July 29th, 2009 by KevinMD in Better Health Network, Opinion
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When it comes to opiate drugs, like morphine, there is a bitter debate between patients who are in chronic pain, and the doctors who are vilified for under or over-prescribing these medications.
But there are some other subtle influences that push doctors to prescribe these drugs, in some cases inappropriately. An ER physician talks about the issue, saying, “when dealing with a patient who is in pain, or appears to be, it can be impossible to sort out when a patient needs opiates for legitimate reasons, and when it is merely feeding a long term addiction. We are trained to provide comfort and relief from suffering to our patients, and we generally will err on the side of treating pain, rather than withholding addictive medications.”
There is also the pressure to provide “patient satisfaction,” and indeed, low scores in this area can place a doctor’s job in jeopardy. Taking a stand against those who inappropriately request opiates will result in low patient satisfaction scores, and “will often times result in arguments, profanity, and calls and letters to administration.”
What’s the answer? Perhaps a little less reliance on these scores, since a good patient satisfaction score is not necessarily correlated with proper medicine.
*This blog post was originally published at KevinMD.com*
July 29th, 2009 by AlanDappenMD in Primary Care Wednesdays
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Few business models can top the inefficiencies, high costs, and overuse of manpower as primary health care. Every minor infection, cut, runny nose, goopy eye, hack, itch, rash, low back pain, stomach ache, urinary tract infection, tick bite, bee sting … ad infinitum must run the required gauntlet of the five-office-staff “touch points” in order to be treated. Let’s count them:
1. Scheduler,
2. Reception / intake window,
3. Nurse,
4. Check-out window, and
5. Billing specialist
Once you’ve seen your doctor and interfaced with all of the “touch-point” staff, next comes the game of musical chairs between the patient, doctor, and insurance company to see who’s going to pay the bill. This game often lasts months and includes pitched battles before a resolution is reached, typically when someone gives up resentfully from sheer exhaustion. All this hassle might be understandable for a surgery, hospitalization or very expensive procedure, but instead we play this game for the simplest booboo. For day-to-day care, this translates into the American people playing this game at least 5 million times a day.
Every practicing family physician/internist’s office employs roughly 4.5 full-time people per provider who slog through the piles of paperwork needed in a third-party driven model. On the insurance side, it can be an even higher body count, with staff lined up to review the claims, police transactions, audit doctors’ notes, data mine patients’ data, review negotiated rates to be paid to each physician, and cut the checks. Instead of a model where the patient gets a direct service and pays an immediate and transparent price, we create the illusion that health care is “free” and then wonder why it costs so much money to see the doctor. Just look at the people we need to pay in order to receive our free care.
Automation has not reached health care as it has with nearly every other U.S. industry. Rather than streamlining healthcare through technology, we instead keep adding new layers bureaucracy, including administrators who find purpose by helping to improve the authorization process, or the reminder systems for patients not to miss their appointment, or the services which broker the whopping cost of care if the patient gets stuck with the bill, or act as navigators of “the system” for people who need to figure out who to see next in the process of care. To stay viable, twenty-first century medical care will have to address these inefficiencies because they create barriers to rapid and transparent care.
The ideal future family doctor’s office will be automated and render most office staff obsolete. Patients will schedule an appointment online without the hassle of a receptionist. Doctors and nurse practitioners will answer incoming phones and emails from their patients thereby immediately addressing medical questions, thus reducing delays and getting 50% of people what they need without an office visits when one isn’t needed. Patients will log-in and get copies of their personal health records that are linked to the doctors’ electronic medical record so that they can have a copy of their labs, vaccines, and update their own personal information whenever they need it. The bill for service will become transparent, immediate and mostly policed by the patient who has a personal stake in the price. No one cries “foul” faster than a person who sees a bill and wonders if he’s been ripped off.
By re-engineering the dynamics of the office visit, far fewer doctor’s office of the support staff are required. Instead of the 4.5 full-time staff per provider, a practice set up like what we’ve done at DocTalker Family Medicine requires only one employee per provider. The DocTalker model, which is a cash-only practice, uses computer, telecommunications and internet technology to enable the clinician to perform functions previously done by the front and back office staff, such as the receptionist, scheduler, in-window, out-window, billing specialist, and office assistant. Thus a person’s care is centralized through one person (the doctor) rather than many, leading to efficiency and reduction in overhead costs. If competition is encouraged, this process will only get better and less expensive.
Shouldn’t this be a consideration when overhauling cost efficiencies for healthcare reform?
Let us hope that it is.
Until next week, I remain yours in primary care,
Alan Dappen, MD
July 28th, 2009 by Shadowfax in Better Health Network, Health Policy
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From the department of “Credit where it’s due,” in the comments of my
post on the Lewin Group, Nurse K pointed out the following:
Come on Shadowfax, you’re blogging about this stuff and you stand to make A TON of money if it goes through…for awhile…until insurance companies decrease your compensation since you’re making more per patient. I know you mentioned this before in like a comment or something, but ER docs stand to benefit (temporarily) probably more than anyone else. HUGE bias on your part.
