Friday, June 15, 2012

Can You Get a Prompt Appointment With Your Doctor?

Having trouble getting an early appointment with a doctor? It’s a common problem. Here is one company’s proposed solution.

It takes an average of 20.5 days to get an appointment with a physician, according to a study by Merritt Hawkins & Associates and related to me by the principals at ZocDoc, a startup company. That’s a long time. ZocDoc aims to fix that problem with a rapid appointment scheduled on line.

Perhaps your need is not urgent in the classical sense but imagine you were just told your mammogram was suspicious and that you should see a surgeon for a biopsy. Waiting three weeks just to be seen (plus another wait for the scheduled biopsy date) will seem like a lifetime of anxiety,  but a company called ZocDoc has set out to improve patients’ access to care by making the market for doctors’ appointments more efficient, to the benefit of patients and doctors alike.

But if the doctor is booked up what can you do except wait it out? It turns out that physicians have a 10-20% cancellation rate. Maybe someone’s serious problem got better on its own. Maybe they went to the ER instead of waiting. Or maybe he or she just forgot because the appointment was made so long ago. For whatever reason, the doctor has many last minute openings; but you don’t know about them.

Cancellations mean no income for that time slot, but the physician’s fixed costs of office rent, staffing, insurance, etc. don’t go away. So he or she would like to fill those empty time slots if possible. 

In response, ZocDoc has created a software system that works with physician’s scheduling systems. Basically, patients go online and insert the particular type of physician they need to see (e.g., primary care, ENT, dermatologist, etc.) as well as their location. ZocDoc scans the real-time schedules of the physicians meeting that search criteria and allows patients to instantly book an appointment online. ZocDoc tells me that 40% see a doctor within 24 hours and 60% will be seen within 72 hours. And, although ZocDoc does not presently put you on a waiting list, you can always check back on ZocDoc and see if an earlier time slot becomes available.

My only concern is that you as a patient are best served with a single primary care physician (PCP) with whom you have a long standing personal relationship. He or she knows you, your medical status and the issues of work and family. Going to a different PCP for a one time problem is not the best medicine – although I would agree that it is far superior to a long wait in the emergency room.

The specialist situation is somewhat different however. Usually, your PCP is the best person to make a referral. As your advocate, the PCP wants you to be well served with quality care and so will generally refer you to a specialist that the PCP knows by years of personal experience is not only competent but respectful of patients. And if the PCP is really on your side, he or she will personally call the specialist, explain the reason for the referral and, when appropriate, ask for an early appointment.

But if you can’t get to your PCP for many days and you just fell and have a swollen ankle, ZocDoc could presumably get you into an orthopedist’s office quickly. Or to a surgeon for that breast biopsy. Getting to see that orthopedist or surgeon in one to three days rather than three weeks would be a godsend – getting appropriate therapy for the sprained ankle or just relieving three weeks of anxiety waiting for a biopsy. 

ZocDoc appears to be at first glance a game changing approach. If they are correct it will make a major transformation in the delivery of medical care. It will be interesting to watch ZocDoc and see how it evolves.

Notes – ZocDoc was noted in a Wall Street Journal article today on innovation. I have no financial relationship with ZocDoc; I learned about it serendipitously. There is more about the delivery of health care in my new book The Future of Health Care Delivery-Why It Must Change and How It Will Affect You.

Tuesday, June 12, 2012

Integrative Medicine Part V - Busting Stress

Stress is with us all the time. Issues at work or at home, getting a traffic ticket, the grocery store out of your favorite yogurt. Life has stresses. We can go to the doctor and ask for a pill or we can learn to deal with our stresses effectively without much medication. 

Acute stress is normal and can even be lifesaving – seeing a truck barreling down the road at us. But when stress is chronic it becomes a major cause of ill health.  

Chronic stress builds up when the demands upon us become greater than our resources to respond in an effective manner. Stress tends to become cumulative. You can handle the first stressor and even the second, but when the third one occurs, even if it was rather minor, it tips over your balance point. Since we cannot completely escape stress, our agenda must be to boost our resources – to “fill up our cup” as Delia Chiaramonte, MD of the University of Maryland Center for Integrative Medicine liked to term it during her “Busting Stress” workshop at the Center’s recent Health and Wellness Conference held in Baltimore, MD.  

Integrative medicine does not avoid traditional “western” medical approaches such as medications. But it does look at the whole person to determine if there are other parts to the “prescription” that might be equally or even more valuable. The agenda is to maintain health and further develop wellness.

There are external and internal sources of stress. Our boss ignored our hard work or disparaged our report – these are obvious external stresses. If they become too much it may be best to just look elsewhere for a new job and escape the situation.  

But other stresses are internally mediated. We might convert an event into a thought that in turn leads to a negative feeling that in turn causes stress. Imagine that a loved one is late to get home and has not called. That is the event. The thoughts can be quite different. One thought might be that he was in an accident resulting in a stressful feeling of anxiety. Or perhaps this event leads to the thought that he is having an affair – leading to a feeling of hurt. Or perhaps the thought is that he just didn’t care that he was late and didn’t bother to call – leading to a feeling of anger. Perhaps more likely he is just stuck in bad traffic and doesn’t have his cell phone with him – in that case you might have a feeling compassion. The three stressful feelings came from your thought interpretation of the event. The question you need to ask yourself is what is the likelihood of any of these thoughts being correct?  

You need to restore rationale thinking. Do this by labeling the irrational thought and then refute it with a new thought like “I have no evidence of an accident; he is probably just stuck in traffic.” Then detach yourself from the thought with the recognition that “this is an anxious thought, not a rational thought.” Finally, do something to distract yourself like playing with the kids.

To “fill up your cup” Dr Chiaramonte suggests considering these approaches. Begin a “gratitude ritual.” This means to take a time each day for gratitude perhaps while falling asleep or perhaps at dinner time. Think about what is good in life – today – maybe a spring flower, a smile from your loved one, the bright eyes of your child. It can’t be a rote thought however. Make it different every day. Amazingly enough, it works. It will increase your happiness and correlates well with general health and well being. 

Here is a line from the song “Counting My Blessings” sung by Bing Crosby and Rosemary Clooney in the movie “White Christmas.” "When my bank roll is gettin' small, I think of when I had none at all, and I fall asleep counting my blessings..." This is the concept of gratitude. 

A second approach is to aggressively try to be a “benefit finder” rather than a “fault finder.” It’s an approach in which you rethink and with doing so decrease your emotional reactions. Instead of the thought, “I have a vision problem that limits me” you might instead think of, “I still have one good eye and the world looks good to me.” 

Sleep is important. You feel more stressed if you are sleep deprived. Most of us get too little sleep. Fill your resource cup with added sleep. And the gratitude ritual at bed time will help you sleep more soundly.  

Food is equally as important. Things to avoid are processed foods with high levels of carbohydrates and fats (of course, these are the ones that taste so good to us!) like doughnuts, macaroni and cheese or pizza. Instead get more high quality proteins and skip the refined sugars as in sodas.  

And add in some exercise. Just moderately paced walking each day will not only decrease your stress but will improve your cardiovascular health, bone health and overall add to your sense of wellness.  

This may sound like a lot of effort. Actually it’s really not. It doesn’t take much time; it improves your physical health; and it will allow you to cope much better with stress. Better to “fill your cup” than rely on an anti-anxiety medication. 

Note: You can find the Center for Integrative Medicine on Facebook at . And you can learn more about improving your health while reducing your costs in my book The Future of Health Care Delivery- Why It Must Change and How It Will Affect You

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).