Each ad terminates with, “Ask your doctor if [our pill] is right for you.” As so instructed, that is precisely what patients do. Every minute wasted discussing an ad about the relatively obscure restless leg syndrome or the “heartbreak” of toenail fungus is subtracted from the already scant time reserved for private and personal conversation between patient and doc-tor. More relevant and pressing concerns such as screening for depression, assessing the risk of a fall at home, or discussing proper nutrition come only after the obligatory product review is completed.
Tuesday, July 25, 2017
The life-advisory aspect of the physician’s care
The life-advisory aspect of the physician’s care falls widely outside the narrowly defi ned procedure codes devised by private health insurers. It is conspicuously absent from the Medicare physician manual, and it also fails to appear in the stepwise diagnostic and treatment protocols that are established by government and health insurance companies that champion effi ciency and uniformity of care.
Women And children first
. The Centers for
Disease Control and Prevention issued an advisory recommending that
the sick and elderly receive priority in vaccination. That was like shout-
ing “Women and children first!” aboard a sinking ship. Patients never be-
fore willing to receive the flu vaccine oddly now demanded one
“I forgot my wallet.... Just bill my insurance.... My son handles my
checkbook.... Under our divorce agreement, my ex-husband pays all of
my daughter’s medical bills.... I’m shocked, shocked that you don’t ac-
cept American Express!” Patients who would willingly whip out their
wallets for their pets at the vet, for groceries in the supermarket, or for
a haircut, suddenly develop tight-fist syndrome in the doctor’s office.
Debt consolidators and personal financial consultants advise: “Pay your
doctor last.”
A tenacious health insurance biller is one of a physician’s most highly
valued staff members, a specialist in his or her own right, worthy of com-
bat pay. My busy practice required that I maintain one full-time employee
whose
Maintenance of an Office of the Exchequer, focused by
necessity on the fiscal fitness of the practice rather than the physical health
Why I Hate Stupid and Poorly programmed Electronic Health records
Ideally, the computer should outshine paper charts when it comes to the organization and retrieval of health information. With a stroke on the
keyboard or the click of a mouse, a patient’s sequential blood studies, chest X-rays, or mammograms should be accessible for immediate review. The potential errors of a lab report misfiled in the wrong patient’s chart, or a critical lab result that goes unnoticed, should be prevented by a computer-based system of data storage and recovery. Every minute saved from searching through a thick paper chart could be utilized by the physician for direct care of the patient.
Unfortunately, the computer does not score as well with regard to the efficient and effective recording of a physician-patient encounter. Software that is presently available demands that the physician personally input all data, obviating the cost of a transcriptionist, but it dips into time that should be spent with the patient.
The Nursing Assistant inputs that theses were all done where as in fact nothing is done.
Diet Education
Seatbelt Education
Alcohol screen
Colon cancer screen
Annual Mammogram
Annual Colon Screening
Smoking cessation Education and counseling
Suddenly Hba1c has been changed to label
Glycosylated hemoglobin
so much so None of the previous A1c readings show up when you click on the new label
Unfortunately, the computer does not score as well with regard to the efficient and effective recording of a physician-patient encounter. Software that is presently available demands that the physician personally input all data, obviating the cost of a transcriptionist, but it dips into time that should be spent with the patient.
Such programs utilize templates rather than providing individualized narratives of a particular patient’s medical history and physical findings. Templates allow the physician to generate, again with just a keystroke, a huge volume of documentary boilerplate for the chart. A prepackaged Re-view of Systems with what are called “pertinent negatives” can be added to the record of any office visit, in effect making it look more detailed and complex than it truly is. Medicare coding rules permit substantially higher remuneration if the chart is supported through thicker documentation; so, in effect, the doctor is paid by the word. The current appeal of EMR is its ability to support and justify “up-coding” of physician charges by “bombing” the chart with paper. Was the man who was referred to the ENT (ear, nose, and throat) surgeon for a simple nosebleed actually asked if he ever contracted malaria? I doubt it.
keyboard or the click of a mouse, a patient’s sequential blood studies, chest X-rays, or mammograms should be accessible for immediate review. The potential errors of a lab report misfiled in the wrong patient’s chart, or a critical lab result that goes unnoticed, should be prevented by a computer-based system of data storage and recovery. Every minute saved from searching through a thick paper chart could be utilized by the physician for direct care of the patient.
Unfortunately, the computer does not score as well with regard to the efficient and effective recording of a physician-patient encounter. Software that is presently available demands that the physician personally input all data, obviating the cost of a transcriptionist, but it dips into time that should be spent with the patient.
