery so that his patients would have higher success rates with fewer complications. He is now, I understand, one of the world leaders in performing robotic surgeries and trains other surgeons around the world in using this technology. He was a master of efficiency. I look back on that experience and realize how well he delegated things to others that did not have to be done by himself but allowed him to perform at his absolute peak for the patients whose lives he was saving. The chocolate milk is just one example. And, as ridiculous as it was for me to run through the hospital to get that for him, it would have been more ridiculous for him to go get it for himself. He knew how to use his team to help prepare himself for the upcoming tasks he would take on for his patients.
I think now about that chocolate milk and medicine and what healthcare is becoming. The chocolate milk phenomenon is present in all other medicine specialties too. Not that we are all performing life saving operations daily like he does. But, in healthcare everywhere, more and more is being demanded of physicians who have a finite number of minutes to perform those responsibilities. Regardless of specialty, physicians need to be operating at peak performance. Lives are at stake and peak performance matters. That requires us, as doctors, to utilize a team of people that are working together with a common vision for our patients. It's the opposite of those Snow Patrol song lyrics "We'll do it all, Everything, On our own, We don't need, Anything, Or anyone."
Medical training to be a doctor is highly competitive and highly individual. It is ingrained into us to always have the answers, always be perfect and never need help. Indeed, we are in a sense brainwashed into "trying to do it all, everything, on our own." Then, we are thrown into a world of being responsible for our own patient care and the wise doctors realize it's impossible to continue to try to do it all, everything, on our own. The best doctors, the peak performers, realize that some of the most important people on your team are the ones doing the most menial seeming tasks. The best leaders thank them for it and recognize them for their role in the team achieving the vision. That's lacking in so much of healthcare, so many doctors see themselves as the strong link in their organization and forget about how important the weak links are. Those are the ones that really affect our outcomes, our customer service, our patient satisfaction.
The responsibilities of taking care of all of my patients requires I have a great team that I can delegate things to so that I can maintain peak performance at the tasks that only I can do. Isn't it ironic? What this surgeon really showed me, who seemed to be so full of himself and his own performance, was the critical importance of a team you can count on.
In the time since I learned from Dr. Cerfolio, he has earned his MBA and is traveling the world to train other surgical teams in using robotic technology for thoracic surgeries. He has even written a book called "Super Performing at Work and Home." I will always be grateful for those wonderful and horrendous weeks I spent learning from him.
Preventive Care ≠ eye exams for the blind (Part 2 of How our healthcare system is making doctors even more paternalistic)
Following last week's post, here's the story of Shannon*...a patient who has suffered one of the horrible manifestations of diabetes, blindness. She uses the assistance of a wonderful guide dog whom we love to see each time they enter the office together.
This story is an example of how you cannot expect recommended guidelines for preventive services to be 100% true all the time. Here's a little background. It is recommended that Diabetic patients need to have annual eye exams to screen them for diabetic retinopathy and other ophthalmologic manifestations of diabetes that can lead to blindness. Medicare and insurance companies thus judge a primary care doctor's quality care of diabetic patients in part by making sure that the patient has had their eye exam annually. This is proven to the insurance company by the eye care provider submitting a certain CPT code (Procedure code) on a claim and sending that claim to the insurance company. However, for diabetic patients that have already experienced these complications and are already blind, they are still labeled as having a "gap in care" and thus non-compliant. Of course there is no real penalty for the patient except that they will get phone call after phone call telling them to go get an eye exam. But, their primary care provider is actually penalized for this. I'm telling you this from experience with this exact scenario within my own practice with patients being labeled as "non-compliant" for services that were not necessarily indicated. I've had to tell my own patients that they need to go see a specialist that they don't really need to see, pay a copay they don't really need to pay, spend half a day in a specialists office they don't really need to spend, and have an exam they don't really need in the name of "improving quality of care, reducing costs and improving patient satisfaction."
Shannon stopped having the recommended eye exams several years ago after she lost her sight and there was no longer any treatment available to help her. But, her insurance company doesn't really care about that because they are required to report the compliance of their Diabetic patients with their annual eye exams. They were contacting us and Shannon repeatedly to encourage her to get her annual eye exam to screen her for the complications of Diabetes that could lead to blindness...which she already has. It is not preventive care anymore when you are screening someone for something you already know they have! Despite my efforts to talk at length to the insurance company to explain this, they still mandated it. So Shannon and her guide dog spent half a day and a wasted copay getting her eye exam so that she could be told she was blind and there was nothing they could do.
