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Imagining a Doctor Shortage

Now, I’m just a country doctor, but I have to say I find it very hard to understand why folks in this country on one hand keep talking about a doctor shortage in primary care and on the other hand keep piling sillywork on those of us who are still here. The net effect is that the doctor shortage is going to be a whole lot worse than it has to be.

But it may just be a relative or imaginary shortage because of how this country defines the duties of doctors.

Public Health agendas have infiltrated health care to a degree that threatens to paralyze it. Physicians are increasingly told their primary concern should be their “population” and not their individual patients. We are charged with preventing disease rather than treat it.


Public Health clinics regularly provide travelers with necessary immunizations. Pharmacists are now giving pneumonia and shingles shots on prescription and flu shots without. States are mandating immunizations for children, and penalizing physician practices with low immunization rates. There are whole departments within every level of Government trying to get people tho behave in healthier ways.

Why should we take the heat for something you don’t need a medical license to do?

A physician’s duty is first and foremost to serve each patient’s needs in treating actual disease. Isn’t that what people worry about when they imagine how a physician shortage would affect them?

Let’s think:

Who would worry that with a physician shortage, they wouldn’t get their flu shot?

Who would worry that there would be nobody to tell them to lose weight, stop smoking and eat less junk food?

Who would worry that there would be nobody to screen them for alcohol misuse or domestic abuse?

Who would worry that they’d be at risk for tripping on their scatter rug because there is no doctor to talk with them about their fall risk?

On the other hand:

You’ve had a cough for a month, and you’re short of breath. Who will diagnose your symptoms?

You have a nosebleed that won’t stop by itself. Who will cauterize it for you?

You have diabetes and can’t control your blood sugar with diet alone. Who will prescribe the right medicine for you?

You’ve become increasingly depressed and are at risk of losing your job because of your symptoms. Your therapist suggests you consider medication. Who will prescribe it for you?

America, the choice is yours: What is the best use of your primary care physicians’ time if there aren’t enough of us to be everything for everyone?

The Power of ACT

She didn’t seem obviously depressed as I entered the room.

“So, we have you taking a good dose of both antidepressants now”, I said. “How are you doing?”

“I feel about the same.”

“Have you done anything lately that could have made you feel a little better?”

“I’m not sure…”

“I’ll give you some examples. They can be different things for different people. It could be reaching out to a friend, helping a neighbor, watching the sunrise…”

“I listen to music. John can tell what kind of mood I’m in depending on what I’m playing. And I watch my shows on cable TV. I feel better when I do those things.”

“Are there things in your life that are more important than music and TV?”

“Our grandkids. Our youngest daughter lives here in town and her kids really light up my life.”

“And you see them quite often, right?”

“Yes, we babysit them every weekend. You should see John with them. He’s such an awesome grandfather. It warms my heart…”

“You’ve started seeing Betty now, right? Did you notice over in the Behavioral Health wing that there is a white board that’s divided in four rectangles with a little circle in the middle?”


“Yeah, I think I’ve seen that…”

Has Betty talked with you about that yet?”


“She probably will. It’s a great way to organize your thoughts and your feelings. It’s called ACT. Let me tell you about one aspect of it. It’s the difference between away moves and toward moves.”

She shifted a little forward in her chair.

“The bottom right is what’s really, really important to you, like your grandkids. And the bottom left is all the stuff inside your mind that keeps you away from what’s important. The top left is all the moves you make that take you away from your sadness, anxiety, pain and so on, but that don’t actually bring you closer to what’s important. We call that Away Moves, almost like escapes. That’s where music and TV might belong, unless they are in the box on the lower right. But those things don’t bring you any closer to your grandkids and the happiness they give you, right?”

“I see what you mean…”

“The horizontal line has arrows at each end. By the arrow to the left it says Away and to the right it says Toward. And in the top right rectangle are little things, steps you can take, that bring you closer to what’s important.”

“I see the difference…”

“So, other than your grandchildren, who or what else is important to you?”

“My daughters in Lewiston and Bar Harbor.”

“Anything else?”

“I don’t know…”

“You have a cross on that chain. What’s your faith?”

“I was raised Baptist. My daughter in Lewiston sings in the church choir there and I used to do that many years ago…”

“How often do yo see these two daughters? How often do you go to church?”

“Not often enough…”

“Could you do more of that?”

“I don’t think John would want to go.”

“He might, or he might want to take care of the grandkids while you do those things, right?”

“I never thought of that…”

“It sounds like you have a lot of love inside you that hasn’t been expressed often enough, and it sounds like your faith hasn’t had enough space in your life lately.”

She nodded.

“I know you as a very caring and soulful person and I think of you as someone who thrives on connecting with others. Maybe your bond with your other daughters could be a lot stronger, and maybe that would help you feel happier and less depressed. You and Betty could talk more about that in your next session…”

“I really hope we can.”

“Because there is more to treating depression than picking the right medicine”, I said.

She smiled and locked her gaze straight at me. Her eyes were moist and she smiled faintly.

