Monday, December 15, 2014

Aging Gracefully – Part 1 The Normal Aging Process

It is possible to slow the aging process.  No there is no Fountain of Youth and no, there is no pill that’s been discovered.  It’s all about lifestyle and this means starting at an early age and sticking with it through the years. 
I was recently invited to give a talk to a group of about 100 individuals contemplating moving to a continuing care retirement community.  The topic - is it possible to slow the aging process?  I titled it “Aging Gracefully.”  Here are my thoughts divided into three major categories:  the normal aging process, slowing the aging process, and (in a post to follow) obtaining the very best comprehensive health care.  The talk was picked up by the Howard Times of the Baltimore Sun; the reporter’s article is available at this link:
 “Old parts wear out.”  That’s normal aging.  It’s universal, it’s progressive and, at least as we know it today, it is irreversible.  Most organ functions decline by about 1% per year.  Fortunately our organs have a huge redundancy and so we can afford the declines without illness.  But eventually if we live long enough and the process continues at the usual rate a point is reached at which functional impairment or actual disease presents. 
Let’s use bone mineral density and cognitive function as examples.  During our childhood and teenage years our bone mineral density increases and with it our bone strength.  It reaches a peak at about age 20 and plateaus and then by age 35 starts a slow but inexorable decline of about 1% per year.  Should we live long enough we will reach a point which we can call the “fracture threshold” meaning that if we fall it’s possible to break a leg or a bone in our back.  Of course that 1% decline per year is an average.  Some people decline faster and some people decline more slowly.  We’ll come back to that point.  The same goes for cognitive function.  We’re at a peak at about age 20 and then there is a long plateau with a slow decline such that by the time we’re in our 80’s or 90’s most people have some noticeable decline in cognition. 
There are certain impairments that come with aging such as reduced vision, reduced hearing and reduced mobility.  We might not consider these as true diseases.  However there is also an increased prevalence of chronic illnesses such as heart failure, cancer, chronic lung and kidney disease and diabetes.  They often manifest in older ages but they actually originated many years ago.  For example coronary artery plaque buildup begins in childhood but may not manifest itself as a heart attack until the late 60’s.  Similarly lung cancer is on average diagnosed at age 72 but the cause began way back as a teenager when the person first went back behind the garage for a smoke. (BTW, not all lung cancers are due to smoking but for those that are, it was a long slow process over time.) 
These chronic illnesses are largely due to our adverse behaviors, our lifestyles.  The four big behaviors that need to be addressed are nutrition, exercise, chronic stress and tobacco.  We could add other factors but especially inadequate dental hygiene and excessive alcohol. All too many of us have poor nutrition (e.g. packaged and processed foods, lack of fresh fruits and vegetables, etc.) and at the same time we eat too much of it.  Most Americans don’t get an adequate amount of exercise.  It seems that everyone has some level of chronic stress and 20% of Americans smoke. 
To summarize, there is a normal aging process wherein organs reduce their function by about 1% per year. This rate of decline is related, in part, to our lifestyles beginning when we are quite young. There are also age-prevalent chronic diseases that are also life style driven. Our personal agendas need to include attention to healthy living so that we can preserve wellness.

Next time – Slowing the Aging Process

Thursday, September 18, 2014

Why Do I Only Get 10 Minutes With My Doctor?