Much as I (really, really) hate to admit it, she’s absolutely right. In fact, I’ll go one further: I first got interested in this part of medicine policy because I was mad that I was seeing all these uninsured patients and wasn’t getting paid a thing for my efforts. I started keeping track of the number of uninsured I saw every day, just as a pet obsession. It was a sobering number. After that I started getting a little perspective, talking to patients and seeing their bigger picture, understanding why they were uninsured, learning the particular challenges they faced getting health care, etc. For me, this cause became something beyond the personal a long time ago and became a moral imperative.
But K is right to note the potential for bias, and it’s fair for me to acknowledge it. I hope that my integrity on this point is evident. The fact that I argued in the New York Times for an increase in primary care compensation, with an attendant decrease in the compensation of specialists, including Emergency Medicine, should speak well for my ability to see beyond personal self-interest. (God knows it didn’t make me popular in EM circles!)
This is something which struck me yesterday, reading the med blogs reaction to Obama’s presser. Quite a few docs mounted their high horse and with great indignation denounced this:
Doctors are forced to make decisions based on a fee payment schedule that’s out there. So they’re looking… if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, “I’d make a lot more money if I took this kids tonsils out.” Now that might be the right thing to do, but I’d rather have that doctor making those decisions based on whether you need your kids tonsils out…
Now it’s a clumsy clinical scenario written by someone who has no clue about medicine. But it’s a damned fair point. Bias comes writ large, as in the Walter Reed orthopod who pocket $850K and falsified his research to benefit Medtronic, and it comes writ small, as in the ER doc who sees a small lac and has to decide whether to use a band-aid or a stitch, knowing that the stitches will pay 10x more. It comes with the cardiologist who has to decide whether to take a low-grade troponin leak to the cath lab. It comes with the surgeon seeing a patient with unusual abdominal pain and a slightly enlarged appendix on CT (you can observe or just take out the appy; guess which pays more).
Whether there’s a “fix” for that in the current reforms is debatable. It harms our standing, however, to deny the possible existence of bias and to claim a moral purity that, as a profession, is not justified. I think and hope that most of us in these ambiguous situations are able to come to the right decision for the patient the vast majority of the time regardless of our economic interests. The best way to remain credible is to acknowledge the mere potential for bias and move on and debate the salient point. Making counter-factual arguments that biases do not exist or that we physicians are too awesomely altruistic to ever be influenced by them does nobody any good.
*This blog post was originally published at Movin' Meat*
July 27th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips
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The following is a message that I received from a reader:
“Professor Auerbach – I am an avid reader of your blog ‘Medicine for the Outdoors.’ Your two posts about foot blisters are really interesting. In my hiking experience there is another foot related issue, that is the subungual hematoma in the toenail. I think it could be an interesting subject in one of your blog posts. Thank you very much for the attention.”
Well, it just so happens that I have been a sufferer myself, so I’m happy to write a bit about this. Subungual hematoma refers to blood under a toenail or fingernail. In the fingers, this usually occurs from a blow or pinch, such as catching a finger in a door or striking it with a hammer. In the foot, it is commonly caused by repetitive blows in a confined space, such as hiking in a boot with a toe-box that is too small and/or too stiff. The photo above is my foot after a 10 mile hike over rocky terrain in hiking shoes that didn’t fit quite right. They were broken in, but they weren’t sufficiently flexible for that type of hike. A couple of hours in, I knew I was in trouble because of the pain, but there was no turning back. No surprise, when I took off my sock, I saw the blue color and knew that eventually that particular toenail was a goner.
What can be done about this condition? When it first happens, applying an ice pack might relieve the pain. Certainly, you should trade out the poorly fitted shoes for ones that provide greater room and comfort. If possible, curtail hiking activities for a day or two, and let the situation settle, or the blood collection might increase.
When a fingertip is smashed between two objects, there is frequently a rapid blue discoloration of the fingernail, which is caused by a collection of blood underneath the nail. Pain from the pressure may be quite severe. If the pain is intolerable, it is necessary to create a small hole in the nail directly over the collection of blood, to allow the blood to drain and thus relieve the pressure. This can be done during the first 24 to 48 hours following the injury by heating a paper clip or similar-diameter metal wire to red-hot temperature in a flame (taking care not to burn your fingers while holding the other end of the wire; use a needle-nose pliers, if available) and quickly pressing it through the nail. Another technique is to drill a small hole in the nail by twirling a scalpel blade, sharp knife, or needle. As soon as the nail is penetrated, blood will spurt out, and the pain will be considerably lessened. Before and after the procedure, the finger should be washed carefully. If the procedure was not performed under sterile conditions, administer an antibiotic (such as dicloxacillin, erythromycin or cephalexin) for 3 days.
