I realize that my blog has been littered with depressing musings on healthcare lately, and so I thought I’d offer up one very positive and “actionable” suggestion for all you patients out there. In the midst of a broken system where your doctor is being pressured to spend more time with a computer than listening and examining you, where health insurance rates and co-pays are sky-rocketing, and where 1 in 5 patients have the wrong diagnosis… There is one “magic” question that you should be asking your physician(s):
“What else could this be?”
This very simple question about your condition/complaint can be extremely enlightening. Physicians are trained to develop extensive “differential diagnoses” (a list of all possible explanations for a set of signs and symptoms) but rarely have time to think past possibilities 1 through 3. That’s one of the reasons why so many patients have the wrong diagnosis – which is both costly in terms of medical bills, time, and pain and suffering.
There is a risk in asking this question – you don’t want to be over-tested for conditions that you are unlikely to have, of course. But I maintain that the cost/risk of living with the wrong diagnosis far exceeds the risk of additional testing to confirm the correct diagnosis. So my advice to patients is to keep this very important question in mind when you see your doctor for a new concern.
In addition to asking this question of your doctor, you can also ask it during a second opinion meeting with another physician. The good news is that these days you don’t even need to get a second opinion in person. I myself have been working with an online second-opinion service called eDocAmerica for several years. Those who sign up for the service can pick the brains of board-certified U.S. physicians on any subject, 24-7 via email (and in some states via phone). The cost is extraordinarily reasonable when provided by employers, and winds up being about one or two dollars per member per month.
If you have a complicated disease or condition (such as cancer) where experts may not all agree on the best treatment plan, a company called Best Doctors offers detailed chart reviews and second opinions from top specialists at academic centers. Again, this service is quite affordable and reasonable if the cost is spread among a group. Employers are able to pay a small fee per employee per month to enroll the entire company in the service.
So why don’t all employers offer these benefits? I suspect that part of the reason is lack of awareness that second opinion services exist, and the other part is tepid demand on the part of employees. So if you’d like to make sure that you’re not one of the five people who have the wrong diagnosis, why not raise the question with your HR department? Enrolling as an individual is also an option, and still as inexpensive as about thirty dollars a month.
My bottom line: make sure you ask your doctor the magic question at least once for every new concern that you have. And if you’re too shy to do it, or your doctor’s answer seems too short, then get a second opinion online or in person.
This one little question could save your life.
A "Medical Service Provider"
As I sat in my orthopedist’s exam room, the discussion quickly turned from my chief complaint to his: “I don’t know why I’m doing this anymore,” he said. “Medicine is just not what it used to be, and I don’t enjoy my work anymore. The bureaucracy and regulations are bad enough, but what really gets me is the hostility. My patients are chronically angry and mean. The only comfort I get is from talking to other doctors. Because they all feel the same way.”
Perhaps this sentiment strikes you as the spoiled musings of a physician who is lamenting his demotion from “god” to “man” – reflecting the fundamental change in the public perception of doctors that has occurred over the past ~50 years. Or maybe you wonder if this surgeon’s patients are mean because he is a bad doctor, or isn’t respectful of their time? Maybe he deserves the hostility?
I’ve found this particular surgeon to be humble, thoughtful, and thorough. He is genuinely caring and a proponent of conservative measures, truly eager to avoid surgical procedures when possible. He is exactly what one would hope for in a physician, and yet he is utterly demoralized. Not because of the hours of daily documentation drudgery required by health insurance and government regulators, but because the very souls he has been fighting to serve have now turned on him. Their attitudes are captured in social media feeds on every major health outlet:
Doctors? I no longer afford that kind of respect: I call them “medical services providers.” They and their families and the medical cabal created this mess when they got control of med schools so that the wealth of a nation would remain in the hands of a few medical elites and their families. The very notion that doctors are smarter, more productive, more anything than others is ludicrous. They are among the worst sluff-offs of our society, yet the richest at the same time. It is an unreal world they have created themselves and they are now watching the natural outcome of such a false system.
The very best physicians have always been motivated primarily by the satisfaction of making a difference in their patients’ lives. That drive to “help others” is what makes us believe that all the sacrifices are worth it – the years of training, the educational debt, the lack of sleep, the separation from family, the delay (and sometimes denial) of becoming a parent, the daily grind of administrative burden, the unspeakable emotional toll that death and disease take on your heart… All of that is offset by the joy of changing and saving lives. But when that joy is taken from you, what remains is despondency and burn out.
What patients need to realize is that they have been (and still are) the primary motivator of physician job satisfaction. Patients have the power to demoralize us like no one else – and they need to take that power very seriously. Because if negative attitudes prevail, and hostility spreads like a cancer in our broken system, the most caring among us will be the first to withdraw.
And in the end all that will be left is “medical service providers.”
I recently wrote about my experiences as a traveling physician and how to navigate locum tenens work. Today I want to talk about the client (in this case, hospital) side of the equation. I’ve had the chance to speak with several executives (some were physicians themselves) about the overall process of hiring and managing temporary physicians. What I heard wasn’t pretty. I thought I’d summarize their opinions in the form of a mock composite interview to protect their anonymity – I’m hoping that locum MDs and agencies alike can learn from this very candid discussion.
Dr. Val: How do you feel about Locum Tenens agencies?
Executive: They’re a necessary evil. We are desperate to fill vacancies and they find doctors for us. But they know we are desperate and they take full advantage of that.
