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Our medical system has become a
fractured mess. The battle over money and resources has
created a situation fraught with unnecessary risk and
inconvenience to the consumer. It may be sad
commentary but, as a primary care physician, one of my major
functions is to protect my patients from the rest of the
medical system. I heard a news story once that
related the medical system kills a 747 plane load of people
yearly. What about those that are “just” maimed,
misdiagnosed or undiagnosed. Most of the people talking
about this have something to gain from “fixing” the medical
system, by creating new systems to prevent the mistakes that
kill or otherwise mutilate so many of us. I would venture
that most of these fixes will make matters worse by further
complicating the issue.
“Keep it simple stupid” was
never so appropriate. Until someone builds a robot that can
ask you how you feel this morning, give you a pill, and take
your appendix out medicine is going to be a labor-intensive
endeavor. The system we have now diverts resources away from
person power. The end result is that the medical
system is woefully understaffed and overly complicated.
You have to know that a nurse taking care of 6 patients is
going to make more mistakes than one taking care of 4
patients.
Another frightful problem has
been the twisting of priorities by medicine’s fear of the
legal system. Many, if not most, specialists today are more
concerned about their liability than the welfare of the
patient. This is reflected in the care they offer. Add
to this the pressure to generate income and the result is
thousands of unnecessary procedures and tests costing us
billions and exposing patients to considerable risk and
radiation.
So what does this have to do
with primary care medicine? Simple: if patients had
the kind of relationship with their personal physicians they
should have, most of this stuff wouldn’t happen at all.
My father is a perfect example. For decades he used one
physician with whom he developed a great relationship;
indeed, they were friends. He had the utmost confidence in
this doctor’s judgment. Second opinions were never required
unless his doctor himself wanted one. Unfortunately as the
medical system became buried in insurance detritus, older
doctors (including this one) bailed out in early retirement.
He told me that he would have continued caring for a few of
his favored patients like my father but the expense of
practice made it impossible to do so. Malpractice
insurance premiums do not change based on the number of
patients you see. A young doctor then took over his
practice and began practicing in the typical modern fashion,
seeing patients as a clip of over 6 per hour. My father’s
confidence in this doctor deteriorated quickly. Soon he was
running around the medical system looking for second
opinions on his own. He wasn’t even calling this doctor with
new problems but self-referring himself to whichever
specialist he thought was appropriate. Last year he fell
off a scooter fracturing his left scapula. He actually
healed fairly well. The shoulder has full range of motion
and doesn’t hurt any more but the left arm is weaker than it
used to be. A little physical therapy would have done the
trick. Instead Dad referred himself to another orthopedist
that had an entirely unnecessary MRI performed and then
recommended a surgical procedure! I hit the ceiling! In the
old days he would have seen his own doctor who would have
simply ordered the physical therapy. If the old doctor was
uncomfortable with the condition of the shoulder he would
have gotten another opinion from a doctor he trusted.
The point of all this is that people who have good
relationships with competent primary care physicians use the
medical system in a far safer and more cost effective manner
than those who do not. I have never seen a patient
who bounces from one specialist to another get consistently
appropriate medical care and I have been at this for 26
years.
The way our medical system has
evolved has minimized the position of the primary care
physician in modern medicine. As the insurance system
has mutated primary care physicians into petty bureaucrats,
many of us have forfeited our skills and our positions as
patient advocates. We have become traffic cops. Most
of the other primary care doctors in my area do not even see
their patients in the hospital. Inpatient care is dumped on
hospitalists and other specialists. So, when a patient is
sickest and psychologically in need of a familiar face their
personal physician is not available.
It is no wonder that people have
lost confidence in us. It is no wonder that we are sued so
frequently. It is no wonder that the cost of modern
medicine accelerates at a rate far greater than inflation.
Medical care is a dance of complex issues beyond (without
careful explanation) the understanding of even the brightest
layperson. I once got into a friendly medical argument with
a lawyer friend of mine, a Harvard graduate. I opened a
common medical text to the topic in question and handed it
to him. After a few minutes he looked up from the book with
a frown. He had no idea what it was saying because it was in
a language he was never taught. He needed me to translate
for him. I am the translator for my patients.