Good question. You call for an appointment and are told it will be about 20 days. You arrive on time only to sit in the apt named waiting room for 40 minutes. Finally you get to see your primary care doctor (PCP). You begin to explain why you came in but are interrupted within about 23 seconds even though it would have only taken you about 6 more seconds to finish your “opening statement.” The doctor asks a few questions, does a brief exam, gives you a prescription, suggests you see the specialist and off you go, all within 8-12 minutes. At the exit desk you are told you owe a $30 co-pay. “Visa or MasterCard please.” And in no time at all you are out the door.
No time for delving deeply into your issues. No time to build trust. No time for compassion. No time for actual healing.
Why so quick? It is all in the numbers. At the risk of being boring, here they are. They might surprise you.
According to the New York Times a PCP earns on average $150,000 per year. A survey from Medscape pegs it at $170-180,000. That is about what a newly minted law student gets if he or she can land a job at a prestigious large firm or a just graduated MBA gets if hired by a big consulting company. But how does our PCP actually earn that money?
If the PCP has a private practice, in order to earn $150,000, he or she needs to bring in about $350,000 to also cover office expenses. Given what insurers like BlueCross, Aetna, United Health Care, Medicare and Medicaid pay per visit, the doctor needs to see about 25 patients per day. That is $30 to the PCP’s pocket for each visit. No wonder the visit is so short.
Said a different way, the PCP has to see 15 patients to cover expenses. Any patients over 15 and the income goes to him or her. So the PCP works for others until about 2pm.
It was not always this way. A PCP today earns about what a PCP earned (in today’s dollars)   few decades back but, in order to earn it, must see almost twice as many patients per day.
The typical PCP takes 24 phone calls per day, 17 emails, processes 12 prescription refills (above those handled during visits, ) and reviews 20 laboratory reports, 11 X-ray reports and 14 specialist consult reports. These are all done outside of the visit and obviously take substantial time. This work is clinically relevant but then there is about an hour a day – least – of time spent of dealing with insurers. And a recent report suggests that the PCP spends an nearly an extra 1 hour per day with the electronic health record (EHR.)
Look at the numbers a different way. A PCP who worked for a well-known HMO in California earned $140,000 and was assigned a panel of 2200 patients, a large percentage quite ill. That is $64 for each patient for the entire year. That is probably less than you spend taking your car for a twice yearly oil change and checkup. If each patient came in three times per year then each visit was worth $21. This PCP found herself highly stressed, unable to keep up to the level she thought appropriate and went home exhausted only to ignore her family and “crawl into bed realizing  it would start all over again tomorrow.”
On the east coast, a highly regarded PCP told me that “I thought I was going to die, literally, if I kept this up. I could not give the type of care and attention that I felt was best for my patients, I could not be compassionate. All the things I treasured doing as a doctor had vanished.”
The answer is straight forward. Pay the PCP more. Not more in total (although that might also be appropriate) but more per visit and have the PCP take care of substantially fewer patients.
There are many ways to approach this. Increase the fee for service payment in return for more attention to, at least, those with chronic illnesses who need close care coordination. At least one example of this with a Blue Cross program has worked well in the fee for service setting. In a capitated system, an insurer could assign fewer patients but pay the same total amount to the PCP. Maybe 1000 patients instead of 2200 for that $140,000. Or if the population in the pool is high risk with either mostly elderly people or those with multiple chronic illnesses as in a Medicare Advantage program, set the capitation rate so that it works with just 300-500 patients. There are good examples of this being highly effective as well.
Yes, in each of these examples the amount of money going toward primary care per capita is increased but the total costs of care comes way down. It comes down because high quality primary care takes care of most issues, offers better preventive care and coordinates the care of those with chronic illnesses. This means less referrals to specialists, less unnecessary testing and prescriptions and fewer trips to the ER or the hospital.
For PCPs in private practice, they can switch to retainer or membership models where the patient pays directly (direct primary care) by the visit or on a monthly or annual basis for all primary care in a setting where the PCP only has 500-700 patients, offers same day appointments, access to his or her cell phone 24/7, and perhaps reduced cost laboratory testing and even generic medications. Many of these practices are quite affordable - “blue collar.” And the savings on drugs can often offset the membership fee.
Insurers should consider paying the retainer for those who buy a high deductible insurance policy since quality primary care substantially reduces the total costs of care. And at a minimum, they should allow the retainer/membership fee to go against the deductible.  Employers could either buy the retainer or place an equal sum in an HSA for the employee who takes out a high deductible policy through the company. Alternatively, the company might initiate its own in house primary care clinic designed so that the employed/contracted PCP has only a reasonable number of employees to care for. In any of these models, the use of health coaches can further improve wellness, maintain health and assist with illness care.
The result: More time with the doctor. More time for the PCP to listen, more time to think, more time to diagnose and treat, more time to coordinate care for those with chronic illnesses and more time for better preventive medicine. So better care, better health, less frustrations, more satisfaction and much reduced total costs of care. Now you will no longer be wondering why the doctor allots you so little time.

Sunday, August 3, 2014

Reframing the Question of Doctor Frustration

There has been a lot of interest in the Daily Beast article written by Dr Daniela Drake, about very frustrated primary care physicians (PCP.) She quoted both Dr Kevin Pho and myself. Dr Drake noted that nine of 10 doctors would not recommend medicine to their children as a career and that 300 physicians commit suicide each year. “Simply put, being a doctor has become a miserable and humiliating undertaking.”  Dr Pho offered his own commentary here pointing out that “it is important to have the discussion on physician dissatisfaction….demoralized doctors are in no position to care for patients…To be sure many people with good intentions are working toward solving the healthcare crisis. But the answers they’ve come up with are driving up costs and driving out doctors.”  
Yes, it is definitely true that PCPs are very frustrated. In a series of in depth interviews, almost all tell me that their major frustration is not enough time with each patient. No time to listen, no time to think, no time to do critical activities. Why? Because they have to see too many patients per day in order to cover overheads. A few of those that I interviewed have left clinical practice because of these frustrations; others felt that they needed to do “something, soon,” to improve their situation.
But patients are frustrated as well. They find they have to wait a long time for an appointment, sit in the apt named waiting room and then get just a few minutes with the PCP. They observe that the doctor interrupts them within just a few moments, never lets them tell their full story, isn’t really listening and shuttles them off to a specialist or gives them a prescription while never really explaining in their terms what is going on. And they know that they pay a lot for their insurance with premiums rising every year along with lots of co-pays and deductibles. So they are in no mood to feel sorry for the PCP who earns, according a Medscape survey, about $170-180,000 per year.
The usual response of the medical community is to point out the years of education and training, the high debt loads, the hours of work and the calls at night. That other doctors earn much more. That there is an ever growing burden of paperwork, of wasted calls to the insurers and nonfunctioning EHRs. That the responsibilities are high and what could be more important than your health. All true -- but it falls on deaf ears for the family with an income of <$51,000 (median US household income in 2011, per census).
One major problem is that the average person just does not know what really good primary care could do for them and their health over time. Nor do they appreciate that primary care is or at least can be relatively inexpensive. We (the collective medical community) have not done a good job explaining the value of outstanding primary care.
So let’s reframe the frustration question.
How can patients get superior care from excellent energized and satisfied practitioners at a reasonable cost all leading to not only care of disease but prevention of illness and preservation of well-being? And if this can be achieved, will it lead to more students choosing primary care as a rewarding career?
Government is not likely to solve the problem nor will most insurers. It will be up to PCPs and their patients to create a new primary care delivery paradigm. And doctors need to take the initiative to educate the public and lobby for useful change.
There are many options. One is direct primary care (DPC) in its many formats such as pay per visit, a monthly membership fee or retainer-based (concierge) models. The latter two with their limited patient panels are often thought of as only for the elite or the rich but membership or retainer based practices need not be expensive. Several have been written up as “blue collar” plans  with low fees yet limited numbers of patients, same day and lengthy appointments, 24/7 cell phone availability and even free or reduced cost medications and lab testing.
I live in Maryland where I looked up the 2014 Blue Cross (not for profit) premiums in the local exchange. A Bronze plan for a 55 year old costs $3660 per year with a $6000 deductible, essentially a “catastrophic” plan. A Platinum plan costs $7728 per year with no deductible but up to $2000 in hospital co-pays. If the individual requires major medical care, the total out of pocket costs for premium and deductibles/copays in either plan is therefore about $9700. Buy the Bronze plan, create a health savings account and then pay the membership/retainer with tax advantaged dollars. The individual gets high quality health care in a setting where it is to the physician’s advantage to keep the patient well. Alternatively, stay with the Platinum plan and get a 12 minute visit.
As to the PCP shortage and patient education issues, Primary Care Progress is one of a number of new organizations sprouting up to bring current and potential PCPs together. To educate patients, they have produced a useful 2 minute animation.
Looking ahead, insurers might one day decide it is logical to buy the membership or retainer for their insured’s. The cost would be rapidly repaid may times over. Likewise employers could do the same leading to a healthier, more satisfied workforce with higher productivity and reduced total health care premium costs. Sounds radical but it is actually logical. Patients would get great care and maintain good health. Providers get to be the true healers they always aspired to be. The total costs of care would come way down. Maybe even more students would choose primary care as a career. Win-win-win-win.

