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Practicing Primary Care: A Lesson In Treading Water

As a primary care physician, I am becoming painfully aware of how hard it is to be good –- I mean really good — at what we do today. I would prefer to believe that it has always been so, yet I do not believe that our predecessors in the medical profession found it nearly as difficult to excel in their time as we do now.

With all of the technological and medical advances, you might ask how I could believe this to be true. Too, you might consider it pessimistic or even crazy to suggest that physicians 20, 30, or 100 years ago found it easier to practice medicine well in their time.

You could counter with numerous or obvious examples such as antibiotics, pharmaceuticals, robotic surgical procedures, or even our wondrous ability to peer inside the human body without cutting it open. You also would be correct to point out that the technological advancements of the 20th century opened the way for the medical profession to become a real science thus giving me and my colleagues the chance and knowledge to make a real difference in our patients’ lives today.

Yet, none can benefit from knowledge they and their doctors lack, so time studying science is a requirement for physicians wishing to properly wield all of this lifesaving technology. Unfortunately, this time is currently needed to learn ICD-9 and CPT codes (with ICD-10 and 10,000 new codes coming soon) or to scour the HHS ruling just released defining “meaningful use” in the practice of medicine.

It would be hard for many to believe that some larger organizations are required by OSHA to actually have their physicians spend time filling out yearly paperwork reminding them to wash their hands or pointing out that needles are sharp and might transmit HIV. This seems to me the equivalent of making an employer remind an electrician not to stick his wet finger in the socket.

Fifteen years ago, my first office was next door to a hospital where I was granted privileges to perform a multitude of invasive procedures including intubations, bone marrow biopsies, and the placement of central lines. An average day would start and end with hospital rounds, with office appointments sandwiched between, and, if I was lucky, a medical conference at lunch time would provide both food and education.

Today, many internal medicine residents choose to either become a hospitalist or to practice only outpatient primary care medicine. And statistics show that patients have better outcomes and shorter hospital stays under the care of a hospitalist than a general “old-fashioned” internist — a trend that points out the challenge today’s primary care doctor has in keeping up in his field while not spreading himself too thin.

Furthermore, the inordinate and incessantly growing amount of time spent on cutting or avoiding the red-tape spun by innumerable government rules and regulations monopolizes our time and makes it difficult to find the time or energy to pursue further medical education.

I believe that some of these restraints preventing us from practicing medicine to our true potential are unique to the primary care doctor and this is, precisely, why many can describe us as “endangered.” It is all most of us can do just to keep our heads above water each day- leaving little time for study and less for research. The Hippocratic Oath I took included the promise to protect the noble traditions of the medical profession — a promise, in my estimation, that is growing harder to keep with each successive Congress.

Until next time, I remain yours in primary care,

Steve Simmons, M.D.


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One Response to “Practicing Primary Care: A Lesson In Treading Water”

  1. Art says:

    With a shortage of primary care physicians the governemnt is moving quickly to replace the shoartge with Nurse Practitioners and Physician Assistants, evidently not seeing that much difference between them and wanting to deliver on the promise of access and affordability.

    It is sort of the Marie Antoinette saying in reverse “let them who eat cake or have nothing at all to eat – eat bread”

    Since NP and AP have limited authority only by having them treat small problems not needing a physician and having the now practicing primary care physicians move to a specialty does the system now in place ahve any chance to achieve anything “meaningful”.

    Having 10,000 mor codes only allows a finer degree of miscoding to increase waste, fraud and abuse!

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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