How To Find a Good PCP?

I was reading a post this morning on Health Beat on CMS's attempts to create a "Physician Compare" website. The idea is that our government will create an easy and accessible site that our patients (ie customers) can go when searching for a physician.

Such information as medical school attended, years of practice, law suite history, and location will be available as well as data representing quality indicators.

I have very mixed feeling about such a site. While on the surface this looks like a good idea....I would challenge my readers to come up with a series of data points that would define what makes a good primary care physician.

Sure...you say...easy. They have to be nice. Communicate well. Have a clean office with good personnel. And oh yah...they have to be good at doing that doctor thing. You know that thing where they diagnose and treat patients correctly. Where they balance the existing medical data, each patients unique situation and needs, and yes even cost effectiveness to come up with a tailored plan.

That so called "doctor thing", which I would argue is the most important quality indicator, is just not so easy to measure. Especially in primary care.

Yes we can tabulate how often Dr. X's perscribes colonoscopies. And how Dr. X's patients Hgb A1c's usually range. We can see how close Dr. X gets to the correct blood pressure goals (even though depending on the data each year these goals are revised!).

But none of that really says a stinkin thing about quality. Sicker, poorer, less educated patients tend to be less compliant. I can offer every patient that walks in my door a colonoscopy but that doesn't mean it will get done.

And then there is the problem of gaming the system. Create quality indicators and physicians will be great at bumping the numbers but what will be ignored at the sake of quality. I know you are having chest pain Mr. Jones...but when was your last colonoscopy? Why is your a1c so high? As seen in England, incentivize physicians to ask certain question and do certain tests. They will be compliant. But it will divert their attention from other important issues.

Lastly, how is the government going to attain such data. Up to this point, medicare is incentivizing physicians to report quality indicators with programs such as PQRI which give bonuses for voluntary reporting. The carrot, however, will become a stick in years to come when physicians will be penalized for not reporting.

So...take beleaguered, unhappy, primary care physicians who are already in shortage and overworked, add more reporting requirements which will take up more of their time and add to their overhead. And see what the future will bring (hint....many less PCPs..which I guess is OK if you don't value their worth!).

The problem is that the number one indicator of physician quality (in my humble opinion) is diagnostic acumen. And that...that my friends is exceedingly hard to measure.

So how do you find a good PCP?

I have no flippin clue!

But if any of you figure it out could you please let me know.....It's hard to find an excellent pediatricians these days!

Are PCP's The New Nurses?

It happened again last week. I received a consult note in the mail. My patient had seen the cardiologist for a follow up on cardiac disease. As I perused the assessment and plan I came across a new entry in the problem list:

1) Dizziness: refer to neurology

As opposed to yelling at the cardiologist and demanding that he refer patients back to me for work up....I called the patients daughter. I explained to her that dizziness can have many causes and only a small percentage of them are neurological. Although, of course, I trust the cardiologist could she have her mother please come see me first before going to yet another doctor.

The mother and daughter dutifully appeared days later. After a few minutes of questioning and a basic physical exam the cause became obvious. She was orthostatic and dizzy upon first rising. Her blood pressure was 90/60. I cut back on her cardiac medicines and followed up by phone two days later. Like magic....her dizziness was gone.

I can't tell you how often this happens. Cardiologists refer my patients to neurologists. Neurologists to orthopaedists. Orthopaedists to ENT. And often if they would just refer back to me I could take care of the problem much quicker (it can take months to get into a specialist) and often with less diagnostic testing.

I am not saying I can handle every issue...but usually I want first crack at it. Because I know the patient, I know the medical history, and I know the meds...I am much less likely to disturb the balance of chronic medical issues when treating somehting new.

But that's the problem with primary care today. We are not seen anymore as the problem solvers. We have lost a great deal of respect from our colleagues and patients.

In some ways I feel we have gone the way of the nurse. Much maligned by both physicians and society, nurses continue to toil behind the scenes with great amounts of knowledge and ability. It's just no one recognizes it.

Some days I am the cardiologists nurse, some days the neurologists, other days the dermatologists.

PCP call the pharmacy and order another months worth of medications
PCP insurance requires a requisition for that test
PCP write out a referral to another specialist because I can't figure this out
PCP the patients dying...go talk to the family about hospice!

Some Thoughts On Hospice

Friday in my office is like happy hour.....for the oldest of the old. They come. 90, 95, 100. Always on Fridays. Some come in wheel chairs. Others walking. Some alone. Others with family. 5,6, 7 sometimes even more in just one short morning. And we talk...about life, about their children, about growing old. I apologize that at that age I really have little to offer. After all... they know more about health then I....they made it to their ninth decade. Some I offer comfort, others medicine, on rare occasion tests. Mostly I just listen.

So it is fair to say that I am used to dealing with geriatric issues. And it is also fair to say that I work closely with hospice and find it one of our best resources in dealing with end of life care.

