Highs and lows of the AAFP convention
Every two years I go to the annual AAFP convention, almost without fail in my long career. This gives me the benefit of perspective, which I will now pass along.
This year’s event in Boston was exceptional. If you’ve never gone, you should. It might become addictive.
Since the Chicago convention in 2007, there has been a major change in format. Previously there were “headline” presentations in a huge hall, with a confusing variety of other talks in several formats – lectures, demonstrations, conversations, etc. The schedule was so overlapping and confusing that I sometimes missed events I wanted to hear, or could only work in half of the presentation.
All that chaos was junked in 2009, hopefully for good. All the events, except for fee workshops, were one hour in length with 30 minutes between. Many were repeated, so I didn’t have to wish I could be in two places at one time. The half-hour intervals provided plenty of time to breeze in and out of the exhibition hall, if I wanted to, which I didn’t. But that’s just me, this year. In the past I enjoyed the dog-and-pony shows.
For the first time I stayed at the hotel attached to the convention. You have to book early. The advantage was the ability to easily stroll down to the optional breakfast and dinner meetings, which were useful and also provided a free meal – a good one, in all cases. I could even get in a quick workout in the exercise room between lectures, which is impossible if you're using the shuttle buses.
The result was that I arrived Wednesday around noon, left Saturday morning after running in the 5K race and squeezing in one more lecture, and accumulated 40 hours of group CME credit. Many of the presentations gave 2-for-1 hourly credit because they were “evidence-based,” even if they weren’t really (listen to the popular "Am I Hungry?" diet talk, and you’ll see what I mean). That’s a bargain.
The presenters are uniformly qualified and useful. Once upon a time most of them were experts in other specialties. Now we've grown our own, and they think like family physicians. When I sit down for the lecture, all I want to know is if I should be doing something different. My habits are well established; that's the advantage of being a veteran. When a family doc presents evidence that I should change a habit, I usually do. The result is that I leave the convention with a few things that I want to change back home.
So kudos to the Academy. The annual meeting is as good as it gets.
Now for the downside.
I missed the annual town-hall meeting with AAFP leadership, which apparently happened during the early part of the week when only the poo-bahs were gathered for their Order of the Moose convention. [Editor's note: This is referring to the Congress of Delegates.] You can tell them by their suits and the decorations on their assembly badges, which make them look like South American military dictators.
Although I poke fun (partly because of my aversion to committee meetings) and although their aspirations do not make my heart glow, I can appreciate their willingness to be active in the political process – unless the political process is all they do, because they work in academic centers. In that case, it's a paid vacation.
I just think we're overdue for an honest, no-holds-barred discussion about the direction of our dying specialty. Enough with the happy faces and glitzy promotions. We need a town-hall meeting that isn't buried in safe territory and that offers members not only a chance to speak but also a chance to cross-examine perfunctory answers.
The president of the Academy came to speak at the Kansas meeting this summer on the patient-centered medical home. I asked those in charge if we could make it a debate. The answer was no. I could, however, drive to Wichita to ask one question at the town-hall meeting. That was too much driving to get one answer.
As I was taking cover in the Boston chill prior to the Saturday race, my ear was bent by a political aspirant from the midwest. He had lost his bid for a seat on the board, and he was lamenting that no one represented people who really ran full-time family practices.
I don’t know if that’s true. But the few folks like him who are willing to make the sacrifice – because their service comes right out of the bottom line – are the salvation of the specialty, if it can be saved.
Posted at 01:59PM Oct 29, 2009 by Doug Iliff | Comments[0]
The economics of the health care industry
On Sept. 25, I referred readers to an article I wrote on the health care debate for Front Porch Republic. It was an overview, and as such made no attempt to provide background material supporting or clarifying my views. It sparked a healthy debate, revealing to me how woefully ignorant even intelligent Americans are about the economics of our profession.
Following a recommendation from reader Dan Schmidt, I just read a long article from The Atlantic entitled “How American Health Care Killed My Father.” Don’t be put off by the title; it isn’t a rant. Rather, it is as close to perfection as anything I’ve ever read on the subject of health care economics. Every point and every example rings true to my experience.
If you have any interest in the subject, which will determine the future of our profession and now controls 18 percent of our economy, please – read this article.
When you do, you’ll realize the futility of any attempts to shoulder family medicine to the front of the federal trough. Oh, I know; at the moment, current legislation will give me an 8 percent raise in RVU compensation next year, probably to be snatched away the year after. Instead, our specialty's leaders should be the voice in the wilderness crying for a free market in health care services, where we would quickly demonstrate our indispensability.
Sometimes it takes a famine for people to appreciate farmers.
Fascinating excerpt: “Let’s say you’re a 22-year-old single employee at my company today, starting out at a $30,000 annual salary. Let’s assume you’ll get married in six years, support two children for 20 years, retire at 65, and die at 80. Now let’s make a crazy assumption: insurance premiums, Medicare taxes and premiums, and out-of-pocket costs will grow no faster than your earnings – say, 3 percent a year. By the end of your working days, your annual salary will be up to $107,000. And over your lifetime, you and your employer together will have paid $1.77 million for your family’s health care. $1.77 million! And that’s only after assuming the taming of costs! In recent years, health-care costs have actually grown 2 to 3 percent faster than the economy. If that continues, your 22-year-old self is looking at an additional $2 million or so in expenses over your lifetime — roughly $4 million in total.”
And on the other hand, we have a Wall Street Journal lead editorial that can’t discern its terminal colon from a terrestrial excavation.
The editors are upset that the Senate Finance Committee bill authored by Democrat Max Baucus would increase primary care compensation at the expense of specialists. This is an assault on the free market, they opine, blissfully unaware that it was federal regulators who created the income disparities that Sen. Baucus is attempting to scale back.
Tell you what: Sometimes the ignorance of educated friends makes me want to weep.
However, I’m sure the AAFP leadership has ripped off a stunning riposte to the Journal, which is always willing to print a letter from the loyal opposition. I’ll let you know how it turns out next week.
Posted at 12:30PM Oct 12, 2009 by Doug Iliff | Comments[3]
RVU ramblings
In the “Practice Pearls” section of the latest Family Practice Management, Kent Moore cites the Medical Group Management Association (which gives us the more reliable health statistics in America) on the average work RVUs generated by family physicians not doing obstetrics in 2007.
After a sentence like that, take a deep breath. The figure is 4,600.