So here's the thing about the value based payment model of healthcare that is being paid for in large part by third parties (insurance companies and Medicare), not patients; patients are loosing their choice of what medical services they want or don't want and yet are being expected to become more engaged in their own healthcare at the same time. I can understand these third parties having to come up with some way to force improved preventive services being ordered and followed through for our country's population, particularly given our healthcare costs are sky rocketing even while overall health is declining. From a population health management perspective, the guidelines that are published by the US Preventive Services Task Force are rigorously studied by Population Health Experts and they are guidelines for a reason - they help large groups of patients be healthier as a whole for reduced costs as a whole. What I fear is being overlooked is that the implementation of this "improved quality of care" is most dependent on quality doctor-patient relationships where it is decided together what services each individual patient needs. In Shannon's case, this requirement did not improve quality of care, it increased costs both to the patient and the healthcare system and certainly did not improve patient satisfaction - the exact opposite of the intent.
This post is not about patients not needing to follow the important preventive services that their doctor recommends. It is about showing the practical implications for you as an individual patient under our healthcare system. I think it is helpful for individual patients to realize that when a third party is paying for your healthcare with limited funds in a value-based payment model, "individualized medicine" is hard to practice (even though everyday more genetic advances are made that make individualized medicine an inevitable way of the future). I find it ironic that part of becoming a "Patient Centered" healthcare system means finding ways to force patients into having preventive services they may not want and limiting choices of what types of diagnostic testing and treatment options are available all while asking patients to become more and more engaged with their own healthcare. I feel that as I have been seeking to improve how "good" of a doctor I am in Medicare and Private Insurers minds, I've become more of a paternalistic provider than I ever have been.
*Shannon's name has been changed to protect her privacy and her story has been used with her permission.
Non-compliant...sounds like something you don't want your insurance company labeling you as, right? I find this term so interesting because today's consumers of healthcare no longer go to see their doctor for absolute directives about what they should do to be healthy. There is no longer a desire, especially among millennials, to see a paternalistic doctor who authoritatively enters the room to give commands to the patient which the patient then obeys without question. Of course it makes sense that patients don't want that. After all, it is the patient's body, health, finances and lifestyle that these directives from the doctor affect, so why should they be blindly followed without a team-like approach to the patient's health. But yet, non-compliant is a term used with increasing frequency to describe patients who are not obliging with their doctors' directives. Among programs like the Patient Centered Medical Home, doctors, healthcare providers and the healthcare system recognize that patients are more engaged with their own health when we actually involve them with their own care decisions. This means practically within an office visit, having a conversation with the patient about what their diagnosis is, what this means for their lifestyle and treatment options for how this can be managed. It means that patients then are given guidance and education from an actual qualified medical professional about their options for treatment and then the patient decides what they want to do. I've had these conversations with many patients for example about their high cholesterol or diabetes. Some patients, when presented with the health risks they have because of their diagnosis, decide to radically change their lifestyle and diet, loose weight and get their disease states under control on their own. Some patients decide they are not going to do that and would rather take a medication. Either way, the patient has chosen and thus they are on board with the plan... and compliant.
All of that is well and good except that our current healthcare system (one in which patients pay a third party for insurance coverage [Blue Cross, Medicare, etc] and expect this third party payor to foot the bill for the entirety of their medical expenses), is not well suited to allow for extensive conversations with patients to enable their own decision making. Further, we are now shifting to the value-based-payment model which means that doctors will be paid based on "how well they are taking care of patients." It is fascinating that non health-care providers believe they can judge how well I am taking care of patients and then will use that judgement to decide how much to pay me for my services. Value-based-payment models of healthcare are intended to improve the quality of care that patients are given, reduce costs and improve patient satisfaction. But, in order for a third party (someone other than the doctor and the patient) to make a judgement call about how well I am taking care of my patient, it has to be some objective measurement. And if there is one thing I know about medicine, it is that there is nothing in medicine that is 100% black and white and purely objective.
Stay tuned for next week's blog...a real life example of how these changes are affecting individual patients.
A "leave of absence".....what I really mean by that is I have reduced the number of patients I see a week to about half what I used to see and am still working the same number of hours per week.