The Nursing Assistant inputs that theses were all done where as in fact nothing is done.
Diet Education
Seatbelt Education
Alcohol screen
Colon cancer screen
Annual Mammogram
Annual Colon Screening
Smoking cessation Education and counseling
Suddenly Hba1c has been changed to label
Glycosylated hemoglobin
so much so None of the previous A1c readings show up when you click on the new label
Unfortunately, the computer does not score as well with regard to the efficient and effective recording of a physician-patient encounter. Software that is presently available demands that the physician personally input all data, obviating the cost of a transcriptionist, but it dips into time that should be spent with the patient.
Such programs utilize templates rather than providing individualized narratives of a particular patient’s medical history and physical findings. Templates allow the physician to generate, again with just a keystroke, a huge volume of documentary boilerplate for the chart. A prepackaged Re-view of Systems with what are called “pertinent negatives” can be added to the record of any office visit, in effect making it look more detailed and complex than it truly is. Medicare coding rules permit substantially higher remuneration if the chart is supported through thicker documentation; so, in effect, the doctor is paid by the word. The current appeal of EMR is its ability to support and justify “up-coding” of physician charges by “bombing” the chart with paper. Was the man who was referred to the ENT (ear, nose, and throat) surgeon for a simple nosebleed actually asked if he ever contracted malaria? I doubt it.
Monday, July 24, 2017
Measuring the easily measurable
Measuring the easily measurable in this fashion is analogous to the drunk who searches for his lost keys under the lamppost because that is where he can see. The Twenty Questions binary format of screening has no place in the evaluation of the fuzzier, more social and subjective element of caring for the elderly. For instance, consider the crusty, cantankerous old man brought to the office by his family because he has refused to take a bath for six weeks. Did the doctor convince him to bathe? “Yes” or “No”? Can the husband who says “What?” be coaxed into wearing his hearing aid? To drive or not to drive? These are not easy, yes-or-no questions. The nuances of good medical care for the elderly are not so easily measured, tabulated, or statistically manipulated.
Like the Heisenberg uncertainty principle in quantum physics, the very process of making a measurement alters that which is being measured
The analogy, again in the field of education, is that of teaching to the middle of the class at the expense of the exceptional students
Like the Heisenberg uncertainty principle in quantum physics, the very process of making a measurement alters that which is being measured
The analogy, again in the field of education, is that of teaching to the middle of the class at the expense of the exceptional students
Sunday, July 23, 2017
hot-button issue
Tell Him Not to Drive~!
Octogenarians are no different from teenagers in that they rank driving as essential to the enjoyment of a good quality of life.
The urge to drive must be on the Y chromosome.
Mass transportation in suburban or rural communities basically does not exist. Driving is freedom.
To the elderly male ego, being behind the wheel is like riding tall in the saddle. Many old men would frankly rather be dead than prevented from driving.I have known patients in their eighties who elected to keep on driving even after losing their licenses. They adopt a sort of kamikaze attitude, figuring that they have nothing to lose, with no consideration given to the safety of other drivers or pedestrians.
As the law stands, patient privacy comes before public safety
There is no Medicare diagnostic code for participation in a family feud. Yet, traditionally, the physician, as an authority figure, has been called on to serve as a judge. The exam room is family court in session.
I recall a patient in her seventies who took a single OTC antihistamine, got behind the wheel, and promptly totaled her brand-new Subaru.
This is scary stuff. So, how do we know when to pull the car keys? Who should be the heavy who just says no to driving?
Finally, an “old-old” widower, no longer able to drive, may seek out and marry a “young-old” woman just for her wheels.
Whose license should I pull? Is a fragile, slightly confused, creaky old man any more of an impaired driver than a distracted, texting, iPod-wearing teenager with a car full of yakking friends? How about the multi-tasking business executive, doing deals on his BlackBerry while doing 50 mph in a 35 mph zone? In an era when drivers view red lights and stop signs more as suggestions than law, it is hard to say who can and cannot drive a motor vehicle safely.
Octogenarians are no different from teenagers in that they rank driving as essential to the enjoyment of a good quality of life.
The urge to drive must be on the Y chromosome.
Mass transportation in suburban or rural communities basically does not exist. Driving is freedom.
To the elderly male ego, being behind the wheel is like riding tall in the saddle. Many old men would frankly rather be dead than prevented from driving.I have known patients in their eighties who elected to keep on driving even after losing their licenses. They adopt a sort of kamikaze attitude, figuring that they have nothing to lose, with no consideration given to the safety of other drivers or pedestrians.