Monday, July 21, 2014

The Value of Integrative Medicine in Primary Care

Beginning with a deep understanding of medical science and years of training and experience, the primary care physician (PCP) needs to delve deeply into the patient’s personal, family and social setting in order to fully understand the context and causes of the patient’s illness. The PCP also needs to know when it is important or even critical to call upon others with specific knowledge, techniques or approaches that might be best suited for a particular patient. Sometimes this means calling in the cardiologist, the surgeon, the gastroenterologist or the psychiatrist. But it may also mean making good use of other modalities and practitioners such as chiropractic, social work, acupuncture, psychology, massage, nutritional therapy and exercise physiology.
Integrative medicine means, at least, a healing environment, a passion for prevention and wellness and not just diagnosis and treatment; working with the patient and the patient’s family as partners; understanding the deeper causes of illness and symptoms; providing approaches for self-care and taking enough time to address all of the patent’s concerns. For some integrative medicine physicians it also means being intimately familiar with proven complementary practices such as acupuncture, yoga, massage, nutrition and health coaching and personal fitness training. Some PCPs have learned techniques such as acupuncture, meditation or the Benson relaxation response and can use or teach their patients directly. The Duke Integrative Center defines integrative medicine as an “approach to medical care that brings you and your provider together in a dynamic partnership dedicated to optimizing your health and healing. Our approach focuses on all of who you are, recognizing that the subtle interactions of mind, body, spirit and community have a direct impact on your vitality and well-being.”
I heard this patient story of an integrated approach to a medical dilemma from Delia Chiaramonte, MD, director of education at the University of Maryland Center forIntegrative Medicine. A medical student had suffered from severe headaches for many years that were limiting his quality of life and his effectiveness as a student. His personal physician had identified them as cluster headaches a few years before and had tried standard medications without much success. Dr. Chiaramonte evaluated him differently - using an integrative approach. She did intensive probing and listening about not just his headaches but also his lifestyle including diet and activity, his stresses and his school work. Like almost all medical students, he studied hard. He said he stayed up until about 3:00am studying, but in part this was because he couldn’t fall asleep any earlier. His diet included a lot of doughnuts and other high carbohydrate and processed foods plus about 12 cups of caffeinated coffee each day, sometimes interspersed with colas. He had no time for exercise. He sat - hunched over - in front of his computer for many hours each day, and his posture showed it.
Instead of recommending other diagnostic procedures or new medications, his integrative medicine “prescription” included the following: He needed to start on a better diet that included protein at breakfast, healthy snacks during the day and he was to establish a set time for exercise. He was to get away from the computer for ten minutes every hour and walk around and stretch. He was also to get eight hours of sleep each night. To assist him, he was to see a nutritionist to devise a more healthy diet. He was to work with a personal trainer to establish the exercise program - one that could be done anywhere without impacting on his studies. He was to visit a chiropractor to release his sternocleidomastoid muscles and other neck muscles back to their normal length. Since caffeine, of which he was getting a dose multiple times throughout the day, has a long half-life in the body, he was to have no caffeine after noon time. The combination of a better diet, exercise, less total caffeine and none after noon meant he should be able to study more effectively and to sleep better; he was instructed to get to bed by 11:00pm each night.  

Given the pain and debility of his headaches, he was more than willing to give this prescription a try although he was somewhat skeptical since it included no medications. It worked. The headaches disappeared, he felt generally better, he was no longer drowsy in class and he began to truly enjoy medical school.  And he was off all medications.

