Monday, December 1, 2008

A Dirty Rumor

There is a rumor out there. And it says that primary care practicioners are running up the cost of medicine. That they have been squeezed so tightly by busy schedules, paperwork, and short visit times that they have become careless. More on this in a moment.....But first a story.

A young lady enetered my office 6 months ago for a physicial. Among other things she was having trouble swallowing. She felt food would get stuck. She was healthy. No weight loss, her symptoms were intermittent. So I questioned her, examined her, and carefully explained my thought process. Given that there were no alarm symptoms we decided to start with an acid reducer for possible reflux and a promise that if she was no better after two weeks she would call and I would send her for a barium swallow.

Months passed and I heard nothing. Then last week she walked into my office crying. She did not try the acid reducer. Instead she went to see an ENT (Her PPO allowed her to go without a referral). The ENT did a scope and sent her to a speech therapist for a swallow evaluation. The speech therapist did a video assisted swallow study and was convinced the patient had a mass in her pharynx. She then sent the patient to another ENT. Who scoped her again and sent her for a ct of the neck. When those were both negative he scoped her one last time for God knows what reason.

So she returned to me, crying, anxious, and having even more frequent difficulty swallowing. So I again suggested an acid reducer (which she promised she would take) and an anti anxiety medication and hopefully she will see me again in a few weeks. And if that doesn't work I'll either do a barium swallow or send her to gi for an egd. The right workup that should have been done in the first place. I bet, however, she won't need it. I bet her symptoms will be gone by the next time she sees me.

So back to that rumor. You can argue that internists consult too much. That they send patients for too many tests. But as my story illustrates....specialists do the same thing. You see...good doctors treat disease expediently and cost efficiently. Bad doctors don't. It has nothing to do with a percieved time crunch. Give primary care doctors more time....the good ones will still do a good job, the bad ones will still do poorly. Period!

It's not a time issue ias much as a quality issue. The harder question is how do we reward quality!

By the way...I think PCP's could benefit from more time with each patient. I just don't think economic ramifications will be as drastic as most think.

1 comment:

gingerb said...

Your swallow-girl doesn't sound like the sharpest gal.

Why in the world would you let somebody stick stuff down your throat before you'd tried something easy like a pill?

Sometimes the smartest person is the one who doesn't think too much and just follows instructions!