That got me wondering how many RVUs I generate per year, since I’m often prattling on about productivity. Right on time, Blue Cross sent me the rolling report on my efforts for the last three years, reproduced here:
If you divide my RVUs for this three-year period by three, and divide by 0.85 (Blue Cross is about 85 percent of my business), you get roughly 8,000. Admittedly, this includes about 20 obstetrical deliveries per year, which is hardly a back-breaking number. Remember, too, that including obstetrics (since I have given the hospitalists my inpatient work) I only work about 40 hours per week, 220 days per year, with about eight weeks of holidays and vacations.
I’m talking to medical students and family practice residents here. You know, those of you who told the Admissions Committee you wanted to go into primary care, or actually chose to do so. Now you’re wondering if it’s a viable choice.
Here are random thought bearing on that choice.
1. If I can generate 8,000 RVUs per year working the same hours as a state employee but enjoying the stimulation of intellectual challenge and terrific personal relationships, avoiding the administrative burden of the patient centered medical home while providing a place where every patient knows every one of my employees and vice versa, and while earning as much money as the average cardiothoracic surgeon, what’s not to love about this specialty?
2. What’s wrong with the practices of all those other family physicians?
3. In his blog, Kent Moore also asks why (based on a Health Affairs article) a family physician would choose to spend an average of $65,000 to comply with the diktats of insurance companies. My answer: That’s half of my expenditure for salaries, so it must be nuts. Where do people get these figures? My nurses must spend at least 90 percent of their time doing meaningful service for my patients.
4. I’ve done my level best to charge Blue Cross for every legitimate 99214 or procedure (thank you, Kent and Cindy, for an excellent column). Still, I keep proving to be 18 percent more efficient than my peers – the ones, I assume, doing only 60 percent as much work as I do. How can this be?
5. I wrote about an old friend and an old student in a recent blog post. The former quit doing OB 10 years ago and is coasting toward retirement with an aging patient panel; the latter doesn’t plan to do OB at all, which is increasingly common among FP residents. I know that OB can be inconvenient, and scary. In the last 24 hours I did a delivery at 3:30 a.m. and a vacuum extraction at 4:30 p.m (followed by a shoulder dystocia resulting in a fourth-degree laceration requiring careful repair). My question: If family physicians give up OB, and therefore a preponderance of potential pediatrics, why choose family practice over med-peds?
As I draw near the end of a year’s worth of blogs, I understand much better why I am successful, and what other family physicians need to do to be successful.
But I am losing confidence that family practice will survive.
Posted at 02:19PM Oct 02, 2009 by Doug Iliff | Comments[3]
A little reason to the health care debate
Once upon a time I wrote an article for FPM called "Ten Hard Questions About the Future of the Specialty." It generated a lot of response, but most of the questions still haven't been answered.
So, having failed at a simpler task, I recently cranked out 3,000 words on the subject of "Ten Key Questions Framing the Health Care Debate." It was written at the request of an editor at Front Porch Republic, a blog dedicated to "crunchy conservatism," that form of conservatism that is also environmentalist and localist in its philosophy.
Go there if the subject interests you, and jump into the conversation. The zanies are winning the battle, and we're losing the chance to have a civil debate.
Posted at 03:27PM Sep 25, 2009 by Doug Iliff | Comments[2]
The amphetamine generation
Yesterday an old friend stopped by for a visit. Jack and I ran cross-country against each other in high school, pledged the same fraternity, moved out together into a rental house (the three guys upstairs ended up in medical school, the three downstairs smoked dope – this was the ‘60s), and graduated together as physicians. Probably hadn’t seen him in 20 years, though, as we went to opposite coasts for our family practice residencies.
Talking to him about life in California reinforced my conviction that all medical politics are local. Managed care is still maybe 40 percent of his practice (it’s now zip for me) and Blue Cross pays him 90 percent of Medicare values (it’s much better in Kansas).
Jack is smart, dedicated and fit. He sees patients the same day they need to be seen, and his practice schedules office hours until 8 p.m. Even on days when he doesn’t have late hours, he may not get home for dinner. As reimbursement has been squeezed, he has responded by simply seeing more patients each day, up to 36. Don’t worry about the quality of their care.
Still, it hasn’t been a hardscrabble existence. He owns a condo in Hawaii and a 700-acre ranch in northern California, to which he escapes to mend fences weeks at a time. It’s a five-hour flight to Hawaii, and a five-hour drive to the ranch. But he’s kept the same wife, a fine one, and raised three boys in the process.
He works at medicine more than I do. That’s just bad luck, but more docs want to live in California than Kansas. As he points out, there’s warmth and sunshine every day. That’s the same argument the Left-Coasters made when Utah tried to poach businesses with TV ads promoting low taxes: “Kiss your assets goodbye” is the way they put it. California responded: “Who wants to live in the desert?”
The solo FP with whom I own a building worked hard for a long time, but he’s smelling the roses more these days. Not roses, exactly. He keeps a live-aboard sailing yacht on the Chesapeake.
Why the shameless capitalist-pig boosterism?
Because I’m conflicted, as anyone can tell if they've read these posts from the beginning, last October. On the one hand, I believe that the income delta vis-à-vis the procedural specialties is pirating the primary care physicians we need to make health care work. On the other hand, if you’re willing to work hard, family practice still offers a better life than maybe 99 percent of the other opportunities outside the medical profession.
I had a couple of beers with an old student from the Great Ideas class I taught for six years – at the private school I started in my spare time (there’s that lifestyle argument again). He’s in his final year of a family practice residency and halfway believes what I’ve been preaching. He confirms that his classmates don’t have much stomach for the rigors of private practice.
The dénouement is this: Due to this generational tectonic shift in animal spirits, the AAFP is forced to gallop to the rescue with an initiative that chiefly appeals to bureaucrats, and individuals who used to occupy the low end of the animal spirit Bell curve – which has now shifted to the left.
I suspect this is why so many of my college-age patients make an appointment to beg for Adderall to get them through finals. This is a generation that needs chemical pepping-up. (Mine apparently needed marijuana, but let’s not go there.)
In the interim, I just got word that I passed my boards, so I get another decade to watch the world pass me by.