This is the power of integrative medicine. It used a holistic approach that began with careful listening and then brought to bear many different disciplines including the best of western scientific medicine plus nutritional medicine, exercise physiology, stress management and chiropractic. Together and coordinated by one PCP, the combined approach had a dramatic effect.
Today most medical schools are teaching about the proven complementary modalities and some PCPs are learning not only when to refer but how to personally use some of these approaches.
In interviews of over 20 primary care physicians, most were unsure of what the term integrative medicine meant. However, they would respond in other questions that they frequently referred to nutrition, health and fitness coaches. Some but certainly not all, were very positive about complementary medicine. They felt it had real value, noted that most patients sought out complementary practitioners anyway, and that there was increasing evidence-based data on the value of some techniques and practices. One PCP had taken a course in acupuncture for physicians and used it frequently. Another said “I am very respectful of complementary medicine. I refer to chiropractic and many other complementary practitioners just as I refer to behavioral health or surgery. I am learning every day. Patients are thirsty for complementary medicine. Traditional medical docs who are not on board are just behind the times.” Another said “Integrative medicine is not a catch all for complementary medicine, it is just good primary care. I think of it as connoting the medical home concept.”  “It is part and parcel of my practice.”
But always the PCPs interviewed stated that the key attribute of the superb PCP (or any physician for that matter) is to listen – to listen deeply and without interruption as the patient explains the narrative of their situation. Such was the case with the medical student evaluation described above. It was not just about the nature of the headaches but just as much if not more about the totality of his life and how the headaches fit into that life story. Armed with that knowledge, his integrative medicine physician was able to offer not a symptom abating drug but a means to deal with the headaches through the root causes - an unhealthy life style that was dramatically affecting his entire life and his ability to be an effective medical student.
Next time - Reframing the Question of Doctor Frustration

Monday, June 23, 2014

Frustrations Among Primary Care Physicians Should Be a Wakeup Call

Primary care physicians (PCPs) are incredibly frustrated. This level of frustration should be a wakeup call. The greatest frustration is “Time, time, time”- or more precisely, a lack of time. From in depth interviews with over 30 PCPs, everyone said lack of time was the greatest frustration of their practice (or was previously if they now were in a practice that limited the patient number to a manageable level.) Each knew that they could not give the time needed to give the level of care that they were capable of giving and that their patients deserved.
Stated somewhat differently, they said that it was very frustrating to always be focused on meeting overheads and trying to earn what they thought was a reasonable income because to do so meant less time with patients and a sense of frustration and perhaps even guilt. New practice patterns have meant not being readily available to patients, not visiting them at the hospital or ER, and no longer being the “captain of the ship.”
In a Daily Beast article, Dr D Drake wrote about “how being doctor became the most miserable profession….Simply put, being a doctor has become a miserable and humiliating undertaking. Indeed, many doctors feel that America has declared war on physicians—and both physicians and patients are the losers…It’s hard for anyone outside the profession to understand just how rotten the job has become—and what bad news that is for America’s health care system.”
The complexity of the healthcare delivery system was a common frustration refrain in my interviews. In such a fragmented system, “I need to go an extra mile to communicate with my patients but there is not enough time to do it.”
Other frustrations were dealing with insurers for preauthorization of a test, procedure or referral; trying to figure out what drugs were or were not on an individual insurer’s formulary (and each has a different formulary) and in dealing with their reimbursement methodology. Some insurers are very slow to pay reimbursements which mean carrying high working capital – difficult for a small practice.  One noted the amount of time required to arrange for something like home care which, if the insurer was logical, would actually prevent more expensive time in the ER, doctor’s office or nursing home. PCPs find it exceedingly frustrating to deal with non-medical people at the insurance company who deny tests or medications that the doctor feels are very much in the patient’s best interest.
So PCPs were frustrated by government and insurance regulations, polices and roadblocks to care; by the fragmentation of the system; and by many others things but the root problem that was most frustrating was the lack of time with each patient. 
Kevin Pho MD, a primary care physician and founder of a very popular blog posted about physician frustration following Dr Drake’s article. “So it’s important to have the conversation on physician dissatisfaction.  It’s important to discuss the cost of medical education, physician burnout, and the myriad of paperwork and bureaucratic mandates that obstruct doctors from giving the best care they can to patients. Left unchecked, the physician profession will become completely demoralized.  Whether you care or not, it matters.   Demoralized doctors are in no position to care for patients.”
What is very clear in this extremely dysfunctional healthcare delivery system is that the primary care physicians  (and most other providers as well) are very frustrated that they cannot give the level of care that they believe they were trained to do  and would like to do. Most of their frustrations come down to the lack of time.
They need to take back the time and give it to patients, perhaps via direct primary care or with other models that offer a higher reimbursement for a patient visit or per member per month.  But medicine is a very conservative profession; change comes slowly. Doctors will make the switch to something better only if they feel comfortable that their patients will follow them and approve. Otherwise they will retire early or go work for the local hospital and medical students will continue to shun primary care as a career. If patients want to benefit from much better care, if they want a doctor that is not frustrated and can spend time with them listening, if they want their total costs of health care to decline rather than rise, then they will need to educate themselves and then to advocate  – to legislators, to insurers and to doctors. Concerted patient action will force the issue and make change occur. When the PCP has more time, care gets better, frustrations come down, satisfaction goes up and costs come way down. Everybody wins.
Next time: The value of integrative medicine in primary care.