[”Acceptance and Commitment Training/Therapy (ACT) is an an evidenced-based way of helping people let go of struggling and get moving toward valued living. “Traditional” ACT is complicated and hard to learn. The ACT Matrix is easy.” Dr. Kevin Polk]

Peer to Peer

My old strategy for getting insurance approvals for imaging tests doesn’t seem to be working anymore.

I used to put my thinking in my office notes so that a reviewer at one of the imaging management companies would clearly see my rationale for ordering that CT scan or MRI my patient needed.

Now I am getting more and more requests to initiate a “peer-to-peer” call instead. My heart sinks every time; each one is a sure time robber. Even with today’s talk about paying for value and quality, I still live in a world where my “opportunity cost” is $7 per minute. That is what I must generate every minute of my work day. A five minute call could mean one less patient visit for a skin rash or an ear infection or a patient call to communicate an important test result instead of sitting in a phone queue, listening to Barry Manilow tunes.

The other day, my “peer” was a nurse, a “near-peer” human filter, who listened to my story about why the abdominal and pelvic CT was necessary for my patient with abdominal pain, diarrhea and elevated liver function tests but otherwise unremarkable blood work, including hepatitis titers. She instantly gave me an authorization number. Afterward I asked, “don’t you read our office notes these days?”

“No, we stopped doing that. In this case we were told the patient had a lump.”

“I coded for the three symptoms.”

“But we need to know what you are looking for.”

“A rule out?”


“But you can’t code for a diagnosis the patient doesn’t have, that’s insurance fraud.”

“Well, that’s what we need to know.”

“So I need to spell that out, if you don’t read my notes. You know, in many offices the one whose job it is to call you is a lay person.”

“And so is the person who answers the call at our end.”

And I thought my notes were still read by a medical person. I should have asked if they stopped reading the notes because they have gotten too long and cumbersome for them to read. I’m sure a radiologist who reviews imaging requests has an opportunity cost, or a must-save-the-company-per-minute cost, of a whole lot more than $7.

Note to self: Always add “R/O” after describing the symptoms.

Of course, in cases where there is no time for the Barry Manilow queue, it is a well known fact that the emergency room doesn’t have to worry about prior authorizations.

All or Nothing

The other day, as I was wrapping up my visit with Mrs. Brown, she said:

“Harry is no better, he is coughing and spitting something wicked.”

Her husband, silent during the visit, was unshaven and looked a little tired.

“How long have you been sick?” I turned to him.

“Going on two weeks now. The cough medicine I got last week hasn’t helped.”

I opened his chart in the computer. He had been in six days earlier. A colleague had noted that his lungs were clear and diagnosed him with a viral illness.

“Let me listen to you”, I said.

He had scattered rhonchi and a few wheezes, and at the bottom of his right lung I heard faint crackles.

“You need an antibiotic”, I said, and made sure he didn’t have a fever and that he wasn’t too short of breath.

I created a “new telephone encounter”, documented my findings and e-prescribed an antibiotic for him.

“Be sure to come back if things don’t turn around quickly”, I said.

There’s no way I could charge him for a brief visit. And that’s got nothing to do with whether I wanted to increase my productivity numbers or our clinic revenue.

In this day and age, there is no such thing as a quick visit to make sure someone is okay or to avert clinical deterioration or disaster.

In order to meet all our quality requirements for being a patient centered medical home and all the other ways we are judged and measured, a visit note has to include, even if the patient was seen just one single day before, a complete medication reconciliation, updated past medical and surgical history, social history and specific questions about any other care the patient has received since last seen. In our EMR it would be impossible to get around all these clicks by building a note template that says nothing has changed since last time; the computer tracks the actual clicks we make in the EMR.

So in cases like Harry Brown’s, I have these choices: Treat him for free right then and there, make him come back some other time when we have time for all the extras, or send him to walk-in care in the big city.

My choice is clear, but I can’t help wondering if the people who created the requirements for overambitious repetitive inquiries into the past history of people we already know quite well really understood that instead of becoming more patient centered, we would start giving free care or turn away patients and thereby fragmenting their care.

Stop Excessive Measurement

“Stop Excessive Measurement.”

Those three little words were music to my ears. The fact that they were spoken by Don Berwick, creator of the Institute for Healthcare Improvement and former head of Medicare, made them even more significant.

I was in our state capital today for a regularly occurring conference by Maine Quality Counts. The theme was “Achieving Excellent Patient & Provider Experience”. There was a lot of talk about provider burnout. Dr. Berwick spoke of the central role of the provider-patient relationship and the failures of the current quality movement.

He told a touching vignette about his brother, who is a patient in a rehabilitation facility. All his brother wants right now is to go outside for a few minutes and experience spring, but the rehabilitation hospital is so focused on keeping their falls statistics down that they haven’t been able or willing to work with him to see how he can safely meet his goal.

Berwick more or less said that if you serve your patient well and keep his or her needs in sharp focus, quality will improve, waste will decrease and provider burnout will diminish. How refreshing.