As the law stands, patient privacy comes before public safety
There is no Medicare diagnostic code for participation in a family feud. Yet, traditionally, the physician, as an authority figure, has been called on to serve as a judge. The exam room is family court in session.
I recall a patient in her seventies who took a single OTC antihistamine, got behind the wheel, and promptly totaled her brand-new Subaru.
This is scary stuff. So, how do we know when to pull the car keys? Who should be the heavy who just says no to driving?
Finally, an “old-old” widower, no longer able to drive, may seek out and marry a “young-old” woman just for her wheels.
Whose license should I pull? Is a fragile, slightly confused, creaky old man any more of an impaired driver than a distracted, texting, iPod-wearing teenager with a car full of yakking friends? How about the multi-tasking business executive, doing deals on his BlackBerry while doing 50 mph in a 35 mph zone? In an era when drivers view red lights and stop signs more as suggestions than law, it is hard to say who can and cannot drive a motor vehicle safely.
Comfort comes from continuity.
Comfort comes from continuity.
Continuity, staying in one place, doing the same thing, slowly and steadily, year after year, is an anachronism in today’s high-speed world of modern American business. “Just in time” inventory control, cost cut-ting by service outsourcing, and the economics of creative destruction are anathema to a profession built on sustained human relationships. Primary care, fundamentally, is not big business.
The physician-patient relationship is an odd amalgam, demanding of the doctor a unique blend of empathy and authority, a comforting demeanor and an even tem-per, a familiarity just bordering on personal friendship (but not quite), and advocacy.
Ninety percent of good primary care is just showing an interest in the patient, as remarkable as that may seem.
Data management, however, cannot supplant good relational primary care. More than managerial, the strong and sustained physician-patient relationship is of prime importance, now more than ever, because it offers solace and solidarity for a patient and family coping with chronic, complicated illnesses. How quaint this seems in an age of whole-body CT scans, comprehensive multidiagnostic blood analyses, and the entire
U.S. pharmacopeia on a chip. Today we are awash in medical data, yet a good primary care doctor is hard to find. For better or worse, the cowboys are gone.
the victim of death by a thousand cuts, the primary care doctor has lost motivation.
Although good primary care is the right of every American, we are, to be sure, a senescing society. Demography is destiny. Demand for service will rise precipitously at precisely the same time as primary care physician morale craters. We are now at a crossroads in care, changing the very meaning of what it is to be a primary physician. This is an experiment in progress, a bit of social tinkering, and we don’t yet know the outcome. As we reconfigure primary care for future generations, however, we should be very careful what we wish for; we may get it at our next office visit.
Continuity, staying in one place, doing the same thing, slowly and steadily, year after year, is an anachronism in today’s high-speed world of modern American business. “Just in time” inventory control, cost cut-ting by service outsourcing, and the economics of creative destruction are anathema to a profession built on sustained human relationships. Primary care, fundamentally, is not big business.
The physician-patient relationship is an odd amalgam, demanding of the doctor a unique blend of empathy and authority, a comforting demeanor and an even tem-per, a familiarity just bordering on personal friendship (but not quite), and advocacy.
Ninety percent of good primary care is just showing an interest in the patient, as remarkable as that may seem.
Data management, however, cannot supplant good relational primary care. More than managerial, the strong and sustained physician-patient relationship is of prime importance, now more than ever, because it offers solace and solidarity for a patient and family coping with chronic, complicated illnesses. How quaint this seems in an age of whole-body CT scans, comprehensive multidiagnostic blood analyses, and the entire
U.S. pharmacopeia on a chip. Today we are awash in medical data, yet a good primary care doctor is hard to find. For better or worse, the cowboys are gone.
the victim of death by a thousand cuts, the primary care doctor has lost motivation.
Although good primary care is the right of every American, we are, to be sure, a senescing society. Demography is destiny. Demand for service will rise precipitously at precisely the same time as primary care physician morale craters. We are now at a crossroads in care, changing the very meaning of what it is to be a primary physician. This is an experiment in progress, a bit of social tinkering, and we don’t yet know the outcome. As we reconfigure primary care for future generations, however, we should be very careful what we wish for; we may get it at our next office visit.
Stupid Federal Rules and Forms actually Kill!