Monday, June 2, 2014

What Are the Characteristics of a Good Primary Care Physician?

PCPs like people. This was true of them long before they started medical school and it will have only blossomed further during training. Ask PCPs, as I have with in-depth interviews, and they will tell you that certain types of individuals are drawn to primary care careers; they have common characteristics. They like to converse with people. They enjoy getting to know about a person – their ideals, their goals in life, their ambitions, their cares and sorrows. They are interested in learning from the patient rather than talking down to the patient; their ego can be strong but not as to impose themselves on the patient. They tend to not only want to know their patient but also to understand his or her place in their family and society. He or she is a person who wants to know the “whole story;” they tend to see the patient as a whole person, as part of a family and part of a community. They see the patient as a unique individual and his illness as part of that totality of the person, not just a diseased organ or system. To paraphrase Sir William Osler, a good doctor tends to the person who has a disease rather than just the disease itself.   
PCPs generally like to engage in an intellectual puzzle, a mystery to solve.  They have a “general contractor” mentality meaning that they see themselves as capable of getting much or even most of the job done themselves but are comfortable in drawing in others as necessary and in so doing are committed to coordinating everyone involved in the patient’s care. As with all of us, they wish to earn a good income but money is not the most important thing in their life nor is it what drove them to become physicians.
What are the characteristics of a good physician? The deputy dean for education at Yale Medical School, Richard Belitsky, M.D., talked to the freshman class a few years ago at their White Coat Ceremony about becoming a doctor. Greatly abbreviated, he told them there was much to learn “but so much of what you need to be really good doctors, you already know… Becoming a great doctor begins not with what you know, but who you are. Being someone’s doctor is about a relationship. That relationship is built on trust…Being a great doctor begins not with what you have to say, but your ability to listen.” 
In my interviews, primary care physicians report that listening is the key and most important attribute of being a good physician in primary care. By listening they mean one who listens to the patient’s story without rushing it and without embellishing it. They let the patient develop his or her own story of their situation perhaps with some prompts to help them focus but without unduly narrowing the narrative. The PCP must at the same time be nonjudgmental if he or she is to learn from the patient and develop a strong doctor patient relationship – the third major attribute.  PCPs need to like people and thus like their patients.  The good PCP is well grounded in basic medical science, the latest in evidence-based care and is constantly seeking continuing education. The good PCP is conservative, meaning that he or she will work with lifestyle, behaviors and other measures such as nutrition or exercise before resorting to drugs or procedures. This requires patience; not everything can be “fixed” immediately. They feel that knowing the patient over the long term aids the care process and enhances the doctor patient relationship as does being attuned no only to the physical needs but also the patient’s emotional and spiritual requirements. Knowing the patient’s family not only helps to understand the patient but they will be the physician’s ally if and when needed later. It is important to attend to the patient in the same manner that one would want to be treated by others. Combined, these will develop trust, respect and partnership. Some will not only be very good physicians but also true healers, a desired state that only some attain.
A physician who saw this post previously commented that I forgot two things – leaping tall buildings in a single bound and being a good typist. The problem of course is that PCPs today do not have enough time with their patients so even if they possess all or most of these characteristics they are trapped in a business model that does not value time.
When a general audience on LinkedIn was asked by Paula Stanziani what in one word constitutes a good doctor the answers varied of course but some of the most noted common attributes are these: Listener, commitment, compassion, humanity, attentive, patient, competent, teacher, healer and ethical. A good overview from one respondent, Scot Sturtevant, was “I’ve met many a physician in 36 years of service. Some brilliant, some not so much. The one thing I have noticed though those that were great, truly great, were those who were humble, but confident. They would listen quietly to a patient's story, and were never really rushed nor found themselves panicking in a critical situation. They were stoic yet responsive, and treated nurses, technicians and even field medics as a valued part of the team. To sum it they know who they are, and where they came from... And like all of us, still put their trousers on one leg at a time. There really isn’t a single word to describe greatness, it’s part of the diverse nature of who they are and how they apply what they've learned and what they know.”
That sums it up well for me.
Next post: The frustrations of being a primary care physician.

Tuesday, May 27, 2014

Time - The Impediment to Being a Good Primary Care Doctor

Did you get more than a few minutes with your doctor at your last visit? Probably not. Why not? Not enough time.
The primary care physician (PCP) is the most broadly yet deeply focused care giver and as such is the backbone of the healthcare system. But to do this work effectively requires time – time which all too often is not adequately available. Lack of time is a real impediment to the best possible care.
What constitutes primary care and who are the primary care physicians? They are the first responders, the first line of care, and very frequently the patient’s confidant on all matters related to health and often more. The PCP is often the first physician contacted because of the long standing patient - doctor relationship but also because the PCP tends to be more readily available than a specialist who does not know you. The PCP needs to know a broad and deep range of medicine and at the same time needs to know when it is time to consult a specialist. And if you have a chronic illness, the PCP should also ideally coordinate all of the various specialists, tests, imaging and procedures that you might require. It is this coordination of the care over the long term that will mean better care at a lower cost.
The PCP deals with most problems/ illnesses with a broad yet deep expertise and knowledge and so is able to diagnose and treat most common and many not so common diseases and problems, including most chronic illnesses. He or she is well versed in the continuity of care for chronic complex illnesses, is in the best position to refer when indicated, and to coordinate care of chronic illnesses or referral for an acute issue. The PCP is or should be focused not just on disease but on the person with the disease, on wellness and disease prevention by means of immunizations, screening (recognizing risk- reward rationales)  and behavior modification – diet, stress, exercise, smoking, etc.
But there are serious issues in Primary Care.                                                                                
There are too few primary care physicians, too few medical school graduates choose primary care as a career and there are too few residency slots after medical school for primary care training.