I've realized that physicians underestimate the toll that seeing our patients daily takes on us. I mean think about it - we listen to the complaints of sick people ALL. DAY. LONG. And, our job is not just to listen, it is to fix them. And, our job is not just to fix them, it is to fix them in less than 7-10 minutes on average. And, in addition to fixing them in less than 7 minutes on average, we are also responsible for:
1. Documenting a complete note about their visit that day meeting all requirements of the insurance company (After all, as the saying goes in protecting yourself from litigation "If it isn't documented, it didn't happen.")
2. Choosing the correct list of diagnostic codes out of a book containing 68,000 choices
3. Ordering the right tests so that we don't miss a medical diagnosis
4. Ordering enough tests to satisfy the patient about whatever they have been googling
5. Ordering only the tests that the insurance company will pay for
6. Refer to specialists as needed but only to whom their insurance company deems to be the "right" specialist
7. Prescribing the right medications for the patient but only the ones that their insurance company will pay for
8. Reviewing "Patient Health Snapshots" (as they are called by one insurance company).
This "Patient Health Snapshot" is a document that we obtain by logging in to the insurance company's website and looking up the individual patient. It tells us what the insurance company thinks the patient needs - such as being overdue for their colonoscopy or mammogram, or needing an eye exam, or receiving certain immunizations, or that the patient's blood pressure is too high, or that they are not getting their medications filled at the pharmacy frequently enough. And yes...this too we are also supposed to address with the patient...in those few minutes.
(Why in those few minutes? Because of the fee-for-service model of healthcare, those are the only few minutes that we are paid for. Work done to take care of patients when they are not in the office is not compensated for. And further, not adequately addressing these Patient Health Snapshots actually means we get paid less. So now, if we are seeing a patient for a rash and it happens that they are also not getting their cholesterol medication filled at the pharmacy because they have heard about statins on TV and refuse to take it, our payment continues to be affected unless we convince them to start taking it. Which all in all means we need to see more patients to meet equivalent reimbursement and now the 7 minutes we did have has decreased even more.)
Is it any wonder we're concerned about medical errors, high costs and poor outcomes in our healthcare system? Practicing medicine in America is insane. And as Albert Einstein said "Insanity is doing the same thing over and over again and expecting different results." So, I'm trying to embrace the upcoming changes in healthcare by prioritizing initiatives such as making our practice a Patient Centered Medical Home (PCMH) and preparing our current patient base for the upcoming MACRA shift. It's estimated these projects take 12 months. We need to do them in 6. 6 months of work that I won't get paid for... yet. Hopefully, it will pay off in the year 2019 when reimbursement for MACRA goes into effect. It's now been determined (source here) that on average 20 weeks out of the year are spent within a single physicians practice reporting quality measures...20 weeks is insane. That's not 20 weeks spent taking care of patients, that's half a year reporting to our insurance companies who then report that data to the government about our patients health. Thank goodness I have amazing CRNPs that are helping me with the actual day to day patient care. Without them, I'd be out of business right now. Due to MACRA beginning in 2019, it's estimated that 87% of solo practitioners will begin receiving reimbursement penalties, which will ultimately drive these practices out of business.
So while a lot of non-health care providers try to reform our healthcare system in ways that will probably only make it worse, I've got to take care of my patients, myself and my family. My "leave of absence" effectively means that I'm seeing half the number of patients I used to while working the same number of hours for less pay in order to add in administrative tasks like implementing PCMH and tools to better report quality measures. It's not really the leave of absence I would dream of:) But, it's better than continuing the sleep deprived, burned out, unhealthy state of being I was quickly making a habit of which was likely to just leave us among the 87% that were going to be headed out of business anyway.
In a physicians training, we're trained to put the patient first. Beyond that, we're trained to be heroes that can tackle any problem on our own perfectly. It's not exactly thought of as a positive trait in medical school to have a growth oriented mindset, make mistakes and learn to ask for help. We quickly learn that we have to set aside our emotions to witness horrendous suffering and try to be the one that can help. We realize that we have to sacrifice our own health sometimes to do this, our relationships suffer, our emotions have to be set aside. And when we take that hero/perfectionist component of our training and enter the healthcare system we are working in, it just doesn't work. It doesn't work because it's not possible. It's not possible to do everything that we are held responsible for (that is actually out of our control) in 7 minutes of time with the quality in which we want to do it. It leads to a lot of burned out physicians cynically practicing medicine. As much as I genuinely love my patients, I've realized that without boundaries, these two sweet souls pictured will suffer, not to mention myself and my dear supportive husband. And so, that is why, I am taking my "leave of absence."
