Sunday, July 5, 2015

Independence Weekend 2015

Independence Day is actually Independence Weekend most years and 2015 is no exception.  Friday the third of July we had some patients to see and closed at two PM. Before a special weekend like this I ask most patients what they are doing for the holiday. Many of them will have an altered experience due to the affliction that caused them to see a doctor.  Others are "a threat to society" because of the contagious nature of their infection.  Vomiting with abdominal pain is especially important to keep away from other people.  Most will be shedding viruses for a few days after the vomiting stops.  (Don't let them breathe near you).

When people mention their holiday plans, they are often sharing information about their values and dreams.  Who, What, Where, When, Why, Who are often included.  This information helps me to understand them and issues that relate to their health.  It also informs me about what people in general are doing these days.

One of the roles of the Family Physician is to act as a public health agent-- identifying issues that affect the health of the public enables us to contribute to prevention efforts and share trends with other physicians and public health officials.  Our generalist role in health care gives us a perspective about health system trends that may be helpful or harmful to patients.  We have to stay aware of our duty to inform and protect people (you and us - we have a duty to help each other).

Warning to you:  Currently the healthcare system seems out of control and constitutes a threat to the financial survival of individuals, families and communities-  in fact it's a threat to the nation.  More, more, more is what we say about everything.  More tests, more medication, more mandatory prescribing, more "quality" bonuses for health plans and physicians.  There is no realistic plan to do otherwise. There are superficial efforts to reduce certain tests and procedures.  I just saw a letter from one of the area practice networks advising their male patients to have the PSA test, which actually is no longer recognized as a screening test for prostate cancer.  It's only supposed to be used in symptomatic males- which is a diagnostic test--not a screening test (for non-symptomatic persons).  How is a patient to know that?  I was shocked and disappointed.  But I can blog about it and tell the people about it and mention to physicians about how the PSA test is supposed to be used.

I'm looking into programs like Samaritan Ministries and Liberty Healthshare as a consideration for our Direct Family Medicine (Direct Pay)  patients to have hospitalization outside the Affordable Care Act.  They are for Christians, but I assume that each religion has some special waivers relative to the Affordable Care Act, although I haven't researched it.  

Huge changes are coming in the next three years.  Stay tuned.

Independence Day.  I love America.  I love patriotic music.  I love the Boston Pops Independence Day Concert and A Capital Fourth both with the 1812 Overture.  I'm getting ready for the third ever West Point Glee Club Alumni Reunion Concert on July 25th.  I sang in the first two.  I'm looking forward to 3 days of the Hudson River Valley, nostalgia and patriotic music.  God Bless America.

Tuesday, June 30, 2015

Family Medicine: Solutionists or Inflictionists

Now you can add Solutionists to the list of novel ways to think of focused medical professional activities.  Direct Primary Care seems to be driving the invention of new terms.  Many see it as "THE Solution", so Solutionist isn't far behind.

Since we have so many pressing guidelines and protocols, I propose that we recognize the Inflictionists.  Those physicians who inflict so much on patients with inadequate regard for the patient's chief complaint or reason for the encounter should be called "Inflictionists".

I hope your doctor is a Solutionist.

Tuesday, June 23, 2015

Doctor Transitions- "Goodbye, Folks" Coming to Your Town Soon



OK, Folks- a message from the near future.  Here's what will be happening in communities across the nation.  Doctors will be sending out letters like this.  You will be surprised. Your primary care doctors aren't being replaced and they are leaving practice in droves for retirement or hospital employment.  In California, the hospitals can't employ them, so they just go to another state.  Since the hospitals aren't training new ones as much as they used to, you'll look to the urgent care in Walgreens, CVS, Krogers, etc. for your healthcare.  It'll seem OK for a while.

"Dear Friends and Colleagues in Healing,
I am saddened to have to announce that I will be leaving ................ It has been my pleasure to get to know you. I know this result is a big disappointment for us both. My work here has been a source of great satisfaction for me. The practices in  have been the best practice situations I have worked in. The relationship with my patients has been warm, rich and varied. The staff who have supported me have been wonderful to work with and exceptionally diligent. I believe we have practiced very good medicine together. The pace has been just right, allowing enough time to get to know you. I admire the mutual commitment to doing the best we can with less, since we don’t have all the fancy medical technology or specialists.
This place is wonderful. I have been fortunate to live in a wonderful house just a block away from the hospital. I have cherished being able to do most of my errands with just a brief walk to the store or the bank. Wherever I go, I see people I know. Every time I step outside, no matter where I am or what the season, I feel exhilaration with each breath of fresh air and every fresh vista.
The most frequent questions I have had over the year have been “Do you like it here?” and “Are you going to stay?” I want every one to know that I have loved it here. That has nothing to do with my decision. It was my hope and wish that I would be able to make this my long-term home and that I would be able to slowly wind my way into retirement over the next ten years.
The reason that I cannot is solely due to the economy and the limitations of  ... law on practices in settings like this.  this is not working out. As everyone knows, the state legislature and the Federal Medicare program have put a near stranglehold on small rural health care systems like ours. .   
Due to these restraints I am leaving at the end of the month. I will miss you all and this special place very much. I have been very blessed to have shared this last year with you."