Today the PCP needs to be “efficient.” This means that it is more efficient to just give an antibiotic for a sore throat than to reassure the patient (and perhaps the parent) that it is likely caused by a virus; that the antibiotic will do no good and could even have some undesirable side effects and that time is the best medicine. But it takes time to do reassurance. And if not done thoroughly, the patient likely will go away unhappy that he got “nothing.” So do the quick thing and give the antibiotic. And add in for good measure – “This should do it!” or “It is good you came in today to be treated.” It also means that the PCP needs to see as few Medicaid patients as possible since Medicaid pays so poorly. And although much can be done over the telephone or with email, preventing a trip to the office or even the ER, the efficient PCP wants to avoid both since there is no payment for either.
PCPs are frustrated. Some see the glass half full and many see it as half empty. Those that see it half empty are quickly selling their practices to the local hospital. Others are trying new payment methods. Either way, PCPs know they are not doing just the “simple stuff” as so often portrayed but the very complex. Many patients have multiple chronic conditions, are on many prescription drugs, have various functional incapacities as a result of aging, and often have problems rooted in family dynamics or their own cultural norms and traditions.  The good PCP understands that the essence of care is the bond that they develop over time with each patient. This is the bedrock of the profession. But the current “culture” of medicine expects high technology to be the answer, imposes financial frustrations and is always threatening malpractice litigation. This combination, but mostly payment issues, has led to a fragmentation of care and the overuse of specialists, specialty care without coordination and an over reliance on technology. The good PCP, despite all of the frustrations, still understands that that bond with the patient is key, the very heart of their medical practice, the basis of their own satisfaction in their career and (as stated in a book review  on primary care) “the essence of a well-functioning medical care delivery system.”
PCPs are departing private practice in droves. Traditionally a newly minted physician would borrow funds to start a private practice or would enter an already established practice in town. In 2000, it is estimated that about 60% of physicians were in a private practice. This had dropped to about 40% by 2012 and perhaps to 33% by 2013. It appears that the rate of decline in private practices is increasing with no apparent end in sight. In 2000, about 20% of PCPs were employed by hospitals; today that is up to about 40% and growing rapidly.
Why the rapid change? Some of it is a change in the desires of the new generation of physicians. They have a desire for more personal and family time and a professional life with fewer administrative obligations, no concerns about borrowing large sums to begin a practice, and a steady paycheck. But this change to employed status is also about the current convoluted billing requirements of practice, the administrative complexity of running a business plus being a physician, and the always changing regulatory requirements.
But there are definite tradeoffs. Most important is autonomy. Physicians over the years have valued their autonomy but when one works for a corporation, no matter how benevolent, it will have its own rules and regulations. Autonomy is lost. And although the administrative burdens are lessened the physician is still expected to cover his or her own salary and expenses which means still seeing many patients per day, 24-25 or more to meet productivity standards. So shifting to hospital employment does nothing to gain time – time to listen, to prevent, to coordinate chronic care and to just think.
Your primary care physician requires time – time which all too often is not available. This issue will be a major topic going forward in this continuing series on the Crisis in Primary Care of which this is the seventh installment.
The next post will consider who chooses to become a primary care physician.

Monday, May 12, 2014

The Doctor’s Customer Is The Insurer - Shouldn't It Be The Patient?

You the patient are really not the customer of your primary care physician. Since the insurer will determine whether and how much the physician will be paid for attending to your needs, you are largely a bystander in the relationship. The doctor’s customer has become the insurer.  

Our system of care is definitely not customer-focused. Doctors truly believe that they have the patient’s best interests in mind and they do. But their work is not customer focused as it is in most other professional-client relationships. You wait long weeks and sometimes even months for an appointment (the national average is 20.5 days), spend long times in the waiting room and are frustrated that you get just 10-12 minutes with your doctor who interrupts you within less than a minute and who recommends you see a specialist but does not personally call the specialist to explain the issue nor to smooth the path for a speedy appointment. All of this because, in the case of primary care, the doctor must see 24-25 patients per day to meet overhead and achieve a personal income of about $170,000. 

As for the insurers, you are not their customer either. Their customers are the ones who pay them - your employer or your government.  And it shows – by our long waits on the phone, by the complex, often hard to understand paperwork and by the frustration when the insurance you thought you had does not cover your latest tests, x-rays or specialist visit. 

So you are not the insurer’s customer nor are you the doctor’s customer. You are a mere bystander. This is hardly the type of contractual relationship you have with your lawyer, architect or accountant. In those situations, you pay them directly. Want more time? No problem, but you pay for it. Want telephone consultation? No problem, but you pay for it. Not so in medicine. You the patient cannot decide and ask for more time or ask to use of email or telephone. Because you are not paying for the time and your insurance will not do so either. It is just not your choice. 

To be clear. Yes, you are paying the physician directly in the co-pays and the deductibles but it is still the insurer that determines whether and how much the physician gets paid. You just get to contribute whatever portion you are told.  

