When has this feat ever been done like this before?
Only one answer: NEVERMORE!!
A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.
A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.
When has this feat ever been done like this before?
I won't be blogging much in the month of November because I'm going to be writing a novel.
(Thanks to all the encouraging commenters on my previous post. Yes, I was having a bad day, and, as always, things were much better in the morning. Because of that last post, though, I feel compelled to point out that this one is intended as humor and not pathos.)
What the hell am I doing with my life?
Cathy has done it again. Thanks for bringing some wonderful blogs (now blogrolled to the right) to my attention:
This doctor went bankrupt.
I am disappointed with whoever is responsible for allowing a shortage on primary-care physicians. Our Dr. Matthew Masewic is closing his practice due to finances and high insurance costs, which are ridiculous.
It's sad and a shame to lose such a wonderful, kind doctor who is much needed and wanted. We pay high premiums every week and expect our doctors to be paid when due. They work long, hard hours and deserve every cent they get.
Dr. Masewic had a dream - helping everyone - and I believe everyone should help him. He kept us on the right track to staying healthy, and he will be greatly missed.
It would be nice if legislators would do there job and stop allowing insurance companies to do what they want, and hospitals from charging a fortune. It costs more for an aspirin than a doctor visit. Hello, what's up with that? It's time we helped keep our doctors, because soon we won't have any.
Did this patient pay her co-pay when she saw the doctor? If he had tried to stay in business by cancelling his contracts with all the insurance companies and insisting on payment at time of service, would she have continued to see him, cheerfully paying the full fee for receiving care from "such a wonderful, kind doctor who is much needed and wanted"? Or would this letter to the newspaper have been in the same mail as a heartfelt letter to the wonderful doctor thanking him for all his kindness while regretfully requesting the transfer of her records to the big practice up the street who will take her insurance so she can see another wonderful, kind doctor for only $15?
We can go around and around and around about what a shame it is that docs like this guy, me and all of the rest of us primary care dinosaurs can't make a living without ever pointing a finger squarely where the blame belongs:
At the Health Care Law Blog; check it out for the gorgeous pictures if fascinating reading isn't your thing.
Caution: contains more personal disclosures (as if anyone cares.)
Somehow over the last two months since I began blogging (hard to believe that's all it's been) I had gotten the impression that DB, that Wild and Crazy Guy, was in favor of Pay for Performance. Where might I have gotten this idea?
Last week, SGIM sponsored a Quality Summit. During this 1 day meeting we focused our discussions on performance measurement and how should adjust for multiple co-morbidities. As the President of SGIM, I organized this conference and greatly enjoyed the intellectual stimulation during the presentations and the discussions that followed.and a few weeks later, in Measurement: blessing and curse:
I consider myself partially responsible (emphasis mine) for the P4P crisis. I have participated in studies which examined “quality” as measured by adherence to performance indicators. While I am a minor player here, I have published literature on this “problem”.I loved that post, especially the Albert Einstein quote:
"Not everything that can be counted counts, and not everything that counts can be counted."and I commented enthusiastically on his blog. An email exchange ensued, in which Dr. Bob thanked me for my comments. I said "You're welcome" and commented that I thought -- perhaps because of his research interests -- that he was in favor of P4P. This was his answer:
[I'm] not proP4P. I am in favor of research which examines how we can help physicians improve their care delivery - 2 different concepts.
An observation dating back many years, from the chief of medicine at med school, now reincarnated as the Eighth Law of the Dinosaur:
The better the surgeon, the more reluctant s/he is to operate.
You know those people who make you sigh when you see their name on your schedule?
"A DECISION HAS BEEN MADE TO AUTHORIZE THIS DRUG BY ADMINISTRATIVE EXCEPTION. THIS ACTION WAS TAKEN DUE TO INTERNAL ADMINISTRATIVE/PROCEDURAL ISSUES AND IS NOT A DETERMINATION BASED ON THE SUBSTANTIVE ISSUES PRESENTED IN THIS REQUEST."
This is a true story; names and some identifying details have been changed to protect privacy, but I'm having a tough time with this one.
Another personal tidbit: I am a cat person. At the moment there are three felines of various sizes, intelligences and proclivities vying for the patch of sunlight on my kitchen floor:
Sid Schwab is a semi-retired surgeon, a medical blogger and an amazing writer. He recently wrote a powerful piece called Taking Trust, about his experience of the intimacy (his word) of surgery.