In reality, my medical training started with hospice. My first clinical experience with real "live" patients was as a hospice volunteer at the beginning of medical school. I started in the inpatient hospice unit. I did everything from laundry, to comforting families, to helping the nurses place dead patients in bags in preparation for transport to the funeral home. Eventually I traveled to patients houses to help with chores and run errands.

Yesterday I signed three death certificates. One died in the hospital of acute illness. Another died in his home with his wife and family present. The last died in an assisted living. They were all hospice patients but each for less then a week.

And I figure these numbers are about accurate. Probably 95 percent of my patients die in hospice. Likely only 10 percent die in the hospital. The other 90 percent die at home or in a nursing home or assisted living. Most of these patients have only been in hospice for a short period of time.

Often when I talk to my hospice colleagues I feel a slight sense of reproach. The conversation ends with a statement to the extent of, "to bad your patient couldn't have enjoyed these services for a longer time period."

I understand these sentiments. I do , in fact, believe that patients with terminal diagnosis live longer with hospice care then traditional management. I do believe the quality of life is better. But the truth is that most of my cases are not so black or white.

Some die of acute illness and the time period from decompensation to death is short...hours to days.

Often my elderly patients and their families are not emotionally ready early in the disease process. It can sometimes take months of conversations to help a family understand that their elderly loved one is slowly fading away from dementia.

Sometimes a patient has chronic illness like COPD or CHF and it is unclear if death is around the corner or a few blocks away. Often I avoid hospice to allow for the agility to move from palliative mode to acute aggressive care without having to explain to a hospice administrator why I want to spend money ordering tests on a patient who they think should have a less aggressive course.

And sometimes I hold off on hospice because the patient is comfortable. The family understands and every ones needs are being met.

I will continue to value hospice services. As time goes on I see the movement flourishing. It is becoming more agile. Moving from palliative to comfort care and back again.

The possibilities are endless.....

We are entereing the golden age of hospice care!

Imprints

I immediately recognized the women as she walked into my examining room. She was petite, pretty, and she couldn't hide the bulging underneath her fall jacket which gave away her late term pregnancy. She was accompanying her boyfriend who apparently had suffered an injury in a mosh pit at a concert a week ago and needed his sutures removed.

"Lisa....Lisa is that you?"
She looked at me with a haze of discomfort and concentration. Her boyfriend (who had been my patient for years) looked on curiously.
"Remember...we used to be friends in High school?"
Actually we had dated for a tumultuous month and then she swiftly broke my heart. That was fifteen years ago. I was an awkward teenager at best...she was my first girlfriend.

Although she assured me that of course she remembered...I could tell by the blank look on her face that neither my name nor my face had brought back much recognition. Amused I chatted comfortably with them as I removed her boyfriend's sutures. Occasionally sprinkling in references to our past and previous friends.

They left as quickly as they came and that would be the last time I would see either of them again. But it wouldn't be the last time I thought about Lisa. Our at least not about her specifically but more about what she represented.

You see...being that I have only dated a few women in my life each of them has left a lasting imprint. For better or worse I remember details....feelings....moments. My dearth of experience serves to magnify the few memories that I have.

On the other hand....for Lisa I was probably one of a number of relationships that neither lasted long nor held extraordinary significance. A normal person may date often before they settle down with that special someone.

And this...this made me think. How often had I made an imprint on others....been part of an important memory..and not even been cognizant of it.

As a physician I am often involved in my patient's lives at critical junctures. How many times have I walked into a room and told a wife that her husband is dying? How many times have I told a suffering patient that there is nothing more we can to do (at least to cure)? How many times have I told a husband/wife/father/child/daughter that their loved one will live?

In my case, I have these conversations so often that they no longer stand out as particularly significant or memorable.

But to my patients....to their families...they may never forget the face and actions of the doctor that day....

the day they were given the news that forever changed their lives.

You Got To Know When to Holdem...Thoughts on Physician Quality

Yesterday my last patient of the day was a young man with a history of multiple surgeries and medical problems. He developed a fever over night to 102 and transient abdominal pain. By the time he saw me his pain was gone but his temperature was still elevated. Knowing this patient as I did, even with the benign exam, I sent him to the ER for a stat cat scan of the abdomen and pelvis and a straight cath (he had urinary retention) for urine. I called the ER Doc to give report before my patient arrived.

From the beginning I was harangued with negative commentary. The Physician shook me down. Why was I sending this patient? The exam was benign why did he need a cat scan. Etc...Etc. By the end of the conversation I simply told the ER Doc...Look, I know this patient..something is wrong. Do the scan!

Two hours later I get a call from the ER. The labs looked OK. He was dehydrated and had a urinary tract infection. His white count wasn't that high. They were going to send him out with antibiotics. So patiently I asked..so what did the scan show?

Of course they hadn't done it. Angrily the ER physician replied, it's going to be negative! Fine we'll do it anyway.

An hour later my cell phone rang. Holy shit....abscess, his temperature is 104. He is going to the operating room now.

And see this is the thing about medicine. Everyone wants to try to measure physician quality using all sorts of strange indicators. Things like blood sugar control, rate of preventative screening exams completed, patient satisfaction. But you see to me...those are all indicators that are highly patient dependent. Either they get them or they don't...often the physician has little to say about it.