"We are the medical police, or MPs, obligated by local, state, and federal government to supervise nonphysician health care professionals, as though our rubber-stamp approval could prevent some unscrupulous occupational therapist from robbing Medicare blind. This is absurd. When the visiting nurse attends a patient in her home, I must sign a form that certifies that the nurse truly was there, guarantees that nursing services were warranted and proper, and verifies that the nursing agency rightfully deserves payment. If a physical therapist is to conduct the craft for which he is well trained, stretching a stiff joint here or mobilizing an elderly stroke victim there, I must sign a form, as though validating his parking stub."
"Why are we so foolishly willing to waste doc-tors’ time and talent on mundane clerical duties? Why did physicians ever allow themselves to be shackled with such nonsense? I was chased out of my own office practice by a rabid fax machine spewing spurious forms for signature."
"the primary care doctor, as guarantor of record, is handed responsibility for any adverse outcome, from wooziness with a head tilt to sudden death under the hair dryer."
We think of physician liability solely as a matter of medical malpractice risk, the wrong drug given to the wrong patient via the wrong route of administration. The primary care physician today, however, is a general liability sink, carrying an obligation as the guarantor of a good day
The nonclinical physician duties, including being a hall monitor, liability sink, and guarantor, are more than a mild inconvenience for physicians. They are a health hazard by distraction, as deadly as chatting on the cell phone while driving. How many iatrogenic errors occur each year because a doctor’s attention is diverted from her primary charge: good direct patient care? There is no way to measure this morbid statistic, but I will wager that forms kill.
Like water, land, and energy, we squander primary care physician man-hours as though we had an infinite supply. We drive doctors out, and ultimately deny our citizens access to care.
"a doctor who at least tries to stay afloat professionally in a world awash in torrents of clinical trials, emerging therapies, and information overload."
There is, however, no diploma suitable for framing that proclaims the doctor a “master of sentience,” compassionate, emotionally intelligent, and perceptive of feeling and human hurt.
"Why are we so foolishly willing to waste doc-tors’ time and talent on mundane clerical duties? Why did physicians ever allow themselves to be shackled with such nonsense? I was chased out of my own office practice by a rabid fax machine spewing spurious forms for signature."
"the primary care doctor, as guarantor of record, is handed responsibility for any adverse outcome, from wooziness with a head tilt to sudden death under the hair dryer."
We think of physician liability solely as a matter of medical malpractice risk, the wrong drug given to the wrong patient via the wrong route of administration. The primary care physician today, however, is a general liability sink, carrying an obligation as the guarantor of a good day
The nonclinical physician duties, including being a hall monitor, liability sink, and guarantor, are more than a mild inconvenience for physicians. They are a health hazard by distraction, as deadly as chatting on the cell phone while driving. How many iatrogenic errors occur each year because a doctor’s attention is diverted from her primary charge: good direct patient care? There is no way to measure this morbid statistic, but I will wager that forms kill.
Like water, land, and energy, we squander primary care physician man-hours as though we had an infinite supply. We drive doctors out, and ultimately deny our citizens access to care.
"a doctor who at least tries to stay afloat professionally in a world awash in torrents of clinical trials, emerging therapies, and information overload."
There is, however, no diploma suitable for framing that proclaims the doctor a “master of sentience,” compassionate, emotionally intelligent, and perceptive of feeling and human hurt.
Hippocrates never had to hustle.
A modern primary care physician, needing to see as many as thirty to thirtyfive patients per day to cover an onerous fixed overhead of a quarter of a million dollars per year, can-not achieve the elasticity of scheduling necessary to provide immediate, comprehensive, and compassionate care and service.
There is no optimal method that maintains a steady stream, guarantees customer satisfaction, and keeps things fair. A classic approach to effective patient scheduling is “the wave.” Three or four patients arrive synchronously, each entering a maze of medical exam rooms, the laboratory, and the front-end business area.
Medical appointment scheduling is both art and science. It is a form of fluid dynamics, regulating the flow of individuals, each moving at a different rate and presenting different needs.
scheduling matrix
identifies a pattern of working and nonworking hours for the medical office.
Stream scheduling
each patient is given a predetermined appointment time based on status and needs.
Wave scheduling
assigns a group of patient appointments to the top of each hour. Assumes that not everyone will be on time.
Modified wave scheduling
schedules patients at regular intervals within a given hour, example every 15 minutes.
Cluster scheduling
groups similar procedures at the same time or day of the week, example all physicals will be thursday afternoons.
Double-booking
scheduling two patients in the same time slot for the same provider.
Open office hours/
all patients are walk-ins and are seen in the order in which they arrive.
