Physicians writing on KevinMD about the primary care shortage, the fifteen-minute visit, panel size, what primary care is paid against procedural specialties, continuity, and the administrative load that has grown around the work. Four maintained records draw on this archive: Primary care: what physicians say, in their own words, Direct primary care: what physicians say, in their own words, Prior authorization: what physicians say, in their own words, and Scope of practice: what physicians, nurse practitioners, and PAs say, in their own words.
As a medical student I was in awe when a professor looked at a patient’s hands or nail beds and described their medical condition without taking a history. I was also enthralled by a TED talk by the best selling author, Abraham Verghese, where he described a lesson that Arthur Conan Doyle, author of Sherlock Holmes, learned as a medical student at the medical school in Edinburgh, Scotland from the famous …
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Estimating a patient’s age-clinical implications
Over the years, my husband’s parents, Helen and Dave, have both suffered unnecessarily from bad medical care. They are not alone.
A botched cataract surgery left Helen with a torn iris. One of her eyes can’t adjust to light, and for the last several years she’s worn sunglasses indoors. Her urologist kept treating her with the same antibiotic for urinary tract infections without testing to see what bacteria she had. When …
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We should value quality when we shop for health care
I recently described the loathsome “relative value unit” (RVU) and its role in the decline in prestige and pay in primary care. The RVU is maintained and updated by a small panel of 31 physicians called the Specialty Society Relative Value Scale Update Committee (RUC). Twenty-seven of the 31 physicians are specialists, which is not at all representative of the physician workforce, given that primary care doctors comprise over one third …
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A new buzz around primary care
When I first met Ralph, he was 82-years-old. He suffered from shortness of breath which started when his wife of 56 years was diagnosed with a rare bone cancer. Upon further investigation, I diagnosed him with a weak heart and a very tight aortic valve which required immediate surgery. Ralph made it; his wife died. Today, twelve years later, he brings me treasures from his metal detecting hobby on the …
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A prayer by a physician
My 87-year-old father broke his hip this past weekend. He was in Michigan for a party for his 101-year-old sister, and fell as he tried to put away her wheelchair. The good news is that he’s otherwise pretty healthy, so he should do fine.
Still, getting old sucks.
During the whole situation around his injury, surgery, and upcoming recovery, one thing became very clear: Technology can really make things much easier:
Technology should enhance connections and improve relationships
If you read my articles, then you likely know about the scam known as pay-for-performance (P4P). This program not only fails to deliver on its stated mission to improve medical quality, but it actually diminishes it.
In short, P4P pays physicians (or hospitals) more if certain benchmarks are met. More accurately, those who do not achieve these benchmarks are penalized financially. I do not object to this concept. Folks who perform …
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Pay-for-performance is all about cost control
A physician I have known for many years recently told me about his decision to enter the world of concierge medicine. His reasoning was telling, saying that it came down to a very simple decision on staying independent or becoming a hospital employee. He liked being an independent solo practitioner, and that was his primary motivation: to maintain independence in a time of consolidation.
Richard Gunderman, writing for the Atlantic, tackled …
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Should physicians work for hospitals?
After I left my position as a staffer for the U.S. Preventive Services Task Force in November 2010, it was three years before I was tapped for another guideline post, this time at the American Academy of Family Physicians. Recently I joined the AAFP’s Commission on Health of the Public and Science, which formulates guidance for family physicians on a variety of topics, including clinical preventive services. My appointment coincided …
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Can conflicting guidelines be good for patients?
Next in a series.
Years ago while in oncology training, I was on night duty when a patient of one of my colleagues was having severe penile pain. He had received a new investigational chemotherapy and it turned out to have an unexpected property of damaging the lining of the bladder and urethra. It gave him a strong uncontrollable urge to urinate yet each time the burning was excruciating. Oral …
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Nonjudgmental listening is the first step in healing
As a child, I often watched science fiction movies and television shows wondering how much would become reality in my lifetime. From space travel in Buck Rogers and Star Trek to time travel in Back to the Future, I often imagined growing up in a world where the impossible became probable. Bionics and the repair of human tissues was captivating and the Six Million Dollar Man became a hit series.
Now, much of what was thought to be …
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Embrace the age of digital medicine
I’m not sure if you’ve heard the parable of the tall man and the cat.
Maybe not, since I had to make it up in light of health care’s unending cost increase.
In this allegorical village, there was a group of citizens who were very upset with a man who lived there. This man was very, very tall, and he made all the villagers feel uneasy (they were insecure about the crowns of their heads, …
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Today’s high deductibles are tomorrow’s bad debt
“So like a concierge doctor?”
That was the most common response upon explaining my future direct primary care practice while in residency. That perception and label really perturbed me. My vision was to care for a diverse group of people. I spent the majority of my residency clinic hours in an urban safety net clinic, but certainly didn’t want to swing the pendulum to the opposite 1%.
To avoid that stigma, I …
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Building a concierge safety net practice
Overwhelmingly, doctors’ reimbursement has been the target of government programs and insurance companies. The idea underlying this movement has been, pay doctors less and curtail their incentive to see patients and the cost of medical care will decrease. As a result of this faulty reasoning, we have ushered in the era of unhappy doctors, those retiring early, and those asking for extra payments to justify the hours needed to give …
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To cut health care costs, pay doctors more
As our nation struggles with the mind-boggling algebraic-like task of reigning in on health care expenditures while increasing provider access and high-quality medical care, provider payment structures are in flux between traditional payment methods and relatively new financial structures.
While I am no means an expert of health policy nor medical business and financing, I think it’s important for medical trainees and enthusiasts alike to understand the very general basics of …
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How doctors are paid today
I chose to leave clinical medicine in 1996 after just three years as a general internist. At the time, I was certain that it was the right decision and necessary for my overall health, but could not have articulated all the reasons why I needed to leave. I loved both the intellectual challenge and the art of medicine. I thoroughly enjoyed my connections with patients. I regarded my professional life …
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Physician well-being is essential to optimal patient care
Prestige in medicine often follows research. Physician-scientists who do basic science research have often been considered among the giants of medicine. As the field of medicine advanced, the gap between what we knew from basic science and how we practiced grew. This created a need for more translational researchers: physicians who could bring what they knew from the laboratory bench to the bedside through large clinical trials.
Now, the next great gap …
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New skill sets are raising the prestige of primary care
Are insurance companies making more decisions about the health care you receive? While a decade or two ago utilization nurses working for insurance companies had some power to approve or reject certain treatments, the reach of insurers into the patient-physician relationship is lengthening.
In March, I reported that insurers were sending questionnaires to policyholders newly insured under Obamacare asking about their health conditions and medical needs. And some people were filling them …
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Who’s making the decisions about your health care?
This is often proposed, but I have trouble understanding it. Real outcomes are not blood pressure or blood sugar numbers; they are deaths, strokes, heart attacks, amputations, hospital-acquired infections and the like. In today’s medicine-as-manufacturing paradigm, such events are seen as preventable and punishable.
Ironically, the U.S. insurance industry has no trouble recognizing “Acts of God” or “force majeure” as events beyond human control in spheres other than health care.
There is …
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Should doctors be paid for outcomes?
