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The Canary And The Primary Care Physician

The vexing problem with “truth” when it comes to healthcare is to understand its limits. Let’s start with two  popular notions. The first: canaries are harbingers for detecting chemical leaks. The second: primary care specialists claim higher salaries for their work will prevent their extinction. Both claims sound plausible, but then come the conditions, the nuances, the variables and empirical testing and observation — the so called threads of truth.

Notion 1, The Canaries: In 1972 my brother passed through the military’s basic training and was Vietnam bound until a perfect score on a standardized test, his Phi Beta Kappa and a chemistry degree from college rerouted his destiny to a remote patch of the Utah desert. Instead of being a foot soldier, he gave back to his country in a chemical warfare lab.

As the story goes (the lab was highly classified, luckily I was not there to be a primary witness), 1/10th of a drop of a nerve agent just on the skin could kill a person in less than a minute. Understandably, the lab employed the services of many caged canaries for testing possible leaks of the nerve gas. This became a time-honored safety measure.

One day a lab tech took the established belief and subjected it to empirical testing. The results rocked “the-canary-in-a-nerve-gas-lab” notion to its core. In reality, the lethal dose needed to kill 50% of the canaries was much higher than it was for humans.  Instead of humans scurrying out of the lab to safety the conclusion of the study predicted that in the event of a nerve gas leak, canaries would be chirping away in their cages senselessly while a roomful of humans lay lifeless on the lab floor.

The brass, confronted with the cold hard facts, summarily dismissed the canaries.

Next, let’s consider Notion 2: Money Can Revive Primary Care, which is built on the belief that throwing more money at a problem can fix it.

I start anecdotally with my cohort of family practice residency friends who are now in their late 50s. Of the eight doctors I keep up with, three no longer see patients – one is retired, one quit medicine 15 years ago and one serves as an administrator. Another three  work part time in patient care ranging from one to three days a week. Only two of us remain in clinical medicine full time.

Observational data suggests that enough money is to be made to either retire early or to work part-time. The comment I hear most often from this very dynamic and intelligent group? “I’m so done with medicine. I’ve moved on with my life.”

Next, 90 percent of primary doctors work for someone else (e.g. Kaiser, Group Health,  hospital systems,  the Veterans Association, private companies, health management groups). Even “private practices” is a misnomer since insurance companies control and out-compete the doctor for the patient.  Patients no longer employee doctors but hire intermediaries to protect them from predatory and unpredictable healthcare costs. Not surprisingly the middle man who pays the doctor cares little about physician morale, work hours or paying one penny more than they have to acquire a doc. We are nothing but replaceable units.

Also, nurse practitioners are rapidly being seen as the new primary care workforce because it is believed that they are easier and cheaper to train and their emerging numbers will create a supply and demand curve that can easily stamp-out any mirage of a doctor magically being offered more money just because MDs are “special” or deserve it.

In addition, healthcare — even after “reform” — is bankrupting America more than any other sector of our economy.  Primary care physicians’ incomes already approach 95 percent of all American’s incomes. The tolerance to pay more money for physicians’ crocodile tears will be but deaf and blind pleadings upon the public and our bosses.

Lastly, the equation between happiness and money in numerous studies show repeatedly  that physicians can’t buy more happiness with more money. They already sit well along  the threshold of money where the happiness curve flattens and no longer responds to money. More money will mean hedging for fewer hours or quitting faster if nothing changes the morale and conviction of the current primary care workforce. Certainly my cohort of residency friends exemplifies this finding.

In sum, a prediction: The brass, confronted with the cold hard facts, will refuse physician pay raises and hire nurse practitioners and physician assistants instead. Canaries will not save chemical warfare workers. More money will not save the endangered primary care physicians. Canaries have enough purpose flying, singing and looking beautiful. The struggling primary physician movement might want to go back to the basics or their mission and take control of their own destiny. There are a plethora of physician collectors who are willing to pay just enough to keep you in a cage. There are also a few primary care physicians out there who have taken flight and have refused to give up hope that others will follow and focus on mission, not money.

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2 Responses to “The Canary And The Primary Care Physician”

  1. Ed Pullen says:

    I think that paying primary care physicians more might encourage more med students to choose primary care, only if we also pay specialists less so that the pay is very similar. I posted about this recently and really think it could help the overall syatem more to have near parity of pay between specialties.

  2. Alan Dappen says:

    I agree with the part that paying specialists less – in many cases, a lot less might help young physicians choose primary care. Paying primary care more without systematic change to their jobs as a whole would just lead many to early retirement or cutting back to 2 days/week of work.

    So whose going to tell specialists that they will get paid less, a lot less just so primary care might be saved? Maybe in a dream but I’m not betting it’ll happen during my lifetime.

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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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