A few weeks ago, I had a wake up call given to me by my youngest son, 2 years old. It was my off day. You would think I'd be more relaxed on these days spending a mommy-son day together. But, when you've been up late working the night before (and the night before and the night before and on and on) and you're still depressingly behind on everything needing to be done and are also intermittently answering calls/messages/texts/emails from office staff and patients AND trying to be present with your children, it's an extreme test of mindfulness. That afternoon it was time to go pick up my daughter from school and I'd been delaying my son's nap until we all got home so it wouldn't be interrupted by having to leave to go pick up his sister. So, of course, he's napless and tired and I'm in my usual state of exhaustion. I wanted him to use the bathroom before we left so he wouldn't have an accident in the time we'd be gone. After telling him it was potty time, I went to the bathroom to wait for him to follow me as he typically would do. This time, I waited and waited. It must have been oh maybe 15 seconds, it felt like 10 minutes. We're going to be late, I'm thinking. And for some reason, I just totally snapped. And you have to understand, I don't do that. I'm calm, cool and collected. I can count on one hand the number of times I remember yelling in my entire life. But this time, I yelled. I yelled at my son for taking 15 seconds too long to come to the bathroom. As soon as the words came out, I was already teary eyed. Then I looked up through my tears and saw my sweet son crawling into the bathroom. He looked up at me with a look of fear, confusion and such sadness and said "I was coming. I was crawling. I don't like it when you do that." He wasn't even disobeying, he really was coming, just not fast enough for me. He just was playing a game with his stuffed animals and was pretending to be a baby and crawl with them. And, I didn't have 15 seconds to wait.
I realized in that moment that my life was not working for me or my children. I mean sure there had been signs before but that was the moment looking at my son through my tears that I was convicted.
I've told my husband, who is thankfully also the Practice Administrator at our clinic, that this next few months is an experiment in figuring out if we can survive the next 20-30 years with a medical business under the ACA. Time will tell...
Here is an example. I diagnosed a patient based on my physical exam of the patient and listening to the patient describe their symptoms (and also the month long diagnostic testing process they had been through). I started treatment for this and the patient was improving. Subsequently, I was called by one of the specialists physicians this patient had seen previously who had learned of this diagnosis and called to tell me that the patient needed a more final diagnosis with more imaging involving more radiation exposure to the patient and an invasive procedure. When I asked this specialist why they would recommend doing this now when conservative treatment was currently improving the patient's symptoms, their only answer was to provide the patient with a more definitive diagnosis based on testing.
For some diagnoses that is true and I wholeheartedly agree - such as genetic conditions where other members of the family may be affected, diseases that require treatment that involves significant risk to the patient, diseases that need to be treated quickly or diseases that mean a devastating prognosis for the patient that they need to be prepared for. This was not the case.
I am noticing that doctors and healthcare consumers alike are less and less trusting of a clinical diagnosis based on the description of symptoms (called the patient's "history") and the doctor's physical exam. As a medical student I was trained over and over that these are the two most critical pieces of any diagnosis. I believe taking a good history of the patient's problem is actually the most important - as this directs all subsequent actions by the doctor. Both of these assessments take time! A lot of time. In a country where the average time spent with a patient in primary care is < 7 minutes, we are loosing the art of actually taking a patient's history and doing an exam.
So in lieu of this, tests are ordered. Labs, ultrasounds, x-rays, CT scans, MRI's, more labs, invasive procedures.
We've become a society that can only accept a diagnosis if there is some "test" that proves it. Unfortunately this is just not the way medicine works. Let me tell you a little truth that no one wants to accept about medicine. There is rarely a diagnosis that is 100% certain.
Let's think about these tests that we all long for. Did you know that 28% of patients that were found to have a disc herniation on an MRI actually did not have one when they had their surgery? A study at Johns Hopkins found that 1 out of every 71 tissue biopsies were misdiagnosed as being cancer or non-cancer incorrectly. Systematic reviews of the accuracy of colonoscopies in detecting colon cancer (which is one of the best tests for diagnosing cancer that we have) still has a miss rate of 2% for larger polyps and up to 26% for smaller polyps.