Sincerely,

Way too many family doctors

Sunday, June 7, 2015

Impending Disaster in Healthcare

Big pressures mount for the new ICD-10 coding system starting October 1 that will be a disaster for patient care.  Concurrent is the realignment of Medicare reimbursement with new systems of care called Accountable Care Organizations.  Most ACO's are unsuccessful.  

More onerous initiatives driven by IT are flooding our office every day.  If you are "late" filling your prescriptions by a few days, we get a letter about your "non-compliance".  If you are not prescribed specific meds with certain diagnoses, such as ACE inhibitors and statins for people with diabetes, we get a letter about the "gap in your care"- repeatedly, even if we send in something saying that you are allergic or have other reasons not to take the medication.

Primary Care is folding under the pressures.  Dr's are moving around, quitting or leaving in preparation for the coming mess. Med students see the piles of useless drivel and shift their specialty selection to specialties that have less hassle and more money. About 3,000 new Family Physicians are produced annually while there are more than 17,000 job openings for Family Physicians, and getting worse.

Both Dayton flagship hospitals don't train primary care physicians since there's not enough profit in it.  The new health plans initiated by the Exchanges from the Affordable Care Act have lots of enrollees, but don't have enough physicians to care for their primary care needs.  We see many of these insured patients in the free clinic I work with in Bellbrook.

We have to consider walking away from all insurances to survive.  Yes.  All independents have to get survival plans ready for the next wave of initiatives- none of which helps health.  You should think of what happens if you have no primary care access in the next few years.  We have to find a survival strategy for the short haul.

We may be shifting our practice style in October.  

Friday, June 5, 2015

Family Medicine: Let's Dialogue to Fight Impending Healthcare Disaster

Healthcare: Disaster of Inadvertence

What's up (or down) in healthcare?
I discuss it on my Dr Synonymous BlogTalk Radio Show at the link above.

I review a blog post by Dr Elaina George that expresses some of the dilemmas facing us in healthcare.  A bleak near future is coming.  Let's hang on AND develop radical strategies to bypass the "inadvertent" mess.

Dialogue is one of the keys to health care success.  Family Physicians should help patients to dialogue about their uniqueness in the context of their individual lives.  Patients should dialogue with persons in healthcare with whom they have contact.  We all need to share what's really important to us and seek to discern meaning in our health/ disease situations. The uniqueness of our individual identities must be clarified and honored in our interactions- both in life and in healthcare situations.

The dishonoring of  human values in the healthcare system is rampant and must be countered with dialogue.  Exposure to unnecessary testing, especially radiation via imaging such as CT scans is generating about 30,000 cancers per year according to the American Cancer Society.

"The rise in radiation exposure due to medical imaging is a cause for public concern because of cancer risk. Imaging techniques that use ionizing radiation (such as CT scans) have the potential to cause cancers to form, and because of the increased use of these techniques over the last two decades, some estimates predict that 2 percent of all future cancers will result from current imaging use.
In their study, Smith-Bindman and her colleagues examined the health records of millions of patients in several western and Midwestern states who participate in six large integrated health care systems. This was the first major study to look at how radiation exposure has increased within these private systems. The collaborating health care systems are all part of a consortium of 19 HMOs across the United States and in Israel called the HMO Research Network, which has made a commitment to conduct research to improve the health care they provide to their members.
To the researches’ surprise, for patients in these systems, just as in the rest of the U.S. population, the average amount of radiation has increased over the last two decades. The new study showed a doubling in imaging rates, and by 2010, for every 100 adult patients, around 20 CTs were performed. Older patients underwent even more CT scans. For every 100 patients age 65 to 75, around 35 CTs were obtained."  From the UCSF newsletter 2012
Physicians routinely don't get informed consent from the patient to perform most CT scans.  Won't this come back to bite physicians and hospitals when the public realizes the harm done?

The principles of medical ethics reminds us of patient autonomy.  "First of all- Do No Harm" is a central tenet of medical practice.  Thirty thousand cancers sounds pretty harmful to me.  Not getting informed consent for a test that can lead to cancer doesn't sound like patient autonomy to me.

Dialogue is needed.  Let's get it going, Folks!