There may some light at the end
of the tunnel. Large companies who are struggling under the
load of their medical expenses such as GM, IBM, GE and
Toyota have looked at data from other countries such as
Denmark and Belgium who have essentially equal health
outcomes to us but spend 1/3rd per capita what we
do on health care. The big difference? They have much more
effective primary care doctors than we have. These companies
are now looking into ways to provide better primary care.
Unfortunately, picking the right
primary care physician for you and your family is not an
easy process. There are many models of primary care because
so many different types of physicians and even some nurses
practice it. The old GP (General Physician) is all but
extinct now. Medicine has become too complicated for that
level of training. Modern primary care physicians are, for
the most part, from one of three specialties. They are
Internal Medicine, Family Practice and General Pediatrics.
It is extremely important to confirm, whichever type of
specialist you choose, that he/she is residency trained and
board certified. All three specialties have been
forced into the modern, high volume style of practice
mandated by the insurance companies and Medicare which I
find to be incompatible with quality health care.
But some, like me, are attempting to develop higher quality,
more convenient alternatives. Look for these practices many
of them in the context of a less expensive high deductible
health plan or Medicare are very affordable.
The capabilities of the three
specialties vary to a great degree. Just within the
specialty of Family Practice there is wide variation in
capability depending on where the physician trained. Eastern
FP’s tend to practice like Internists that also do General
Pediatrics. Midwestern and western FP’s are more generalized
in that they do a lot of office surgery, dermatology and
many still deliver babies. As a general rule the more
procedural capability a doctor has the more convenient the
practice will be for the patients and more efficient in
terms of expense.
The same is true of
availability. The patients of primary care doctors who
are available at all times wind up with higher quality, more
convenient and much less expensive medicine because drift to
high cost providers such as emergency rooms is limited.
80 % of all diagnoses are made by history. The patient
actually tells you what is wrong you just have to listen and
ask the right questions. 15% are made on exam and 5% by some
test. What this means is that a smart doctor can make the
right diagnosis over the phone 80% of the time and initiate
therapy without having to inconvenience the patient with an
office visit. Most doctors won’t do this because they do not
know their patients well, are covering for another physician
and don’t know the patient at all, won’t accept any
liability and most importantly they only make money on live
patients in the office, not on phone calls. In many
instances this will be the rule of an employer such as a
hospital clinic…which brings us to one very important item.
NEVER use a primary care doctor who works for some other
entity. Your personal physician should be employed by
his/her patients ONLY. Any other arrangement is a
conflict of interest. I include insurance companies
in the category of “other entity.”
The single most important aspect
is the physician-patient relationship itself. Once you
find a doctor you like, get along with and is available –
stick with him/her. One of the saddest and most destructive
aspects of this insurance run medical system is the doctor
bouncing it causes. An employer changes insurance
companies and the employee has to use an “in network”
physician or be penalized monetarily. It is virtually
impossible for the best doctors to contract with every
insurer. Because they are so busy they knock off the poor
payers or the insurers that cause the most headaches. So,
patients are frequently forced to move away from a physician
they have developed a good relationship with. GET THE
INSURANCE COMPANIES OUT OF PRIMARY CARE.
I am a Family Physician so it
should be no big surprise that I gravitate towards that
model of primary care. For a younger family with children it
certainly makes more sense. Internists do not handle younger
children and General Pediatricians are not trained to handle
many of the accidents children get into. They do not suture
lacerations as an example. There are many excellent
Internists in the area that would be great for older
families. Most will handle children over 15. However, many
internists are not given a great deal of procedural training
so just about any injury is going to result in an emergency
room or subspecialty visit. Many internists are giving up
private practice and becoming “hospitalists.” Doctors who
only take care of hospitalized patients.
If it sounds like I am shaking
the trees rather hard…I am. Many of my colleges are going to
be very unhappy with what I have to say. As one of my
favorite authors (Kurt Vonnegut) use to say “So it goes.”
12/12/07
Dr Mike
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