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.
I have a patient with very unusual visual symptoms and sense of imbalance that has persisted for more than a year. She describes very unusual and concerning symptoms including true diplopia, a sense of major visual disturbances like the floor buckling in her visual fields, vertigo, severe sense of imbalance and swaying, headache, memory fog and concentration difficulty.
Of note is that her symptoms seemed to start after a cruise. I …
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Mal de debarquement: Vertigo and dizziness after a cruise
Bewildered, panicked, and disheartened. I watched my mother’s eyes dart back and forth as she read the pharmacy’s prescription cash price list, knowing she could not possibly dig deep enough in her faded purse to pay for her monthly medicines. In her early fifties, she did not qualify for Medicare, nor could we afford the COBRA payments that would extend coverage for our family since my father’s recent lay off.
We …
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The costs of care challenge requires a physician’s creative compassion
Next in a series.
The primary care physician (PCP) is the most broadly yet deeply focused care giver and as such is the backbone of the healthcare system. But to do this work effectively requires time — time which all too often is not adequately available.
What constitutes primary care and who are the primary care physicians? They are the first responders, the first line of care, and very frequently …
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The impediments to being a good primary care doctor
Do you believe that I have to mention this? I can’t believe it either but since the advent of the EMR, this seems to be an issue; a really big issue. Amazingly enough, you are there, as a doctor, to treat the patient and not the computer. You would think it was the other way around with all the bogus quality indicators, meaningful use baloney and pay-for-performance nonsense being stuffed …
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Don’t take the damn EMR into the exam room
This month, the literature and medicine group at my hospital met to discuss Arthur Miller’s Death of a Salesman. The play, which first opened in 1949 with Lee J. Cobb in the leading role (clip here) and is now playing in Boston at the Lyric Stage Company, concerns Willy Loman, a man in his sixties who hauls a sample case up and down New England with “a shoeshine and a smile.” …
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Don’t hesitate to talk to your doctor about work
So, you’re setting up a website for your practice. You thought you’d just grab a .com, .net, or maybe .info. But now there’s .health. Will one of those set you apart from the .com crowd?
So what do you need to know about these new domains?
1. Will patients come looking for me on .health? The bottom line is that it’s highly unlikely patients …
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Should doctors grab a .health domain?
As health care rightly moves towards a model of rewarding quality over quantity, the issue of how best to reimburse physicians is also taking a front seat. If not fee-for-service, then how best to judge and reward quality?
In this new value-based system of the future, some members of the medical community have been increasingly advocating for billing purely for time. In fact, over the years I’ve heard many doctors (usually …
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Why doctors shouldn’t bill for time
As a doctor, it’s my job to figure out what patients really need. Some need antibiotics. Some need pain pills. But everyone needs love.
During medical school I cared for burned children. One of my patients was a 3-year-old with severe burns over most of his body. His roommate, an older boy, had just burned one arm. Yet the older child withered in the …
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People die without love: Why I prescribe the love drug
My friend breathed a sigh of relief as she finished her last clinic visit for the day and headed down the hall to the physician workroom. It was only 5pm. She still had notes to write and labs to check, and as a senior resident she needed to make it back to the hospital wards to check on her team’s interns, to get updates on the afternoon’s events and help …
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The doctor will see you now, or will she?
I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.
The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost …
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Redesign the medical home to thrive in the real world
Recently, a patient I have known for several years called my office and spoke to my nurse. She said that while she was driving, her vision had gone blank for one second and then she was fine. My schedule was already overbooked. Almost all of the slots were filled with patients with the usual array of multiple chronic medical problems for follow-up and management of what were, for the most …
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Primary care: The importance of a doctor who knows you
More than a century of American medical history was turned on its ear recently by the announcement that the groups that accredit medical residencies will unify their standards. Don’t be too hard on yourself if you failed to understand the significance (or notice at all). But this should be viewed as good news across the land. As someone who trains doctors from both traditions, I certainly welcome a more level playing field.
First, …
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The merging of MDs and DOs: A unification of training standards
Sorry for the long gap between blog posts. I have been distracted by the volume of work that I have had to do. Is that a good thing? Yes. Is it a bad thing? Certainly.
I recently heard an interview of Mark Cuban, the owner of the Dallas Mavericks basketball team, billionaire entrepreneur, and one of the “sharks” on the show “Shark Tank.” The show involves entrepreneurs the opportunity to pitch …
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Growing a new kind of practice: Success is based on executing ideas
As part of a family medicine rotation, we recently discussed the importance of bringing spirituality into the hospital. The conversation was led by Stanford Hospital’s chaplain, Dr. Bruce Feldstein, an ER doctor in a former life. We began with definitions of spirituality, discussed personal experiences surrounding a spiritual moment, and concluded with how to take a “spiritual history,” a series of questions that explore patients’ spiritual or religious beliefs.
We even …
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Is there a place for religion in the exam room?
I have been a way from blogging for a bit and tried to clear my head a bit with a vacation skiing. I left the computer at home, disconnected (as best I could), and had the luxury of feeling the knees working less fluidly than they had before, but still had some fun for a brief 3 day stint. It was nice to notice that there’s a whole world out …
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Physician time means nothing to programmers and policy makers
One of my goals is to help doctors be happier in their day jobs. This does not mean you put on a fake smile, and grin and bear it through your day. What it does mean is you consciously set your boundaries for what you need. Stick with them and let others know. Because the truth is, you teach people how to treat you.
This is not only reserved for your …
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Stop being a doormat for your patients
There was a brief scare in our neighborhood this past weekend. Our phone rang. Our friend, who lives nearby, asked if her 12-year-old son was at our house. He wasn’t.
The child had been gone for about 15 minutes. Their family had just returned from a shopping trip with a family friend, and that family friend had forgotten one of his items at our neighbors’ house. The child said, “I’ll run …
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A physician approach to a missing child
I wrote a column recently about the role computers play in the doctor patient relationship, and my concern that screens shift physicians’ focus away from their patients. This column is part of a large conversation going on nationally and beyond about what I’d call “distracted doctoring.”
A Wall Street Journal opinion piece by my colleague Dr. Victoria McEvoy addresses the issue of whether all the digital box checking now required of doctors as part …
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Patients should silence their phones in the exam room
It has been freezing cold in much of the country for the last two months, but things have been heating up in the controversy over the implementation of ICD-10. First, a quick primer for those of you who have not been following this.
The “ICD” in ICD-10 stands for International Classification of Diseases. The “10” refers to the version of the taxonomy, which is maintained and revised periodically by the World Health …
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The real reason doctors hate ICD-10