Posted at 08:00AM Sep 14, 2009 by Doug Iliff | Comments[7]
The Nanny Practice
Due to pelvic pain without a clear etiology by history and physical exam, you schedule an abdominal ultrasound for your patient at a different facility the next morning. Which of the following best describes your personal responsibility for follow-up of this test?
a. You tell the patient to call for a report next week if she hasn’t received results by phone.
b. You tell the patient to call for a report the next afternoon if not contacted by your nurse.
c. You ask the ultrasonographer to call you on your cell phone when results are available, and then you call the patient personally.
d. You set your PDA alarm to notify you 60 minutes after the scheduled sonogram, and you call the ultrasonographer for results.
e. You set your PDA alarm to notify you to call the facility to see if the patient shows up at the time of the exam.
f. You set your PDA alarm to remind you to call after breakfast to remind the patient about the test.
g. If the patient does not answer or show up, you call her work, and if she is not there, you notify the police to put out an APB and escort her to the facility.
From that spectrum of choices you can catch my drift. It is not a simple choice, because it involves two competing values: to do your best to assure a good medical outcome, and to do your best to encourage and empower the patient to take responsibility for her own care.
Last night I watched a DVD of The Soloist, the story of a schizophrenic Juilliard dropout homeless on the streets of Los Angeles, and the reporter who tries to “help” him. It is a frustrating task, because society refuses, as a matter of law, to force a psychotic to take the medicine that would allow him to function.
It’s a story I saw played out before my eyes in 1975, when I was an intern in charge of psychiatric services at a medical school emergency room. The ACLU in those days was judicially emptying the long-term psychiatric facilities, arguing that patient autonomy trumped imposed medical care.
On March 20, 1981, Bradley Boan marched into the emergency room and murdered a doctor, a nurse and a patient. I had admitted him several times, only to see him exercise his right to be crazy the next day. The lawyer for the families of the victims considered naming me in a lawsuit, but reconsidered.
Go figure. No one ever said value judgments were easy.
So where do you stand on the Nanny State paradigm? The legal profession, and society in general, is deeply conflicted on this issue. Are you going to make 14 phone calls to track down a patient who fails to deliver a follow-up urinalysis?
Because there are so many variables, general rules are impossible. That’s not going to stop me from offering a general opinion, in the hope it will inspire young family physicians to think deeply about this issue.
I believe that I have an obligation to do my best to assure that tests I obtain in my office are tracked back to my office, and acted on appropriately. For that reason, one of our staff members maintains a log of these tests.
Once the patient leaves my office, though, I think the responsibility is on him. We do our best to grease the skids, making specific appointment times when possible. But I’m not going to follow him around town or serve as his alarm clock.
From the first day I opened my practice, every family has been given a loose-leaf notebook with educational materials and dividers to organize their health information. They get copies of all their lab and x-ray reports, and my handwritten progress note sheets include a punched NCR copy for them to file away. Do they do it? Some do, some don’t. I don’t check. But I send them a message from the start: This is your health, and I expect you to be the lead partner in this relationship.
At the other end of the spectrum in our town is a pediatrician, an excellent and dedicated clinician and a nice person. She fosters dependency in her patients to a degree I would not have thought humanly possible. When I see her in her car, she is on her cell phone. She was evicted from her group practice because she didn’t produce her overhead, and her partners couldn’t tolerate taking calls from her patients. (She doesn’t have a family).
Do I encourage patient self-care and independence because it is more profitable, and lets me sleep at night? Only God knows. I do know this: The biggest health care crisis involves the American lifestyle, not coverage for the uninsured.
And I’m not going to be there to help my patients make good choices at the grocery store, the restaurant or the refrigerator. It’s on them, and I think we’d better get that straight.
Posted at 09:44AM Sep 08, 2009 by Doug Iliff | Comments[2]
Big Brother will be watching!
As I was driving home from the airport Wednesday morning I heard an enlightening interview on NPR, my default radio station.
Massachusetts, under then-governor and future Republican presidential candidate Mitt Romney, implemented the nation’s first full-court press toward insuring everybody. Now they’re having trouble paying for it. Imagine that! Who woulda thunk? So Congress is watching closely.
“The first thing they decided – unanimously and right off the bat – was that the current way of paying doctors, hospitals and other medical providers has got to go," reports Richard Knox. "… Massachusetts is going to try to kill off fee-for-service.”
Massachusetts policymakers want to replace it with "global payment" – paying groups of health care providers a flat yearly fee for each patient they cover. "Global means it's for all services," says Dr. Rick Lopez, chief physician executive of Atrius Health, one of Massachusetts' biggest doctor groups. "It includes when the patient comes in to see the physician, hospitalization, pharmacy, skilled nursing facilities, home care services – the whole spectrum."
Gee, that sounds a whole lot like “full capitation,” doesn’t it? That means they’re going back to “gatekeepers,” aren’t they? Remember how much fun that was? The calls in the middle of the night for permission to patronize the ER for belly pain? Patients questioning our integrity and commitment to them, rather than our income?
Ah, but this time it will be different! The problem in the 1990s was that there was no way to track, identify, prosecute and execute the bad apples in the primary care specialties. But now there IS a way! Read this carefully:
"To avoid a repeat of that experience, advocates of global payment say health providers will have to be watched closely. 'You need someone monitoring this,' says Nancy Kane of the Harvard School of Public Health. 'You can't just walk away because you've set the limit.' Kane is a health care finance expert who also served on the recent Massachusetts Payment Reform Commission. She says there are ways these days to prevent stinting on care. 'There's a lot of quality measuring that can go on now that didn't used to be available,' she says. 'We now have electronic medical records. It's easier to monitor what's going on. So I think the whole reporting system and the intention to maintain a monitoring infrastructure is all critical to avoiding the bad days of managed care.'"
Academics and bureaucrats love terms like “monitoring infrastructure.” That’s an Orwellian term for “Big Brother Is Watching You.” It sounds so easy, and so painless. But, of course, the Devil is in the details.
And, of course, there's the problem of the surgeon who examined my nurse for five minutes, sent me a three-page dictation, and charged for a top-dollar consultation physical. The system Massachusetts is heading toward will punish the honest, and reward the liars. Next step: Every encounter will be filmed by a hidden camera, and stored on government servers.
Until I heard the italicized comment above, I thought my friends in the blogosphere – who viewed the EMR as a plot by insurance companies to deny care – might be a bit paranoid. Mea culpa. They were right all along.
Dr. David Kibbe, who is as close as it comes to a guru in FP-IT, penned a great opinion piece in the latest Family Practice Management. He advocates plug-and-play modularity for components of the electronic medical record. Rather than a single vendor providing a comprehensive program at an extortionate price, with the separate elements always lagging the latest innovations in the marketplace, these elements should be disintegrated.