Dr. Val: What do you mean?
Executive: They charge very high hourly rates, and they don’t care about finding the right fit for the job. They seem to have no interest in matching physician temperament with hospital culture. They are only interested in billable hours and warm bodies, unfortunately. But we know this going in.
Dr. Val: Do you try to screen the candidates yourself before they begin work at your hospital?
Executive: Yes, we carefully review all their CVs and we interview them over the phone.
Dr. Val: So does that help with finding better matches?
Executive: Not really. Everyone looks good on paper and they sound competent on the phone. You only really know what their work ethic is like once they’ve started seeing patients.
Dr. Val: What percent of locums physicians would you say are “sub-par” then?
Executive: About 50%.
Dr. Val: Whoah! That’s very high. What specifically is wrong with them? Are they poor clinicians or what?
Executive: It’s a lot of things. Some are poor clinicians, but more commonly they just don’t work very hard. They have this attitude that they only have to see “X” number of patients per day, no matter what the census. So they’re not good team players. Also many of them have prima donna attitudes. They just swish into our hospital and tell us how they like to do things. They have no problem complaining or calling out flaws in the system because they know they can walk away and never see us again.
Dr. Val: Yikes, they sound horrible. Looking back on those interviews that you did with them, could you see any of this coming? Are there red flags in retrospect?
Executive: None that I can think of. All of our problem locums have been very different – some are old, some are young – they come from very different backgrounds, cultures, and parts of the country. I can’t think of anything they had in common on paper or in the phone interviews.
Dr. Val: So maybe the agencies don’t screen them well?
Executive: Right. I think they probably ignore negative feedback about a physician and just “solve the problem” by not sending them back to the same hospital. They just send them elsewhere – and so the problem continues. They have no incentive really to take a locums physician out of circulation unless they do something truly dangerous at work (medical malpractice). That’s pretty rare.
Dr. Val: I recently wrote on my blog that there are 4 kinds of physicians who do locums: 1. Retirees, 2. Salary Seekers, 3. Dabblers and 4. Problem personalities – would you agree with those categories?
Executive: Yes, but I think that a large proportion of the locums I’ve met have been either motivated by money (i.e. they want to make some extra cash so they can go on a fancy vacation) or they just don’t get along well with others. There are more “problem people” out there than you think.
Dr. Val: This is rather depressing. Have you found that some agencies do a better job than others at keeping the “good” physicians coming?
Executive: Well, we only work with 2 or 3 agencies, so I can’t speak to the entire range of options. We just can’t handle the complexity associated with juggling too many recruiters at once because we end up with accidental overlap in contracts. We have booked two doctors via two different agencies for the same block of time and then we are legally bound to take them both. It’s an expensive mistake.
Dr. Val: Does one particular agency stand out to you in terms of quality of experience?
Executive: No. Actually they all seem about the same.
Dr. Val: For us locums doctors, I can tell you that agencies vary quite a bit in terms of quality of assignments and general process.
Executive: There may be a difference on your end, but not much on ours.
Dr. Val: So, being that using locums has been a fairly negative experience for you, what do you intend to do to change it?
Executive: We are trying very hard to recruit full time physicians to join our staff so that we reduce our need for locums docs. It’s not easy. Full time physician work has become, quite frankly, drudgery. Our system is so burdened with bureaucratic red tape, decreasing reimbursement, billing rules and government regulations that it sucks the soul right out of you. I don’t like who I become when I work full time. That’s why I had to take an administrative job. I still see patients part-time, but I can also get the mental and emotional break I need.
Dr. Val: So you’re actually a functional locums yourself, if not a literal one.
Executive: Yes, that’s right. I have some guilt about not working full time, and yet, I have to maintain my sanity.
Dr. Val: Given the generally negative work environment that physicians live in these days, I suppose that temporary work is only going to increase exponentially as others take the path that you and I have chosen?
Executive: With the looming physician shortage, rural centers in particular are going to have to rely more and more on locums agencies. What agencies really need to do to distinguish themselves is hire clinicians to help them screen and match locums to hospitals. Agencies don’t seem to really understand what we need or what the problems are with their people. If they had medical directors or a chief medical officer, people who have worked in the trenches and understand both the client side and the locum side, they would be much better at screening candidates and meeting our needs. Until then, we’re probably going to have to limp along with a 50% miss-match rate.
I have been an outspoken, and often times exasperated, patient advocate and student of healthcare reform. There is no doubt that the U.S. healthcare system is operating far below its potential in terms of efficiency, effectiveness, and affordability. In fact, an entire industry of policy wonks and consultants have sprung up in both the public and private sectors – all with recommendations about how to “fix” our system. In my opinion, the most insightful suggestions will come from those who are currently doing the work of healthcare (i.e. clinicians) and change will be adopted and promoted most fervently by the young and freshly minted among them.
Medical students, residents, and physicians newly in practice now have a place to voice their opinions – The American Resident Project is an ambitious movement to promote fresh thinking from tomorrow’s physician-leaders. I am pleased to be supporting this effort here on my blog and in face-to-face meetings with fellows at medical centers across the country. I hope you’ll bookmark the website and join in the community conversation about how to innovate in the midst of a broken system. This is more than a think-tank for change – the ideas and opinions of young doctors may be our best hope for a brighter tomorrow.
Stay tuned for some fresh ideas in the setting of some healthy talk therapy!