In my mind what makes a good physician is a little bit more subtle. In the immortal words of Kenny Rogers:

You got to know when to hold'em, know when to fold'em
Know when to walk away and know when to run!

Snapshots From Childhood-Memories Of My Father

It was too beautiful for words. At least from the perspective of a five year old with greedy eyes and a lustful heart. It was silver, and shiny, and fit perfectly into my little hand.

I watched as my father stood doubtfully at the department store counter. He made a gesture to the attendant and she opened the case and lifted out the object of my adoration. My father took the lighter and held it in his hand. I could see his hand sway gently...getting a feel for the weight of the silver jewel that lay resting quietly in his palm.

He flipped the top of the zippo and it made a wonderful, throaty sound as it opened. Inside a white stranded wick, and a small wheel covering a tiny flint. His thumb fingering the wheel and then giving it a whorl. Sparks flew momentarily and then disappeared.

As my dad looked down at my face he studied my exuberance and then quickly made a decision. He paid the clerk and we exited the store. In the car he opened the lighter. He pulled on the wheel and to my delight he released the inner casing from the shell. He removed the wick, with the caustic smell of lighter fluid emanating from it, and returned the casing. He then handed over the object of my affection.

The lighter was disabled but he left the flint in place. I flicked open the top and fumbled with the wheel. After a few attempts I successfully initiated a spark.

Later that day we drove to summer camp. As I pulled off my seat belt he put his hand out. I fingered the lighter in my pocket and contemplated my next move. I couldn't bare to part with my new found treasure.

He tried one more time...then he warned me. He explained that if he let me keep the zippo I couldn't take it out while at camp. It would surely get taken away. I agreed gratefully and went off to play.

Hours later, my father's warning deeply lost in the recesses of my childhood brain, I pulled out my toy and demonstrated to my friends how to make a spark. Of course I had no idea that the camp counselor was just steps away. She swiftly took the lighter.

I would never see it again.

Years later after my father died I would find a secret stash among his belongings packed in a box.

About a dozen silver zippo lighters...

each beautiful and perfect in its own way....

with flint in place but wick carefully removed

just how he left them.

Why EMR's Are Bad For Helathcare Reform

I was working away in my office yesterday, doing my best to squander our health care dollar, when to my dismay I was hit with a conundrum. The patient in front of me was a young healthy female with right lower quadrant abdominal pain. As I recklessly took a history and examined the patient I formed and incomplete and cost ineffective differential. Her belly was definitely tender. She had a low grade temperature. The list of possibilities danced through my economically unsavy brain. Appendicitis, right sided diverticulitis, kidney stones, gynecologic issues.

Then the answer hit me like a ton of bricks. Gleefully I went to order and expensive cat scan of the abdomen and pelvis. I reached over and picked up the order form and my hand gently moved to the breast pocket of my lab coat. And then it happened...wait for it...wait for it....there was nothing there. I ran, in a quandary, to my desk to find a pen to fill out the form. My desk was picked clean.

And then....then things started to click. My medical assistants and secretaries had been roving the building looking for pens for months now. Slowly but surely they had stripped the doctors office's.

One by one the great pen migration had begun. Months ago. Doctor's in exam rooms and hospitals everywhere had started to feel the pinch. I didn't even flinch the other day when, on my way into the hospital, I was approached by a former friend and colleague. He had a rabid look in his eyes and a uncanny desperation. I quickly brushed him off and assured him that I wasn't hiding any extra pens in my lab coat.

But why...why had the pens in medical facilities become as rare as a primary care doctor who sees his own patients in the hospital?

It was the government. The government had been working for years to curb pharmaceutical influence on our impressionable physician work force and made it illegal for drug companies to use pens as marketing tools. The logic was impenetrable. Ignorant, careless, bonehead physicians were being coaxed to use expensive, harmful pharmaceuticals to the benefit of the industry and the harm of patients everywhere.

The government, however, had no idea how fortuitous this ban could be. Strapped (and cheap) physicians struggling to make ends meet would be very unlikely to replace this free revenue stream by buying more office supplies. As the great pen migration continued physicians would find themselves unable to do the very thing that bureaucrats and reformers have been trying to stop for years. Write new orders!

After all the most expensive technology in medicine is the physicians pen. Now physicians would no longer be able to write for cat scans, mris, and expensive chemotherapy. The health care crises was solved!

And indeed as I struggled to find a writing utensil I did momentarily contemplate skipping the CT Scan and just putting my patient on antibiotics. After all if she actually had appendicitis it would eventually rupture and we would find out soon enough. Right?

But the Obama administration made one fatal error. In its zeal to promote Emr's it forgot that there is one glitch....electronic order entry.

I skipped...nay I ran to the nearest computer. Within minutes I had ordered the cat scan electronically.

Another day...another dollar spent. I guess I could get to like this EMR thing!

Boy....I think I have been reading too much Dr. Rich!