I will reach in gently and caress the liver, the stomach and spleen. Slide over the top, into the recesses, curl the fingers enough to sense the texture, the fullness. The bowels move away and under, and over the top as I direct my hand. I can describe your kidneys now, I've circled the top of your rectum, held your uterus, measured your ovaries between my fingers. Part of you is gone at the moment, but I'm here, I know you now. You trusted and let me in, you opened your belly to me, and I entered with force. I'll stay until it's right. It's what I must do. You think you'll never touch me so intimately as I've touched you. But you have. You have.
He ran his hands all over me, inside and out … gently at first, and then rougher and rougher. After what seemed like an eternity of having his hands prying, pinching, pressing … he positioned me the way he wanted me … and did what I knew he was going to do. I remember thinking that it was never going to end. Rough doesn’t even begin to describe it. I hurt for a long time afterward in places I didn’t even know I had.
I am about to reveal two pieces of information about myself that I have been withholding -- for the sake of "anonymity" -- until now.
There's an interesting discussion taking place in the comments trail of my opening salvo on the topic of P4P. Rob and Diora are going at it hard and heavy, but they're not actually discussing P4P anymore. They're locking horns over the value of screening tests in particular and preventive care in general, trading figures and citations. As it happens, I agree with both of them, at least on that particular topic: preventive care is a good thing, but patients should have the final say about all testing and treatments -- including screening -- in consultation with their physicians.
From the comments, regarding the issue of "loyal patients who adore you but still haven't had mammograms and colonoscopies":
Isn't screening a patient's choice? Yes, colonoscopies can prevent cancer. Yes, mammograms might diagnose one of those cancers that are destined to spread before they become palpable, at just the right time. But the probability of an individual benefitting is small - less than 1/1000 after 10 years of mammograms, for example, and this is a pretty optimistic estimate. And screening has risks. Like overdiagnosis, for example, in case of mammograms. Like longer period of "being sick" if the cancer is so aggressive that early detection doesn't make a difference in the course of the desease. Like biopsies for false positives.My point exactly. You have to have something to measure in order to call it "Performance." It's easy enough to count up how many of your patients have submitted to assorted screening tests and other procedures, so that's what is being done in the name of "quality," and that is what I disagree with.
So if a rare patient feels that for her personally a higher chance of becoming a cancer patient, for example, is too high a price to pay for less than 1/1000 chance of having her life saved 10 years from now (forgetting that we are talking about desease-specific mortality and not all-cause mortality), how are you going to convince her? Assuming she is really informed, should you waste the precious time of the visit to try to get her to change her mind?
And what is quality? Openly discussing both benefits and risks of screening or just using scare tactic to get more patients screened? If you are not mentioning the risks, if you using relative mortality reduction and not mentioning the real chance of your patient benefitting, are you not misleading the patient?
There are some doctors who have better outcomes at lower costs than others. Were it possible -- and I'm not at all sure it is -- it would be nice to see an effort to figure out the differences and encourage them.This was actually one point the speaker addressed that I felt was valid. He described data showing the number of tests a cardiac patient had from first presentation to cath lab. In cardiologists' offices with diagnostic equipment (echos, treadmill stress tests, etc.) the average was 4.5; in offices without such equipment, it was 1.5 (average number of tests between presentation and cath lab.) This information was made public, and the results were gratifyingly predictable: the overutilizing offices were promptly contacted by referring physicians who said, "We're not sending any more of our patients to you." Surprise: the number of tests from presentation to cath lab decreased. But this valid and useful intervention is a far cry from "pay for performance" in general, and specifically in defining "quality" in the office interaction between patient and primary care physician.
As a patient I have a right to decide for myself whether certain small risk reductions are worth the risks or side effects for me or not. I don't want an incentive for a doctor that would depend on the choices I have a right to make.[emphasis mine]followed by Fat Doctor's observation which, as always, is right on target:
I am not a salesperson. I am not a factory worker. I am a physician. Who will judge my performance best? I hope it remains the patient.Amen, sister.
Comment from the esteemed Dr. Flea:
With all due respect, Dr. Flea, my experience has been somewhat different. One of the coolest things in my 17 years of practice has been watching families come into existence, expand, grow and develop. Not just the kids but also their parents, as both parents and people. I feel an important part of my job is not just teaching the parents about caring for their child, but supporting them -- explicitly and enthusiastically -- in their child-rearing abilities. And guess what: it works.