“I have good news, Mr. Smith! The X-ray of your foot is absolutely normal. You may return to work first thing tomorrow morning,” she advises in an animated upbeat voice. Flustered by a favorable report, Mr. Smith snaps back, “There must be some mistake. I can’t possibly go back to work so soon. Put the doctor on the phone!” Nothing is easy.
Persevering, though, saves lives. It is a value-added service and an absolutely critical component of good primary care.
As primary care physicians’ patient panels continue to swell, spreading our services and our selves ever thinner, the dilemmas of time management will become ever more difficult.
Those who maintain that better information technology will wring greater efficiency from the primary care provider disregard that basic physical principle of time and matter.
Rigidly structuring phone time is as ludicrous as penciling in
quality time” with young children. It doesn’t work that way.
The heavy volume of physician phone calls is a symptom of a swamped system of primary care.
There is no optimal method that maintains a steady stream, guarantees customer satisfaction, and keeps things fair. A classic approach to effective patient scheduling is “the wave.” Three or four patients arrive synchronously, each entering a maze of medical exam rooms, the laboratory, and the front-end business area.
Medical appointment scheduling is both art and science. It is a form of fluid dynamics, regulating the flow of individuals, each moving at a different rate and presenting different needs.
scheduling matrix
identifies a pattern of working and nonworking hours for the medical office.
Stream scheduling
each patient is given a predetermined appointment time based on status and needs.
Wave scheduling
assigns a group of patient appointments to the top of each hour. Assumes that not everyone will be on time.
Modified wave scheduling
schedules patients at regular intervals within a given hour, example every 15 minutes.
Cluster scheduling
groups similar procedures at the same time or day of the week, example all physicals will be thursday afternoons.
Double-booking
scheduling two patients in the same time slot for the same provider.
Open office hours/
all patients are walk-ins and are seen in the order in which they arrive.
“I have good news, Mr. Smith! The X-ray of your foot is absolutely normal. You may return to work first thing tomorrow morning,” she advises in an animated upbeat voice. Flustered by a favorable report, Mr. Smith snaps back, “There must be some mistake. I can’t possibly go back to work so soon. Put the doctor on the phone!” Nothing is easy.
Persevering, though, saves lives. It is a value-added service and an absolutely critical component of good primary care.
As primary care physicians’ patient panels continue to swell, spreading our services and our selves ever thinner, the dilemmas of time management will become ever more difficult.
Those who maintain that better information technology will wring greater efficiency from the primary care provider disregard that basic physical principle of time and matter.
Rigidly structuring phone time is as ludicrous as penciling in
quality time” with young children. It doesn’t work that way.
The heavy volume of physician phone calls is a symptom of a swamped system of primary care.
A patient’s most strident complaints
A patient’s most strident complaints may vary widely from what health policy analysts and lawmakers fret about today: quality of care, access, and cost. The straight-laced puritanical woman rightly should have stood up to complain that everyone seated in my waiting room that day would pay a widely differing fee for professional services rendered, depending on age (Medicare), job (various private health insurance companies), or dire financial straits (Medicaid). That is a fact far more obscene than any risqué photojournalism found in the New Yorker.
There is surprisingly little correlation between the severity of an illness and the time devoted to it in the course of a patient visit. Complexity of care is more a function of a patient’s personality traits, such as maturity, adequacy, coping capacity, and social support structure, than of blood test results, X-ray and scan reports, or other objective findings.
Hippocrates, primary practitioner of Periclean Greece, presciently summed up the root challenge of medical office scheduling when he said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.”
A disconsolate young man, how-ever, scheduled to see me for a minor and transient somatic complaint, a sore shoulder, casually mentions as an aside that he is recently divorced, laid off from his job, shopping for a gun, and giving serious thought to suicide. Suddenly his ten-minute visit swells to sixty, triggers unexpected phone calls to secure speedy psychiatric help, and dams the flow of patients seated in my waiting room.
There is surprisingly little correlation between the severity of an illness and the time devoted to it in the course of a patient visit. Complexity of care is more a function of a patient’s personality traits, such as maturity, adequacy, coping capacity, and social support structure, than of blood test results, X-ray and scan reports, or other objective findings.
Hippocrates, primary practitioner of Periclean Greece, presciently summed up the root challenge of medical office scheduling when he said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.”
A disconsolate young man, how-ever, scheduled to see me for a minor and transient somatic complaint, a sore shoulder, casually mentions as an aside that he is recently divorced, laid off from his job, shopping for a gun, and giving serious thought to suicide. Suddenly his ten-minute visit swells to sixty, triggers unexpected phone calls to secure speedy psychiatric help, and dams the flow of patients seated in my waiting room.
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