Who is to blame for the current state of affairs? Each party looks to the other but perhaps each should hold up a mirror and take a close look. Nevertheless, here is what physicians think based on a recent survey. Ninety per cent say the medical system is on the wrong track; 83% are thinking about quitting; 85% think the patient-physician relationship is deteriorating; 72% do not think the individual mandate will lead to improved care; and 70% think that the single best fix would be reducing government intrusion. Further, 49% will no long accept Medicaid patients and 74% plan to stop accepting new Medicare patients. Finally, 80% believe doctors and other medical professionals are the most likely to help solve the mess.  

So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery of health care is truly dysfunctional. What is needed is fewer patients per PCP so that each gets the time and attention really needed. The PCP needs time to listen, to prevent, to coordinate chronic care and time to just think. This means increasing not decreasing the cost of primary care per person. An increase in costs, yes, but an increase that will dramatically lower the total cost of care. More effective preventive care. More attention to the complex chronic illness with fewer referrals to specialists.  Better coordination of the care of those with chronic illnesses, enhanced prevention such that many chronic illnesses don’t develop. Spending  the time to listen and become trusted as the healers that they could and should be -- all leading to better care at much lower total cost.  

A new vision for our system must make it a healthcare not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness. It must address the needs of those with chronic illnesses to both improve the quality of care while dramatically reducing the costs of care. And it must be redesigned so that the patient is the customer that he or she should be. And, critically, to make it work effectively, America needs many more primary care physicians – they are and should be the backbone of the healthcare system – who are able to offer outstanding preventive care, care for the vast majority of complex chronic illnesses, offer coordination for those with chronic illnesses and do it in a manner that is satisfying to doctor and patient alike – with true healing along with expert medical care. It’s doable but it means a rethinking of how our delivery system is structured and assuring that PCPs have fewer patients for more time each.  

It is possible but it will require both doctor and patient alike to demand it. There are many ways to skin the cat but the most promising is direct primary care (membership/retainer/concierge) practices. More on this later.
My next post in this series on the crisis in primary care will be about today’s impediments to good primary care.

Tuesday, May 6, 2014

The Paradox In American Healthcare

We have a real paradox in American healthcare. On the one hand we have exceptionally well educated and well trained providers who are committed to our care. We are the envy of the world for our biomedical research prowess, The pharmaceutical, biotechnology and diagnostic equipment industries continuously bring forth lifesaving and disease altering medications, devices and diagnostics. So we can be appropriately awed and proud and pleased at what is available when needed for our care. 

But, on the other hand, we have a very dysfunctional health care delivery system. A fascinating paradox. One wonders just why it is that Americans tolerate this paradox of incredible medical advances and outstanding providers yet a dysfunctional delivery system. 

Our medical care system works poorly for most chronic medical illnesses and it costs far too much. Chronic illnesses are ones like diabetes with complications, cancer, heart failure and neurologic illnesses like stroke. 

These chronic illnesses are increasing in frequency at a very rapid rate. They are largely (although certainly not totally) preventable. Overeating a non-nutritious diet, lack of exercise, chronic stress, and 20% still smoking are the major predisposing causes of these chronic illnesses. Obesity is now a true epidemic with one-third of us overweight and one-third of us frankly obese. The result is high blood pressure, high cholesterol, elevated blood glucose which combined with the long term effects of behaviors  lead to diabetes, heart disease, stroke, chronic lung and kidney disease and cancer.  

And once any of these chronic diseases develops, it usually persists for life (of course some cancers are curable but not so diabetes or heart failure). These are complex diseases to treat and expensive to treat – an expense that continues for the rest of the person’s life.  

Primary care physicians can deal with most of the issues of these patients – if they have the time to do so. But referrals to specialists is often necessary. Primary care physicians generally do not have the time needed to coordinate the care of those with chronic illness – which is absolutely essential to assure good quality at a reasonable cost. Over time, most chronic illnesses will need a team of caregivers. Consider a patient with diabetes who may need an endocrinologist,  nurse practitioner, podiatrist, nutritionist, personal trainer, ophthalmologist and perhaps vascular surgeon and cardiologist and many others as well. But any team needs a quarterback and in general the person is the primary care physician. He or she needs to be the orchestrator as much if not more than the intervener. This need for a team and a team quarterback for the patient with a chronic illness is much different than the needs of the patient with an acute illness where one physician can usually suffice. It is this shift to a population that has an increasing frequency of chronic illnesses that mandates a shift in how medical care is delivered. Unfortunately, our delivery system has not kept up with the need.  

In healthcare the money is in chronic illnesses. These consume about 75-85% of all dollars spent on medical care. So we need to focus there. 

Since most chronic illnesses are preventable, what are needed are aggressive preventive approaches along with attention to maintaining and augmenting wellness. This would reduce the burden of disease over time and greatly reduce the rising cost of care. Unfortunately, America places far too little attention and far too few resources into wellness and preventive.  Most primary care physicians do not give really high level preventive care. Yes, they do screening for high blood pressure and cholesterol and for various cancers and they attend to immunizations. But this is not enough. Patients need counseling on, at least, tobacco cessation, stress management, good eating habits and a push toward more exercise. They need an admonition to not drink and drive, not text and drive and to buckle up. They need to be reminded that dental hygiene today pays big dividends in the later years of life. And they need someone to really listen closely to uncover the root cause of many symptom complexes as in the story given in the first of this multipart series on primary care. 