His remarks were originally made at the IHI and published in JAMA a year ago today, during a time when I fell behind in my journal reading.

He describes three eras in medicine.

The first era was the autonomous physician, serving a calling and belonging to a self-regulating profession. Science exposed variation and inconsistencies in the healthcare of the first era, and a second era was born.

That second era, which we now live in, is the era of accountability, measurements and incentives.

The ideals of those two eras are incompatible, but they point the way to a possible third era, which he calls the moral era, where providers are subject to fewer measurements because organizations trust their commitment to their patients and to the principles of quality.

I need to hear things like that now and then.

Watch Don Berwick speak about the third era:

Why Can’t We Speak Our Own Language?

My voice recognition software insists on typing “when needed” when I say “PRN”, and the other day I saw an orthopedic note that said “before meals joint”. I was sure that the straight-laced orthopedic surgeon was not intending to tell the world anything about anybody’s cannabis use. Instead, it was obvious he had spoken the words “AC joint”, meaning acromioclavicular (on top of the shoulder). But AC can also mean “before meals”, (ante cibum).

Hospitals and health care credentialing bodies make us use plain English instead of medical terms and abbreviations. They say it is to avoid confusion. I think it often creates confusion when doctors are forced to speak as if we didn’t know medicine.

Why are we singled out for this dumbing down? Why are we robbed of the language of our own craft?

How would it be if the tech industry couldn’t use abbreviations like LCD, LED and HDTV?

What if Wall Street outlawed terms like hedge, spread and spot market?

What if military jargon was verboten in the war rooms of the Pentagon?

What if coaches weren’t allowed to scream any technical terms to their teams from the sidelines?

Do we really think a jargon free, plain speaking world will move with greater accuracy and with anywhere near acceptable speed if we remove the majority of the new language our progress was built on?

Remembering the Inpatient Workup: All the Tests to the Patient’s Bedside

The most high powered rotation in my medical school was Endocrinology. There, you got to see things most doctors never come close to diagnosing themselves. Uppsala University’s Akademiska Hospital served as a referral center for the Swedish population north of Uppsala, an area the size and shape of California.

Back in the seventies, laboratory testing wasn’t as sophisticated as it is now, we didn’t have CT scanners even at the major hospitals, and MRIs weren’t in use yet.

The Endocrinology ward accepted referrals from northern Sweden for evaluation of suspected pheochromocytomas, Cushing’s Disease, Wilson’s Disease and other exotic conditions. The Chief, Professor Boström, had established the most appropriate workup, or “utredning” (investigation), for each type of problem, and patients would undergo these tests in rapid succession with almost real-time interpretation. Within two or three days, they would be on their way home with a diagnosis and treatment recommendations for their local doctors or followup appointments with Uppsala specialists.

The other feature of the Endocrinology ward was that every day, the Chief or his deputy would do rounds with the junior doctors and doctors in training who carried out the testing protocols. Each patient’s progress was presented to the Chief, who would suggest modifications or additional interventions. That way, each patient had the benefit of having the Professor of Medicine oversee their care. This is the way hospital rounds are done everywhere in Sweden; the head of the clinic directly supervises every patient’s care.

Two differences in how health care is delivered in American hospitals stand out:

First, Patients seldom get admitted for testing here. People end up having serial imaging tests as outpatients. Someone with vague upper abdominal pain may go for an ultrasound that shows a normal gall bladder and borderline dilatation of the common bile duct and slightly irregular texture of the liver, followed a week or two later by a CT which shows only a harmless fatty liver but confirms bile duct dilatation. Next, they might have an MRI that suggests a blockage of the bile flow somewhere in the head of the pancreas where there appears to be a tumor. By that time the patient is feeling worse and is suddenly jaundiced and finally gets admitted for an ERCP that provides a tissue diagnosis of pancreatic cancer.

Second, the quality of care you receive depends on the hospitalist(s) in charge of your care. They work as a team, but many of them are young or temporary hires who practice without the day to day involvement of hospital clinical leadership. I see patients admitted for the same thing to the same hospital being handled completely differently because somebody else was on duty when they came in.

In Sweden, it seems that even today, bed-nights are relatively inexpensive, and patients are sometimes kept simply for “observation”. Here, bed-nights seem to be a rare and exclusive commodity that cannot be wasted. So we make the patient with chest pain that went away come back on Monday for his stress test if it happens to be Friday. And we get paid the same whether we discharge someone early or end up keeping them a little longer because of the bundled payments of DRGs.

And, oh, here we have to justify “medical necessity” for every admission. So we make an older woman take her laxatives at home and have her grandson drive her 50 or 100 miles to the hospital in the predawn hours for her early morning diagnostic colonoscopy.

In the Socialized system in Sweden, there always was the freedom to admit someone because it was the right thing to do, even if you had to use the diagnosis “Causa Socialis” (social reasons).

I hear there’s even now a diagnosis code for that (ICD-10): Z60.9. I remember using it during my early years in practice there.

Sometimes you need to do what’s right for the patient. Actually, we should always do what’s right for the patient.

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