Certainly we can't diagnose cancer and disc herniation simply from talking to a patient but it's important to recognize the limitations of diagnostic testing. We can't hold them up as the only way to give a diagnosis to the patient.
There is a lot of pressure placed on physicians to come up with the "right" diagnosis in a science that is simply not filled with 100% accurate answers. This has pushed us to all rely more and more heavily on something else telling us what the diagnosis is - that way, it's not all our responsibility if we are wrong. I think that is what it comes down to. Being a physician is cited as one of the most stressful jobs over and over - due to it's high level of responsibility and minimal control over the outcome. We're not trusted by many patients. We're not trusted by all these regulatory bodies overseeing our every decision. In primary care, we're often not even trusted by our own specialists colleagues. We begin to not trust ourselves to make a diagnosis without something else backing us up.
But here's the thing... you cannot treat test results. You have to treat patients. You have to talk to patients. You have to examine patients. And at some point, your patient just has to trust that you have their best interest at heart. Without this "art of medicine" and a strong patient-physician relationship, the cost of medicine will continue to rise as health outcomes fall. The secret ingredient for all of this is TIME - time with our patients to listen, to examine, to explain, to have a relationship.
The world has enough beautiful mountains and meadows, spectacular skies and serene lakes. It has enough lush forests, flowered fields, and sandy beaches... What the world needs more of is people to appreciate and enjoy it."
- Michael Josephson
The majority of my patients are current STEM employees, spouses of STEM employees, children of STEM employees, or retired STEM employees or spouses. It's true, they really do bring in graphs of their blood pressures, PSA's (prostate specific antigen lab results), blood sugars and cholesterol numbers plotted over time- a phenomenon I experienced oh.... none in Birmingham. But practicing medicine and being responsible for highly educated patients' health is additionally challenging, especially for physicians who are used to being able to tell patients what to do. As medicine shifts to more of a consumer's market, I notice that older trained physicians are being called out by patients for not providing what they really want. Especially here in our community, where our patients are possibly researching genetic diagnosis and treatment in more detail that even mentioned in medical school, we are called to partner with our patient customers in a way that many other physicians in more average communities do not experience. Older physicians and even some newly trained physicians with this attitude, don't understand that patients want a conversation. You don't want to be told what to do. You want to have a conversation about why we come to a particular diagnosis, what your test results mean to us and what your treatment options are. You get to make the decision, it's your body. Our role is to guide you along the way with our expertise to help you in making the best decision for you. This is a very new way to practically practice medicine for many physicians. I graduated from medical school in 2008 and was hardly trained with this approach by most of my physician attendings. But, you deserve to have a partnership with your physician, not a relationship that does not provide you understanding.
Here is the problem with that.... our health care system as it is currently structured where doctors are reimbursed in a fee for service model does not allow for that. Partnering with patients and making decisions together takes a lot of time and conversation with patients. So even if physicians want to do that, generally their schedules just simply can't allow for it. Payment is based on volume of patients seen primarily. It is much simpler for me to use my past 11 years of medical training and experience to review your test results, your exam and treatment options before I walk in the room and have a plan to present to you in the few moments we can actually spend face to face. In fact, the expected time that Medicare and insurance companies have decided all of that should take on average is 15 min. This past Friday, I happened to have 60% of the patients on my schedule here for what I would consider a complicated medical decision making diagnosis and treatment plan. Medicare tells me this should take about 25 min per patient (of which at least 10 min of that is spent rooming the patient and documenting Medicare requirements to bill that office visit) so that leaves 15 min. This. is. not. true. Several of these patients were already frustrated by the health care system in our community dismissing them and not explaining to them what was actually happening to their body. I easily spent over 30 min with each of those patients resulting in longer wait times for subsequent patients, no lunch break for myself or my staff, cancelling the lunch training meeting I was to have with my staff and leaving the office later than anticipated. Some days are like that, you just have to do what the patients need. But, seriously, it would be nice if physicians were paid based on a more realistic expectation of face to face time needed with patients. Sometimes patients tell me "Do whatever you need to do, my insurance will cover everything." I'm sorry to tell you my friend, your insurance does not care to pay for the additional time you need me to spend with you. That is my most valuable service, my time. And now, I will get off my soap box and return to finishing documenting my office visit notes on each of those patients that I did not get to yesterday while my amazing sister has taken my kids to the park so I can finish my work.
Brooke Uptagrafft, MD
Dr. Brooke is a family medicine doctor.