When a patient is sent for extra tests, imaging or specialists’ visits the expenditures go up exponentially yet the quality does not rise commensurately. Indeed it often falls. But primary care physicians are in a non-sustainable business model with today’s reimbursement systems so they find they just do not have enough time for care coordination or for more than the basics of preventive care.  And they just do not have time to listen and think. 

So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery is not what it should or could be. The result is a sicker population, episodic care and expenses that are far greater than necessary. The fix is change the reimbursement system to get PCPs the time needed to listen, to prevent, to coordinate and to just think. This will lead to better care and less expensive care.

The next post in this series will be about customer focus.

Monday, April 14, 2014

Lack of Listening is the Core Problem in American Health Care

The Crisis in Primary Care – Part 4
There is and will be a need for many more primary care physicians (PCPs).Why? There is a shortage now and it will be exacerbated in the coming years for at least four reasons. The population is growing, the population is aging and there will be more individuals with health care coverage as a result of the Affordable Care Act (“Obamacare”). I believe that the need will be much greater than the estimate of 52,000 in 2025 as proposed recently in the Annals of Family Medicine. The authors did not address this fourth and particularly important reason driving a need for more PCPs.  If PCPs actually cared for only a reasonable number of patients, perhaps 500 to 1000 (depending on demographics) rather than today’s common 2500+,  such that they no longer were seeing 24-25 or more patients per day in their offices, then the need for more PCPs would be much greater. With fewer patients seen per day, the PCP can then spend the time needed to listen, to prevent, to coordinate and to think – four key activities that they often are not able to do effectively today. This drives a need for substantially more PCPs.
The need is not to graduate more total medical students but to make primary care desirable as a medical professional career. This means overcoming the current non-sustainable business model so that graduates once again will select primary care.
Here is an example of the value of a primary care physician being able to take the time needed to thoroughly listen to a patient and assess the situation. The PCP saw a lady one day that he had known for many years. She was always very enthusiastic and very articulate. One day she came in for a routine visit. The PCP noticed that her speech patterns were slightly different than he remembered from the past. No one who did not know her well nor anyone who had only a brief conversation would have recognized her speech as changed. She was unaware and felt fine. The changes were subtle but they were clearly changed in his mind. The rest of the history was unremarkable. He did a neurologic exam which was also unremarkable. But he was certain that something was amiss. So he ordered an MRI of her brain. Her insurer refused because she had no specific indications with an otherwise normal history and examination. He had to call multiple times and explain his rationale; finally the insurer relented. The MRI showed a primary brain lymphoma – treatable, probably curable. 
The message is simple. The PCP knew his patient well and because he had the benefit of an extended visit time he was able to notice the subtle changes in her speech pattern. His skill combined with a long history with his patient and adequate time made all the difference and probably saved her life. 

Compare that experience to the following story sent me recently.  

“My mother's "real world" story is mostly about a cardiologist but touches on the very problem you describe about PCPs in a brief but pointed way.  

“I took my mother to the cardiologist this week. He spent a good amount of time with her, mostly listening, trying to figure out her medical issue. Once he thought he'd hit upon what was causing the problem and the solution (which happily, did not involve a drug or surgery but behavior modification), he said he'd call her internist who she has been seeing for many many years to tell him about the discussion. My mother waved her hand dismissively and said, "He doesn't know me." The cardiologist looked surprised and a little confused but I understood. My mother was saying that her internist had not spent time listening to her and getting to know her unique situation like this cardiologist had done. 

“My usually non-compliant and defiant mother called me the morning after her appointment to report she had done what he recommended and would continue to do so. His unhurried gentle questioning, sympathetic listening and obvious desire to figure out how to help her is what made my mother trust him. I felt that my mother had actually consulted with a physician - a healer.” 

There is both a good and a not so good side to this story. The good is obviously that the cardiologist listened to her and then developed a plan of action – with her and her daughter - that she could accept and follow. The not so good or even most unfortunate is that she felt her PCP that she had visited for many years didn’t really know her – because he did not listen.  

When doctors do not have enough time to really listen the result is that they do not listen. A study from 1984 of primary care physicians observed throughout patient visits revealed that the doctor interrupted the patient within 18 seconds on average. Relating to this article, Koven commented on KevinMD “In only 17 (23%) of the 74 visits was the patient provided the opportunity to complete his or her opening statement of concerns. In 51 (69%) of the visits the physician interrupted the patient's statement and directed questions toward a specific concern; in only 1 of these 51 visits was the patient afforded the opportunity to complete the opening statement.”  This is not only remarkable but a sad commentary on the short visit and the lack of attention by physicians to actually listening to the patient.
This lack of listening is the core care problem in American healthcare today. It is prevalent, pervasive and getting worse, not better. It is the inadequate income per patient (by whatever payment system – fee for service, capitation, etc. -- is used) that is driving the lack of listening. Today the PCP sees too many patients for too little time each. Until the payment system is corrected and, in return, doctors get back to listening, healthcare will not be true care and certainly not healing. Call this a future combination of shared rights and responsibilities – the doctor earns a decent income in return for offering superior care to a reasonable number of patients. This would be a good balance all around. And although primary care would cost more, the total cost of care would come way down. 

My next post in this series will address the “paradox” inherent in today’s American medicine.

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).