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]