In the case of my toe (above), the pain subsided with a day’s rest from hiking, so there was no benefit to be obtained by draining the blood. A new nail grew in underneath the one shown in the picture, with the entire process taking a full nine months from injury to nail replacement.
This post, Blood Under The Nail – What To Do, was originally published on
Healthine.com by Paul Auerbach, M.D..
July 26th, 2009 by KerriSparling in Better Health Network, True Stories
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Earlier this week, I had a bit of a medical issue. Painful urination, high blood sugars, and the constant need to pee. (Ladies, I know you already know what’s up.) Urinary tract infection looming large. I was livid, because it was the day before I was scheduled to travel for this week’s business.
I haven’t got time for the pain, so I called my primary care physician, Dr. CT. “Hi Nurse of Dr. CT! It’s Kerri Sparling. Listen, I’m pretty sure I either have a kidney stone or a urinary tract infection, and I need to rule it out before I leave for a week-long business trip.”
Dr. CT was on jury duty. Damnit. So I had to call a local walk-in clinic, instead.
The clinic was a hole in the wall. Part of a strip mall structure. My confidence wasn’t high, but my blood sugars were and my whole body was screaming for attention, so I knew I had to follow through.
The receptionist was very nice. The nurse was even nicer. They took my blood pressure (110/74), my temperature (98.8) and a urine sample (ew). 
I should have known from the moment the sample cup was given to me that it wasn’t going to be a fun visit. The very kind nurse handed me this —>
That is not a urine sample cup. That’s like a party cup that you use for lemonade on a hot summer day. Not for pee. Oh God.
And then the doctor came in. For the sake of anonymity, we’ll call him Dr. Idiot.
“Hi. I’m Dr. Idiot.”
“Hi, I’m Kerri.”
“Kerri, I see you are here for pain when urinating. Are you urinating frequently? You see, you are spilling a significant amount of urine. I believe we may have found the source of your troubles.”
He closed his file, proud of himself.
“Dr. Idiot? On my chart there I wrote that I have type 1 diabetes. I know my blood sugar is elevated right now, which sucks but at least it’s not a surprise. But that’s not why I’m here. I actually suspect that …”
He cut me off.
“I think we need to address this first problem. You are aware of your diabetes, you say? How many times a month do you check your sugar? You know, with the glucose machine and the finger pricker?”
If I wore bifocals, it’s at this point that I would have slid them down my nose and given him a hard, Sam Eagle-type stare.
“I test about 12 – 15 times a day. But the real reason …”
“You mean a month,” he corrected me.
“No, I mean a day. I have type 1 diabetes. I wear a continuous glucose sensor. And also an insulin pump. I’m very aware of my condition, and I’m also very aware that it’s slipping out of control today because of this other issue, the pain issue. Can we talk about that?”
He looked at my chart again. “So you don’t use a meter?”
“Sir, I use a meter. And a machine that reads the glucose levels of my interstitial fluid. This is in addition to my insulin pump. I don’t mean to be rude but …”
Now he gave me a hard look. “Why the interstitial fluid? Why not the blood directly? I mean, you could have more precise readings with the blood.” He picked up my Dexcom from the chair next to me and pressed a few buttons to light up the screen. (Mind you, he did not have permission to touch it, but I’m again not saying anything.)
“You mean like a pick line? I don’t know. I’m sorry. Ask them?”
“Yes, but it would make much more sense and …”
I just about lost it.
“I’m sorry. I didn’t come here to talk about that. I want to talk about the issue I’m here for. Which is not diabetes. Or your ambitions to know more about CGMs. Please can we address what I’m here for?”
“The sugar in your urine.” With finality, he says this.
“NO. The fact that I think I have a UTI or a kidney stone. Please. Help. Me?”
I kid you not – we went ’round and ’round about this for another ten minutes. He didn’t believe me that I was at least sort of familiar with diabetes. His ignorance included, but wasn’t limited to, the following statements:
- “High sugar causes frequent urination. Maybe that’s why you are peeing often?” (Not because I was drinking a liter of water per hour to flush my system? Nooo, couldn’t be that.)
- “Did you have weight loss surgery?”
- “Grape juice also causes high blood sugar.”
- “That thing should really be pulling blood samples. Pointless otherwise.” (Meaning my Dexcom.)
- “The urinalysis won’t be back until Friday, and in the meantime you should start on a regimen of insulin immediately.”
- And also: “I didn’t peg you for a pink girl.” (Are. You. Serious??)
The end result, after an escalating argument that involved me yelling, “Stop. Talking about my diabetes and PLEASE focus why I’m here!” was a prescription for Macrobid that I could elect to take if my symptoms didn’t alleviate, and the instructions to call back on Friday for official lab results.
“Thank you. Really. Can I go now?”
He at least had the decency to look ashamed.
I’ve had some wonderful doctors over the last 30 years, and my health is better for it. But this guy? Complete disappointment.
*This blog post was originally published at Six Until Me.*