As Paul Nutting wrote in his initital assessment of the National Demonstration Project, “[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connection, evidence at the point of care, disease registries, and interactive Web portals without an EMR.”
To which I say, “Amen.”
Dr. Kibbe goes on to describe the ugly political state in which the Academy is trapped. (It essentially backed the wrong horse in the Derby, and now there's no winning ticket to cash.) Big vendors are fighting tooth-and-nail to slow the shift to plug-and-play modularity – that is, the same way you can buy separate applications, cheap, for your iPhone. They succeeded in getting the Feds, as part of their incentive program to adopt EMRs, to mandate comprehensive applications from single vendors.
This is an old, and familiar, political game. This is how we continued to subsidize tobacco farmers while we stigmatized tobacco users. This is how we continue to subsidize corn farmers while Americans are fattening on fructose-flavored soft drinks. This is why politicians should be banned from certain activities.
The fundamental problem, of course, is that we are led by politicians. They’re not bad people. They’re just different than those of us who would rather deal with chronic fatigue syndrome than collaborative back-scratching.
I suppose it’s my own fault – me, and tens of thousands like me. I never liked committee meetings. I liked patients. Mea culpa, mea maximal culpa.
Posted at 11:37AM Aug 27, 2009 by Doug Iliff | Comments[0]
Family (physician) values
I know I’m fakin’ it. I’m not really makin’ it. This feeling of fakin’ it – I still haven’t shaken it. – Simon and Garfunkel
Bill James is a world-renowned baseball analyst. After laboring for years in near-obscurity, his views are now near-gospel in many professional circles.
For four years we were contemporaries at the University of Kansas. He was the last Kansan drafted for the Vietnam War; my lottery number was 313, so I was safe. He went on to fame as a statistical genius; I passed on that internship at Sports Illustrated to attend med school.
C’est la vie. Look who gets to blog for Family Practice Management, Bill! Can you hear me now?
Bill once wrote, and no truer words have ever been writ: “One of the unwritten rules of economics is that it is impossible, truly impossible, to prevent the values of society from manifesting themselves in dollars and cents. This is, ultimately, the reasons why athletes are paid so much money.”
Allen Barra, writing in the Wall Street Journal, adds this: “It isn’t some vague indefinable ‘they’ who pays the players. It really isn’t even the owners. It’s you, or rather, it’s us. If we put our money where our mouths are and support cancer, AIDs or Down syndrome research and then buy our tickets with what’s left over, athletes and rock stars will actually be paid what we pretend they should be paid.
“The fault lies not in our All-Stars, but in ourselves.”
Barra is quoting the Bard, as I was on June 1. It all comes back to Shakespeare, and ourselves, in the end. Society gets what it deserves; doctors get what we deserve.
Since I’ve fallen into a rut of quotations, let's make it a little deeper by paraphrasing Lincoln: "Now we are engaged in a great civil war, testing whether that profession, or any profession so conceived and so dedicated, can long endure."
Week by week, we’re watching it play out in Washington. Will family medicine survive? We are met on a great battlefield of that war. It’s an ugly process. It’s unbelievably messy, and contentious. Winston Churchill said: "Democracy is the worst form of government, except for all those others."
For all its inconsistencies, sham, pretense, inefficiency and corruption, democracy always beats tyranny or oligarchy, just as free markets always beat central planning. Sometimes it takes a long time.
In the end, all you can control is what is under your own thumb. Society is going to get the health care it wants and deserves, and you are going to get the medical career you want and deserve.
Make no mistake: You are not a helpless pawn in an inscrutable system. Our situations are all different, but we have this in common: We are free moral agents, and our actions (but not our passions) will always have an effect.
Are you fakin’ it? Are you murmuring and complaining about the System, or the Man? Get off your keister, and make something happen!
Posted at 09:50AM Aug 18, 2009 by Doug Iliff | Comments[0]
How to manage media medicine
In a prescient letter to the Wall Street Journal, Homer Jack Moore, MD, responds to a previous article bemoaning the ignorance of the medical profession about fibromuscular dysphasia:
“Your report reminds me of yet one more reason why medical care in the U.S. is so vastly expensive with little extra gain in any actual outcomes. While the implication in this article that American doctors know little or nothing about this 'common' disease is terrific for newspaper circulation, it results in terrible practice of medicine. FMD was fully reviewed in the New England Journal of Medicine in 2004 (in a report co-authored by Dr. Jeffrey W. Olin, no less), and in multiple other medical journals since then. I know what it is. So do my colleagues.
“But never mind that. I can now full well expect a flood of anxious young women (and gentlemen, too, even though FMD is even more rare in men than women) in my office, being among them those afflicted with migraines, aches and pains, anxiety neurosis, depression and other of life's ills, who have all now become convinced that the doctor is a dolt; that indeed, all life's problems would have long been solved had just that right test been done. And they will demand, now, that these tests be done, paid for with other people's money, of course. And I, knowing full well that there is no particular advantage to even the smallest particle of risk of being at the wrong end of some lawyerly deposition inquiry, will give them exactly what they demand.
“Alas, the overwhelming majority of these people will still have only what they ever had: migraines, aches and pains, anxiety neurosis, depression and other of life's ills. But in the vanishing few that, lo, do turn out to have unsuspected FMD, my advice to them, for the most part, will be exactly the same as it ever was: Take an aspirin every day.”
Ever feel like Dr. Moore does? Me too.
I think, honestly, that medical writers are better than ever in my lifetime. Often I get tipped off to relevant scientific developments by reading their columns.
But then there are the cheap-shot artists just looking to make a buck. They start with a sob story, add a dash of factoids, and then bake into an epidemic. Usually an epidemic ignored by the medical establishment; something common. After all, a malady experienced by 1 out of 10,000 patients strikes 35,000 in America every year. Pretty common, right?
There are two ways to deal with this problem, to avoid wasting time playing whack-a-mole with patient questions.
My first effort, early in my career, was to browse the contents of magazines like Ladies Home Journal and Men’s Health in an attempt to stay abreast of the breaking misinformation. That didn’t last long. There was too much trash, and it was depressing.
Then I started my own information campaign. I wrote my own practice newsletter once a year – for an example, see the dig at Dr. Gott at the end of last year’s newsletter. When I read something egregious in the local newspaper, I wrote back for publication. When the Internet revolution came along, I steered patients to reliable sites.
Before too many years had passed, my patients viewed me as the authority to be reckoned with, not the hack in the magazine. I had gotten ahead of the information curve, at least in their minds. That doesn’t stop them from asking questions, but it does stop them from questioning my answers – most of the time.
Unless writing is excruciatingly painful for you, I think you will find this useful, and maybe fun. Start with the mini-lectures you give every day. We all have them. Why not write them down? Let your personality flow through.
One of the worst pieces of advice I got in medical school was to guard my ‘professionalism’ – which meant, act like a talking robot. Balderdash. We’re all unique, and the better patients get to know us, the better they’ll sort themselves into good matches with their primary physician.
The Academy has hundreds of patient information sheets available, but they’re pretty bland. Not bad, just safe and boring. The rule seems to be “don’t say anything that stands a remote chance of being misconstrued” – like they are written by a committee. And they often advise to consult your doctor for this, check with your doctor for that – for stuff, it seems to me, ordinary commonsense people usually handle without consultation, except maybe from Grandma. If I wanted to engender dependency, I’d become a Democrat.
Frankly, when I write an information sheet it is with the intention that they won’t consult their doctor. That’s how I get an uninterrupted night’s sleep.
Posted at 06:26AM Aug 07, 2009 by Doug Iliff | Comments[3]
The Ringelmann effect, or Has family medicine lost its élan vital?
A French agricultural engineer named Maximilien Ringelmann performed a classic experiment over a century ago that you could replicate in your own backyard, playground or office.
He measured people pulling on a rope connected to a strain gauge, both as individuals and as part of a group tug-of-war. Result: People pull harder as individuals.
Ringelmann called this “social loafing.” We all remember it from group projects in school. Since as physicians we are overachievers, chances are you remember carrying the load for the deadbeats, as I do. Teachers think this is great. I think it’s nuts.
What happens to per-doctor productivity when a hospital buys a private practice and everybody goes on salary? Yep. Productivity plummets. That’s Ringelmann for you.
As the Dare to Slack poster says, “When birds fly in the right formation, they need only exert half the effort. Even in nature, teamwork results in collective laziness.”
On the other hand, teamwork is essential in the business of medicine. Without loyal, intelligent and hard-working (not to mention beautiful and handsome) colleagues, life would be a nightmare anywhere except a micropractice. So what are the laws of productive teamwork?
First, the team has to have a good Captain, and the lines of authority and responsibility must be clear. The buck has to stop somewhere; that would be the boss. Some bosses can’t make decisions, or they fear responsibility. Their teams won’t be productive.
Second, productivity must be rewarded. I’ve dealt with this at length elsewhere. In a solo practice, this happens by default. In a group, the compensation formula must be simple, fair and transparent. There is no shame in not wanting to work as hard as the next guy. The shame is in wanting to be compensated as if you were.
When I first came to Topeka in 1980, I intended to join a group practice run by a man I respected greatly. But I also wanted to start a private school for my kids. So I negotiated a half-time job. I didn’t want to be paid 75 percent of what the others made; 50 percent would have been just fine. There was nothing immoral about that. One member of the group just couldn’t believe I wasn’t going to be ripping them off, so I withdrew and went to work in the emergency room. But there’s no problem in principle for wanting an honest half-day’s pay for an honest half-day’s work.
What’s immoral is expecting the other members of a group to financially support your desire to carry on leisurely chit-chat with 15 patients per day.
The profession changes with the culture. When I was a resident, taking call every third or fourth night, old-timers thought I was a slacker. They had spent 120 hours a week in the hospital. But their mentors thought they were slackers, because they were allowed to be married. Not so very long ago, you see, only single men were admitted to medical school.
So I don’t want to play that game. You won’t find me looking down on someone because they want to enjoy spouse and family, as well as the medical profession. That’s what I wanted, and that’s what I got.
My disquiet comes from a suspicion that fledgling family physicians want their jobs microwave-ready; that maybe their mentors weren’t all that successful in private practice and found academic medicine a haven from its demands; that, perhaps, the specialty has lost the dynamism, creativity and entrepreneurial zeal it had in 1975.
Teamwork has its uses, but it is not the font of dynamism, creativity and entrepreneurial zeal. So when I hear the “leaders” of family medicine talk too much about teamwork, I want to ask: Quo vadis, Captain?
Posted at 12:01PM Jul 30, 2009 by Doug Iliff | Comments[4]
What to do with the difficult patient
These thoughts were inspired by “The Burden of Difficult Encounters in Primary Care” in the February 23rd Archives of Internal Medicine.
Since the subject surfaced in the 1990s, it has been repeatedly demonstrated that physicians of all specialties find 1 in 6 patient visits to be “difficult” (synonyms: “heartsink” and “black hole” in British literature, and “problem,” “disliked,” “frustrating,” “troublesome” or “hateful” in America).
But you know the type.
Over the years it has increasingly been recognized that this is not all the patient’s fault. The doctor plays a role, too. This article indicates that it’s a pretty big role. That’s good news, because there’s not much we can do to change anyone except ourselves.
Subspecialists have a much higher percentage of difficult encounters than general internists or family physicians. No surprise there. If you can’t handle long-term relationships, with all the attendant conflicts, choose work at the other end of a colonoscope.
The interesting thing about this survey of 423 primary care physicians is how they stratify. For instance, 41 “low difficulty” physicians were characterized by “an almost complete and unanimous indication of no perceived difficulty with patients they saw.”
On the other end, 113 “high difficulty” docs “had almost complete and unanimous indication of working with difficult patients.”
Obviously, it’s not the patients.
When I read the accompanying editorial, and before finding that 10 percent of primary care physicians experienced virtually no obnoxious patients, I was thinking, “I am either in denial or really weird.” Now I know that I have a little company.
The question is, can “we few, we happy few, we band of brothers” recruit converts from the rest of the profession?
Hints: We happy few averaged 46 years of age, while les miserables averaged 41. So hang in there another five years; there’s hope. And 50 percent of les miserables were women, compared to 27 percent in the “low difficulty” group. Somehow I don’t think a sex change operation would solve this problem.
Ethnic/racial and work status (full- or part-time) didn’t seem to make a difference. High-difficulty docs are 12 times more likely to experience burnout than low-difficulty types. No surprise there, either.
The authors duck hypotheses for the dramatic gender differences but offer two explanations for the effects of experience, one of which seems reasonable to me.
One is that older physicians have developed coping mechanisms to mitigate the difficulty. For me, one of these mechanisms is simply “tincture of time.”
I have so few perceived difficult patients in my practice that they come immediately to mind. One is a distinguished looking lady who is never, ever satisfied with the care she receives; yet she comes back for more. Recently I received the usual humane and thorough referral letter from the Mayo Clinic, which is my Golden Turf. The office staff laughed out loud as we read the author’s exquisitely phrased note, which said, between the lines, “Boy, I’m glad she’s going back to Kansas! She wore me out.”
That makes me feel better. Mayo can’t stand her, either. So we’ll just hang on and do our duty.
Another is a woman so severe-looking, with every facial line pointing toward her toes and a voice to match, that she invokes Alexander Theroux’s classic description: “Her piss would etch glass.” Since I found a huge ovarian tumor on a database physical visit she had long resisted, we have achieved rapprochement. In repayment for saving her life, she occasionally blesses us with a smile.
A smile from her is better than a slap on the back from anyone else.
Another effect of time is that the better I know a patient, the easier each encounter becomes – both professionally and personally. My world-class hypochondriac, after 20 years of relationship, now opens every encounter with, “I know you’re going to think I’m crazy, but … .” And I do, and she knows I do, and we get along just fine. She now believes my reassurances, sort of.
A second factor raised by the authors is “self-selection” on the part of patients. This doesn’t make any sense, unless they mean that disagreeable patients seek out disagreeable doctors. Here’s what does make sense: If I kindly but persistently refuse to meet the unreasonable demands of a difficult patient, either he will learn to behave or leave my practice. This is a win-win for me, and a win-lose for him. Three out of four ain’t bad.
Or it could mean this: I once gave one of my best friends the heave-ho from my practice. He was sweet as pie to me, but an absolute jerk to my staff. I don’t like “respecters of persons,” to quote St. Paul. After two warnings, he got walking papers. My staff learned that I stood behind them, even when it cost me personal pain.
My advice for all you whippersnappers is to give private practice at least a decade before throwing in the towel. But you’ve got to work at it. If you don’t, at some level, love the knuckleheads in your practice, bail early. I’d suggest anesthesia or pathology.
The authors suggest additional training in the biopsychosocial arts, or counseling, but I’m not sanguine about those. Part of it is having the right personality (maybe part of that is having the right religion), and the other part is motivation and will to fix what’s wrong in your attitude and your practice. That comes from within, not without.
Posted at 11:31AM Jul 20, 2009 by Doug Iliff | Comments[1]
Surveys and other time-wasters
In case you don’t read the papers or listen to the news, good for you! And here’s an executive summary of the last two weeks.
Health care “stakeholders” pack congressional hearing rooms; embarrassing picture taken, reminding ordinary people that no one is lobbying for them. President Obama promises a nice raise for primary care physicians, and cuts for everyone else. Procedurists scream like stuck pigs. Congressional Budget Office scores health care proposals; looks like no raises for anybody. Rep. Charlie Rangel solves scoring dilemma: tax surcharge on everyone making over $350,000. Procedurists scream like stuck pigs.
That’s the news for the last fortnight, and good luck to you if you’re counting on the politicians to save us. So, in the meantime, lets talk about something practical. Like surveys.
Surveys are big right now. If you want to be a “medical home,” you’re going to need to survey your patients. You’re going to ask them to respond (on a scale of one to five, with five being “strongly agree”) to items like “I can get an appointment with Dr. Iliff quickly,” or “Dr. Iliff spends enough time with me at our office visits.”
You know the drill. And if you’re in a big group, you’ll have to grin and bear it. Even solo physicians like myself are periodically exposed to patient surveys by insurers, although I don’t have to waste any personal time participating.
Then will come the results. You’ll find that when it comes to waiting for appointments, you rate a 4.1 against the group average of 4.3. But hey! Once you get them into the room, you’re a 4.2 against the group’s 3.9!
So what are you going to do with that information? Quicken your visits by 0.2 in hopes of shortening the wait by 0.4? And does a delta of 0.2 mean anything, anyway?
The problems associated with surveying are legion. Just ask someone doing meaningful research – that is, something other than devising the 1,232nd question to detect the closet alcoholics in your practice. If you’re relying on a survey, your research is crap. That’s why I always file them in the wastebasket.
If you’ve read this blog more than once, you sense that I’m impatient. I don’t like wasting time. If it’s not actionable intelligence, bother somebody else.
But I know I’m in the minority. If I were still in academic family medicine, it would be an infinitesimally small minority. The world is full of talkers. Cogitation and blophilating* pass for action. But they are not action. They are vapor, like carbon monoxide.
If you are a young family physician, and you like to spend time with your family while earning a good living, you’ve got to develop strategies to avoid the time wasters in your professional life. President Obama can’t do it for you. The AAFP can’t do it for you.
On rare occasions I read something heartening in my local paper. The city council voted to spend $20,000 for a study of bike trails. They were “incentivized” by the Feds, who would toss in another $80,000. That’s the way the Feds add value.
Our elderly mayor, a man of distinguished character and long experience, is fighting pneumonia. He rose from his hospital bed long enough to veto the expenditure, noting that the city planning staff is quite capable of performing that function in the normal course of their duties. In fact, the staffer who designed a wonderful plan of bike trails for our town – which is being implemented, one year at a time – is one of my patients.
The mayor knows that a whole industry has grown up to “facilitate” planning, strategizing, surveying, resolution-writing, brainstorming, consulting, goal-setting, and focus-grouping. If you don’t read Dilbert, do**: that’s where you go to get your head straight after you’ve run into one of these gurus. They want your $100 grand, in time or money.
Just say no. You must develop a bias for action, and a nose for BS. To help get you started, browse at despair.com. I put their posters on the ceiling, for patients suffering indignities in the prone position.
* neologism: "the love of being a blowhard"
** Six hours after I wrote this (no kidding) the Sunday paper arrived on my driveway. The Pointy-Haired Boss tells Dilbert to collect useless information that will be out of date before it is compiled. Dilbert: "The best way to compile inaccurate information that no one wants is to make it up." Pointy-Haired Boss (to Catbert, evil head of HR): "I hope no one ever comes here to learn our best practices."
Posted at 11:03AM Jul 17, 2009 by Doug Iliff | Comments[1]
Six myths that frame the health care debate
This week I am shamelessly plagiarizing the rant of one of my few good friends, Dave Clark, a dermatologist who was once a general internist in private practice before illness prompted a career change. It has to do with the foggy state of public thinking about medicine.
Myth 1: President Obama is trying to pull a fast one. He wants to ration care based on medical evidence.
To see how he’s getting grilled on this issue, including his awkward response to the daughter of a 105-year-old who survived a pacemaker implantation at age 100 that her doctor had advised against, see this article (I'm not a World Socialist-- it was just a good link). In fact, medical services are rationed now in any number of ways – including, but not limited to, ability to pay, insurance approval, location, transportation, attitudes of relatives and competence of medical professionals. Americans don’t get upset at rationing of BMWs or Viking ranges. Pacemakers are a horse of a different color.
Myth 2: Medical care is a private service business, like the local donut shop. Do you like cake or glazed?
In fact, the health industry is so big, and often so monolithic, that it has become more like your local utility. When it comes to utilities, Americans get pretty goosey about cutting off the juice. This issue has not been settled yet, but it doesn’t take a weathervane to know which way the wind blows. Once medical care is deemed a utility in the public consciousness, and the pipelines run short of gas, rationing is inevitable. Ask your grandparents about life during World War II, and see Myth Number One.
Myth 3: Physicians are disinterested with regard to cost-effectiveness.
In fact, every one of us makes decisions daily that remove money from the wallets of our patients and insert it into ours. A professional is an individual who works with little or no supervision, in the service of a client, with only an internalized ethical standard preventing him or her from taking advantage of an asymmetric power relationship. And the decisions of physicians – largely in those specialties where new procedures and technologies require ad hoc reimbursement determinations, or where restricted residency slots create barriers to entry and cost competition – are bankrupting the country. Often these decisions are blamed on lawyers and defensive medicine. I think greed and cowardice play a part too.
Myth 4: We’re smart enough now, or will be soon, to consistently make “best practices” decisions in our exam rooms.
In fact, we aren’t and never will be. Dave posits a good example: for that basal cell on your face, is it a curettage for $250, which leaves a white divot and a 5 percent chance of recurrence, or a Mohs for $2,500, which is invisible with a 0.1 percent chance of recurrence? Forget “number needed to treat” or “years of quality life expectancy” for choices like that. Who gets to choose? And who gets to pay?
Myth 5: Consumer empowerment, in the form of Health Savings Accounts, carrot-and-stick incentives from employers, or whatever, can save us from ourselves.
The key question is this: with or without our consent and/or cooperation? I will take it as a fact, based on being the medical director of a minor emergency clinic for 23 years, that one-fifth of the population has adequate insurance or money but still chooses to practice “breakdown maintenance” when it comes to their health. Medical home? Fuggedaboudit. What are you going to do with these knuckleheads, and the many other varieties who sabotage their bodies on a daily basis? I remember from my boyhood a Life magazine cover displaying thousands of communist Chinese doing mandatory morning exercises in Tiananmen Square. That would be my personal solution, but somehow I think I’d get lynched before it was implemented.
Myth 6: We’re in a war between Republicans and Democrats, capitalists and socialists, and to the winner belongs the future of health care.
This is a logical fallacy (“false dilemma”) which omits consideration of other reasonable alternatives. Republicans and Democrats are Tweedle-dum and Tweedle-dee. In fact, Americans of all political and philosophical persuasions are increasingly locked into a mindset of radical individualism, of personal rights without commensurate community responsibilities. This is the back story of this debate, and politicians may not be up for the challenge.
Optimism has worked pretty well for me over 60 years, although I’ve been mugged by reality and have scars to prove it. I agree that all of these are more-or-less myths. But I won’t be sucked into a reductio ad absurdum: Taken uncritically, the sum of these myths is that the cost of health care is inevitably going to bankrupt America, and there’s not a doggone thing we can do about it.
I’m not smart enough, wise enough, or clairvoyant enough to predict the final solution. But one way or another, the polis will accept some limitations on their desire for unlimited benefits, some responsibility for their own actions, and some requirement for wiser shopping and sharper questions – all in some way compatible with the unique character of Americans.
One way or another, primary care is going to be in the middle of that solution. I’ll probably be in a rocking chair by the time we figure it out. In the meantime, there is no excuse for family physicians not to be doing well (or at least better) by doing good.
Posted at 11:50AM Jul 09, 2009 by Doug Iliff | Comments[5]
Dittoheads of the world, unite!
I know I’m running out of things to say about practice management when I read a series of great articles in great publications – and all I can add is “ditto.” I never wanted to be a dittohead, and I don’t listen to Rush Limbaugh. But there are only so many valid points to make, and unless I want to make them again with different examples, or move on to some other subject, I’m reaching the end of my tether.
Dr. Mark Sklar, an endocrinologist and assistant professor of medicine at the hospitals of Georgetown and George Washington University, popped a good opinion piece in the June 23rd Wall Street Journal. Although he is a specialist and I am a generalist, the fact that we have both experienced academic bureaucracies and opted for private practice makes us blood brothers. Like this:
"Contrary to what you may have heard, my experience is that smaller practices provide better patient care than larger practices. There are no economies of scale in medicine. If you hire more physicians, you need to hire more support staff to deal with the increased work demands. Larger practices with less support per physician often end up providing worse service. They also require office managers, and sometimes even managers of managers, all of which just bloat costs."
Like I said before, doctors are really piece workers. There are no efficiencies in numbers. Have I mentioned that I don’t have an office manager, so I don’t have to pay my share of a $50,000 salary? That goes to my kids’ college fund. True, I have to make small day-to-day decisions between patients. Also true, I don’t have to meet with the office manager to go over those decisions, and check on the implementation later. I wouldn’t remember anyway. Short attention spans have their advantage, in the right setting.
"I worked in a university multispecialty practice for seven years before establishing my own private practice. At the university practice, I found that patients' requests often went unfulfilled. Phone messages didn't get to me, and charts and laboratory tests were routinely lost. In my own practice, my fingers are continuously on the pulse of my staff and patients. Because I can overhear how staff interact with patients, I can intervene rapidly if patients are not getting good service. We routinely have patients transferring to us from larger multispecialty practices where they often wait for hours to be seen, aren't called with their test results, and their phone calls are ignored."
My town is crawling with good doctors, including primary care – we had a family practice residency here for a long time, and lots of them stayed put. Every time I call my primary hospital, I listen to an advertisement for my competitors while I’m on hold; I read their full page ads in the paper; they dominate the evening news and the Yellow Pages. How is a solo FP supposed to compete? Like Dr. Sklar says. Our patients are treated like royalty. I was recently invited to join a large “concierge” organization, but there was a major problem: How was I going to offer VIP patients better service than they’re getting now for nothing?
"Electronic medical records have been praised as a way to save money and avoid duplication of tests. It's true that electronic medical records will save some money, but not as much as you probably are counting on. In my practice, if a patient tells us he had a test performed, we call the physician or medical facility to retrieve the results…. When I refer a patient, I fax or mail over pertinent notes, lab work and radiology results so that the specialist knows the patient's problem and doesn't need to perform additional unnecessary tests. The specialists that I refer to either call me or write comprehensive consultation letters so that I am aware of their treatment plan and can coordinate future care with them."
When I read articles lauding EMRs, I feel like I’m in a parallel universe. You need an EMR to avoid duplication of tests and services? Like Dr. Sklar says, that’s what a fax machine is for. An EMR will save paper? Every time I get a “Practice Partner” five-minute office visit from one consultant, it occupies four pages of trees. An emergency room visit runs to eight single-spaced pages. It’s damn difficult to find the important stuff in all that computer-generated, ass-covering verbiage. If everyone shared a common platform, that would be one matter. But the government refused to mandate that a decade ago, and I’m paying for the results. Some day the Betamax/VHS, Blu-Ray/DVD, 8-track/cassette issue will be settled, and that’s the day I’ll shop for an EMR.
Don’t try telling that to the Patient-Centered Medical Home folks, though.
Posted at 12:22PM Jul 02, 2009 by Doug Iliff | Comments[4]
The health care debate heats up
On occasion I am brutally honest with patients about their differential diagnosis. I tell them of several possibilities, but conclude that the most likely is “God Only Knows.”
This has been an active fortnight for news about reforming our health care non-system, highlighted, I suppose, by President Obama’s frank talk with the AMA and the Congressional Budget Office shooting Sen. Edward Kennedy’s plan out of the water.
As of this writing, and for the near future, God Only Knows is the front-runner.
What I look for is honesty about the real challenges. And, lo and behold, we’re starting to get a little honesty.
It started with Dr. Atul Gawande’s New Yorker article (see my June 1 blog post), which President Obama made required reading for White House staffers. Then he mentioned it in his AMA speech. In his punch line, he referred to “…a system of incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I’m talking about.”
Throughout the speech, the president got a lot of nervous applause, and one standing ovation (“You entered this profession to be healers – and that's what our health care system should let you be"), but the line about incentives got stony silence.
If you want a useful and perceptive commentary, read Dr. Abraham Verghese’s article, “The Myth of Prevention,” in the June 20 Wall Street Journal.
If you don’t have access to these articles, or the time to read them, here’s an executive summary of the debate to date:
The CBO decided that Sen. Kennedy’s bill would cost roughly $1 trillion over 10 years, and still leave 37 million Americans without insurance. That was a big "OOPS!" for congressional Democrats.
Dr. Gawande usefully observed that doctors make a lot more money when they decide to order tests and procedures which make them a lot more money. He did not have a solution to this problem. The solution I favor, Health Savings Accounts, he dismissed by noting that no one shops for price when chest pain strikes in the middle of the night, which is true. He failed to point out that lots of people shop for price in the course of my routine office practice, which, to be fair, is completely outside his limited experience as a surgeon and author.
Dr. Verghese, an internist and infectious disease specialist, writes:
“Cut, poke, sew, burn, insert, inject, dilate, stent, remove and you get very well paid; if you learn how to do this efficiently, maybe set up your own outpatient center so you can do it to more people in a shorter time (which is what happened when this payment system was put in place in 1989) and you are paid even more. If, however, you are a primary care physician, and if, just like the young doctor who saw my parents yesterday, you spend time getting to know your patients, and are willing to play quarterback when your patient enters the hospital, so that you can herd the consultants and guide the family through a bewildering experience that gets surreal if you are in the intensive care unit, then you may have great personal satisfaction but you will make five to tenfold less than your colleagues in the doing-to disciplines.”
No argument there. But aside from “behavioral things – eat better, lose weight, exercise more, smoke less, wear a seat belt,” he is skeptical about preventive medicine. Primary prevention through the use of statins may not be cost-effective (unless you are careful to use generics when possible); there are lots of technological gimmicks, like CT scans for coronary calcium, which don’t add much except anxiety.
Dr. Verghese is also skeptical about electronic medical records: “…an electronic medical record (EMR) may or may not save money (it won’t be anywhere as much as is projected) but what it will do is ensure that we doctors, nurses, therapists, particularly in hospitals will be spending more and more time focused on the computer, communicating with each other, ordering and getting tests, buffing and caring for our virtual patient – the iPatient is my term for this phenomenon – while the patient in the bed wonders where everybody is. Having worked exclusively for the last seven years or so in hospitals that have electronic medical records (EMR), I have felt for some time that the patient in the bed has become an icon for the real focus of our attention, the iPatient. Yes, electronic medical records help prevent medication errors and are a blessing in so many ways, but they won’t hold the patient’s hand for you, they won’t explain to the family what is going on.”
He asserts “the single most important fact about health care in America that you or I need to know. ... all of us – doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others – are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not? – it’s hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman’s plan and scuttled Hillary Clinton’s proposal."
Our leaders in the AAFP are, at this moment, trying to shoulder their way into this trough. And I wish them well, I really do, because their ideas are better than the proceduralists’ ideas. In a perfect world their proposals would be enacted. This is not a perfect world.
Meanwhile, I know this from personal experience: If I am given complete control of medical dollars through a full-capitation model, I will make a lot of money, because I practice evidence-based, cost-effective medicine. If I am simply scored against my peers based on costs that pass through my fingers, even if there is no monetary incentive, I will rank high for the same reason.
For around $200 per patient per year, you can have all of my services, including office visits, labs, x-rays, and obstetrics. My Job One, except for delivering babies, is to keep patients out of the hospital. I'm good at it, Dr. Verghese. Prevention works for me.
Based on proposals he has entertained thus far, President Obama is suffering from delusions about what it will take to reduce health care costs. I am not.
What we need is a system in which patients trust their family physicians, internists and pediatricians to direct their care in a cost-effective, patient-centered, wise and humane manner. This system should not interpose itself between me and my patient, and it should not raise questions about my motives. The inevitable and necessary rationing decisions must be made by patients and their families with the advice of their personal physicians, not by insurance companies or government commissions.
Aside from a universal system of Health Savings Accounts with refundable credits for the poor, I am waiting for alternative proposals that meet these criteria.
But this is beyond my pay grade. In the meantime, I’m Making It just fine, and you should be too.
Posted at 10:41AM Jun 27, 2009 by Doug Iliff | Comments[3]