Another proposed Dino Law, Flea version:
"Nervous first-time parents tend to become nervous second-time parents".
At least that's been my experience.
I just got back from a meeting tonight; a meeting of my state specialty society, not something sponsored by Evil Pharma (a term invented by one of their employees, to whom I happen to be married.) The main reason I went was because the restaurant was
Comment from Still More About Money:
Everyone is replaceable when they are not making a whole lot. Once you are paid what you think you are worth that's when you move more towards the irreplaceable realm. Those 2000 people will find someone else to treat them and you are more likely to have more satisfaction by working less and making more in another market.
Thanks again (for nothing) DP (and RN Wannabe). I actually followed this meme from its inception:
Unfortunately retitled "Viagra keeps you up at night" by Blog Around the Clock, Sleepdoctor has this:
There is a full abstract of the study at his post here.
Each year, millions of men in American seek treatment for erectile dysfunction (ED), a condition that is often associated with obstructive sleep apnea (OSA). Since its introduction in 1998, Viagra has become the most common form of treatment for ED. It works by enhancing the effects of nitric oxide, a compound that relaxes muscles in the penis and allows for increased blood flow, triggering an erection. Now a new study by a team of Brazilian and American researchers suggests that a single 50-mg dose of Viagra may actually worsen symptoms of obstructive sleep apnea (OSA). The study involved 14 middle-aged men with severe OSA in a double-blind crossover study. Using polysomnography, the researchers analyzed the severity of symptoms and found a significant increase following a dose of Viagra compared to placebo.
This one is so dead on, it just hurts.
MedStudentGod over at Creating the God Complex is having a little crisis of confidence:
In some ways I think I’m inferior to other medical students around the country simply because I attend a “humbler” medical school. I’m not trying to sound arrogant here, but a sizeable portion of my class wouldn’t have been accepted anywhere else and were only allowed in after completing some after undergrad program...I don’t know. Right now I consider myself lucky to be in medical school at all, but wonder how it would have been in another school – a top 50 medical school.Here's my answer to him (edited, because I've had more time to think about it):
From the Right Time comments:
When my son swallowed a penny, the doctor asked if we knew the year. Yes, we did (it was from my older son's collection.) We told him.I'm reminded of a story a patient told me of her old pediatrician: she called him frantically one day upon finding her daughter eating kibble from the dog's bowl.
The doctor said "That's a worthless penny. I've already got it in my collection. Just let it pass."
I ran across this post at Freakonomics the other day:
[My dentist] told me that tooth decay in general, even among wealthy patients, is getting worse and worse, particularly for people in middle age and above. The reason? An increased reliance on medications for heart disease, high cholesterol, depression, etc. Many of these medications, Dr. Reiss explained, produce drymouth, which is caused by a constricted salivary flow; because saliva kills bacteria in the mouth, a lack of it means increased bacteria, which leads to increased tooth decay. Given the choice of taking these medicines versus having some tooth decay, I’m sure most people would still choose the medicines—but I am guessing that most people haven’t thought about the link between the two.followed by this in the comments:
The dentist's comments are a classic example of anecdotal beliefs espoused by many healthcare professionals to their patients without the backing of evidence-based medicine; i.e. clinical trials. If Dr. Reiss could back up his assertions with some evidence I would be more prone to believe them. And in case you are wondering, my skepticism arises from his broad claim that most medications used to treat modern chronic medical conditions cause dry mouth. Many medications do cause dry mouth, but of the ones I know that are used for today’s most common conditions, none of them stand out as particulary drying to the oral cavity. Furthermore, there is an alternative explanation that seems to me to more closely follow Occam's Razor, an explanation I might add that is popular among many other dentists. The increase in tooth decay seen in modern times can be linked to the increased popularity and pursuant consumption of bottled water, the nonfluorinated cousin of regular tap water. And of course we know that one of the greatest things you can do for your teeth is consume adequate amounts of fluoride. Go figure.A little further along there was this:
I thought if a child ate enough toothpaste, he’d die of fluorosis – is this urban myth?Dino to the rescue! (Someone else beat me to it, though.) I was researching an answer to the effect that no, fluorosis was a cosmetic discoloration of the tooth enamel (but the author may have been thinking, correctly, of the danger to children from mouthwash with high alcohol content) but in the process of finding links to document my comments, found this: