Category Archives: primary care

Primary care’s bad rap

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Primary care’s often-negative reputation as stressful and unrewarding apparently starts early in the medical education process – possibly before students even enter medical school, a recent study has found.

The study appeared earlier this year in the Family Medicine journal. More recently, the findings and their implications for family practice medicine were explored in an interview by the American Academy of Family Practice with one of the study’s authors, Dr. Julie Phillips. an assistant professor of family medicine at Michigan State University College of Human Medicine.

Primary care has struggled for several years with perceptions that it’s boring, stressful, demanding, low-paying and hemmed in with constraints on everything from insurer requirements to time pressures in the exam room. Whether this is perception or reality, it has had an impact: Fewer students who enter medical school are choosing a career in primary care.

The authors of the study wanted to learn more about how primary care is perceived by medical students and whether their perceptions are changed by what they experience during their training.

Surveys were conducted among 983 medical students at three medical schools between 2006 and 2008. The students were asked to rate statements such as “primary care physicians have too much administrative work to do” and “time pressures keep primary care physicians from developing good patient relationships.” Similar questions were posed about the students’ perception of specialty physicians.

Perhaps the most eye-opening conclusion of the study is this: Negative views of the daily routine of primary care were already present in many of the students at the beginning of their training. What’s more, these views didn’t really change as students progressed through medical school, even after they had a chance to directly observe and participate in patient care.

What to make of these findings? It’s clear that “contemporary physicians struggle to meet the high expectations set by patients and their profession with limited time and resources,” the authors wrote. “Our date demonstrate that students are paying attention to the struggle.”

The results were “kind of discouraging,” Phillips told AAFP News Now. She said she also was surprised that the students’ perceptions were formed so early. “That makes me think that some of their views of what it’s like to be a doctor actually don’t come from medical school but from the larger cultural perception of what physician work is like – and especially what primary care is like.”

There were some glimmers of hope. Students who completed a primary care clerkship (typically during the third year of medical school) and had seen real-life primary care in action were more positive about the ability of primary care doctors to develop good relationships with their patients, in spite of the time constraints in the exam room. “It may be that actually spending time observing physicians helps to break some negative stereotypes,” the study’s authors noted.

The researchers also learned that some students will choose primary care regardless of their perceptions about the daily grind. This suggests that individual values and goals play an important role in the career choices of medical students, the authors wrote. “The study reinforces the importance of admitting students with primary care-oriented values and primary care interest and reinforcing those values over the course of medical school, if we are to produce greater numbers of primary care physicians.”

We’ve come a long way from the romanticized ideal of the family doctor that prevailed a generation or two ago. But did the ideal ever really match the reality? If you talk to physicians privately, some of them will admit there’s a great deal of grumbling about the profession and not enough focus on what makes it rewarding. To be sure, there are all too many reasons for doctors to be frustrated and exhausted and discouraged, but at what point do the negatives start to drown out everything else?

Phillips challenged the medical profession to become more involved in supporting new models of care, such as the patient-centered medical home, that can breathe new life into primary care and make it a better career choice. Family doctors also should try to share what’s good about their specialty, she said. “Students listen to what we say. We should try to be positive about the great things in our everyday work, because there are many wonderful things about being a family physician.”

Hello, doc, I’m your mystery shopper

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You know what my first reaction was to the federal government’s plan to use mystery shoppers to gauge how easy – or difficult – it is for patients to make a primary care appointment?

Bring it.

The concept has been getting a ton of negative feedback. Online critics are calling it “government snooping” and an “anti-doctor campaign.”

To recap: The Obama administration is recruiting a team of mystery shoppers to pose as new patients and call doctors’ offices to see how much effort it takes to get an appointment. One of the purposes of this research is to gauge the accessibility of primary care doctors – a key issue as millions of Americans gain health insurance coverage under provisions of the Affordable Care Act. Another purpose is to look at the extent to which physician practices might be accepting new patients with private insurance while turning away those on Medicaid and other public programs. The project, which is still only a proposal at this stage, will potentially be carried out in nine states, including Minnesota.

If this sounds subversive, consider the state of primary care these days.

It is a cold, hard fact that patients frequently have to wait several weeks to see a doctor for something that’s non-urgent. Those of us who live in rural communities encounter this reality every day. The last time I made a doctor’s appointment, the earliest available opening was seven weeks out. I’ve had other wait times ranging from 10 days to three weeks. For a specialist once, it was five weeks.

Is this a hardship? It wasn’t for me, but it might well have been for someone else. How many times do patients end up in an urgent care clinic or an emergency room because they couldn’t – or wouldn’t – wait that long?

Fact #2: Many primary care doctors already have full panels and are no longer taking new patients.

Last month the Massachusetts Medical Society released a report on wait times and physician access. Of the 838 physicians who responded to the telephone survey, 51 percent of internists and 53 percent of family doctors were not taking new patients. The average wait time to see an internist was 48 days; for family doctors, it was 36 days. Average wait times also were rising for specialists such as orthopedic surgeons, cardiologists and gastroenterologists.

Fact #3: An estimated 65 million Americans live in officially designated primary care shortage areas. Shortages are the worst in areas that are rural, poor and/or minority.

Fact #4: Publicly funded programs such as Medicaid (and, here in Minnesota, the MinnesotaCare program) are not attractive to physicians because of the paltry reimbursement. One of the most severe access problems in Minnesota is with dental care for individuals on MinnesotaCare, because so few dentists will take these clients. It is not mandatory for providers to accept Medicaid, MinnesotaCare or any of the other public programs – but when they opt out, access inevitably is diminished.

Fact #5: Access is integral to the overall functioning of the health care system. When patients do not receive timely access to care, the result can be more use of expensive emergency care, higher risk of hospital admissions and readmissions, inadequate management of chronic diseases and worse health outcomes.

I would have cringed if the mystery shoppers pretending to be patients were actually coming to the clinic and using valuable appointment time needed by real patients. Based on what I’ve read about this initiative, however, it doesn’t appear to extend beyond the appointment-making process.

To those who are already familiar with the primary care shortage, this entire proposal may sound like a product of the Department of Duh. But if the federal government is serious about addressing what ails primary care, which is the better strategy: collecting hard evidence or relying on anecdote, perceptions and personal experience?

There’s also something valuable about measuring physician access from the perspective of patients themselves – even if the patients are secret-shopper fakes. Most of what we currently know about wait times and provider shortages is derived from surveys of physician practices and insurers, not from patients. No matter how much clinicians and policymakers think they know about the patient experience, they can’t claim to truly know if they don’t include the patient’s viewpoint in their data collection.

If I have any reservations about the mystery shopper proposal, it’s this: When reimbursement for Medicaid, MinnesotaCare and other publicly funded health programs is so disappointing, there’s virtually no incentive for any practitioner to want to see these patients. It’s easy to criticize them for their refusal yet overlook how they’re financially penalized when they do accept patients on public programs. This is an untenable situation for everyone involved, and it’s to be hoped that the information collected by the mystery shoppers will lead to some genuine and constructive change.

If there’s a better way to collect patient access data than by using mystery shoppers, I’m all ears. In the meantime, it’s hard to see how a physician with a well-run practice would have much to fear from a phone call from a government-funded mystery shopper.

Addendum: Here’s the posting in the Federal Register.

Update, June 29: The heat appears to have been too much; the Obama administration announced yesterday it has shelved its plans for the mystery shopper survey. Perhaps the idea was a public-relations disaster from the start – but it was dismaying to see how much of the debate was focused on the survey methods rather than on the bigger picture of access to health care. Doctors and politicians seem to have had plenty to say; where’s the voice of patients?

Image: Wikimedia Commons

The annual physical: yes or no?

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It’s almost July, which means a postcard will soon be arriving in the mail, reminding me my cat is due for her yearly visit to the veterinary clinic. As usual, I’ll make an appointment and bring her in (although I suspect she’d rather we just skip the whole deal).

Do annual visits to the doctor make sense? Are people healthier when they receive yearly checkups, or is the yearly visit something we do mostly because we think we’re supposed to?

There’s a fair amount of debate in the medical world about the value of that time-honored custom, the annual checkup. Many experts question whether it’s really necessary to subject healthy, asymptomatic adults to a battery of one-size-fits-all tests that might or might not be helpful.

As long ago as 1989, the U.S. Preventive Services Task Force, an independent panel of experts that weighs the evidence and issues recommendations on the use of screening and preventive health care services, found insufficient proof to endorse the benefits of the standard yearly checkup for otherwise healthy adults.

The task force has not suggested that people can skip seeing a doctor unless they’re sick. Rather, guidelines by the USPSTF, researchers and other physician groups increasingly have tilted in favor of individualized assessment and counseling based on the patient’s age, gender, risk factors, health history and preferences. In other words, EKGs don’t need to be administered to every middle-aged person who comes in for a physical, nor does everyone need to have annual chest X-rays or a comprehensive blood panel unless there’s a reason for doing so.

This isn’t always an easy message to convey, especially to an American public who’s accustomed to being told to get screened for everything.

The whole issue, in fact, is more nuanced than it appears. When a group of researchers undertook a review a few years ago of the evidence on the pros vs. cons of the routine physical, the results were mixed. In their findings, published in 2007 in the Annals of Internal Medicine, the researchers reported consistently clear benefits for regular cholesterol screening, gynecological exams, Pap smears and fecal occult blood testing. Regular physical exams also appeared to be reassuring for patients. But the benefits were less clear on other measures, such as whether regular checkups resulted in better clinical outcomes, fewer hospitalizations or lower health care costs.

Why, then, do we continue to have regular checkups, and why do most doctors continue to believe they’re an important part of health care? The real benefit, it seems, lies in the intangible things: the opportunity for doctor and patient to get to know each other and to develop a relationship when the patient is well rather than sick or in the middle of a crisis.

Dr. Steven Reznick, who has a concierge practice in Boca Raton, Fla., tackled this very issue last week in a guest essay at Kevin, MD. “Is it cost-effective? Does it prevent disease? It doesn’t matter,” he wrote. “It is an essential part of the development and continuation of the doctor-patient relationship.”

It’s also a way to benchmark the patient’s health from one year to the next and address important issues such as previous illnesses, family history and lifestyle, Dr. Reznick writes.

In a column that appeared a couple of years ago in the Wall Street Journal, Dr. Benjamin Brewer takes the debate one step farther:

The annual physical gets a thumbs-down from public-health researchers who find no real evidence to support its effectiveness, despite tradition and widespread use.

Physicians continue to perform the exams, patients continue to request them, and many insurers pay for them. The question is why? Should we keep spending money on a health-care intervention without a proven benefit?

My answer is yes. I believe there is more to the annual exam than researchers have studied so far. If they haven’t found a direct benefit, then I’d say they’re not asking the right questions.

Health is more than the absence of disease, and quality care is more than the sum of the tests that can be done on your organ systems. Relationship-based care has a beneficial impact on health quality, costs and outcomes that goes way beyond disease detection and health screening.

There’s nothing wrong with debating the value of the annual physical exam. Indeed, it’s a question that needs to be asked. But like many things about health care, the answer isn’t always straightforward or easy to quantify. Even though we might not be able to objectively measure the benefit of the yearly exam, it seems it’s still a worthwhile thing to do.

Everyday heroes

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When you’re a member of an ambulance crew, you never quite know what your day will bring. These are medicine’s everyday heroes – the emergency medical technicians and paramedics whose work is stressful, demanding, exacting, skilled, professional and rewarding.

What is it like to spend a day in their shoes? To mark National Emergency Medical Services Week, we’re taking readers behind the scenes today with live guest-blogging by the Willmar Ambulance Service at Rice Memorial Hospital. Follow us from 7 a.m. to 7 p.m. and see how the day unfolds as entries are live-blogged continuously throughout the day. Readers are invited to ask questions or provide feedback via the comment section below; the paramedics will try to answer as many of your questions as possible. Be sure to check out the links posted above to learn more – and visit us often during the day for live updates.

7:03 a.m.: Good morning, everyone, this is Brad Hanson, the operations manager for the Willmar Ambulance Service. I will be blogging with you today as we respond to calls and bring you up to speed on a day in the life of a Willmar paramedic.

I am just heading into the office after helping my wife get the kids up for the day and off to school and day care. As the manager, I have a take-home paramedic vehicle so I can always be available if there is a major incident or have to cover call in town due to our crews being busy on other calls.

Our service responded to over 2,600 calls last year, so we have some very busy days where all five of our ambulances are being utilized. You may have seen one of our big blue ambulances in the community!

I am looking forward to giving you an inside look today, so let me know if you have any questions!

7:34 a.m.: Well, looking back over the night shift we have already been a bit busy. As I was saying earlier, I am on call pretty much 24/7. As I was making breakfast for my wife with my 8-year-old daughter this morning (we decided we were going to serve breakfast to her in bed since today is our 14th wedding anniversary), my wife Michelle was awakened by my cell phone ringing. One of the crews called regarding a transfer to St. Cloud, as they were just finishing up an intercept call to Atwater. I will explain intercepts more later. S0 much for the perfect surprise breakfast in bed…

Oh well, we had a good breakfast, and in reviewing the night I remember hearing several pages for the crews since 11 p.m. I counted five with the transfer. It makes for a long night and morning for the crew that started last evening at 7 p.m. Looks like it’s going to be a 16-hour shift for Jim and Keith. This also leaves us a bit short in town so only one crew now until 9 a.m., then back to two. Let’s see how the rest of this day goes.

7:59 a.m.: Checked in with the new 0700 crew, Lonnie and Jim B., today, having a bite of breakfast, then on to rig checks.

Our mornings start out fairly typical with equipment checks to make sure everything is on board and ready and the narcotics are counted and signed off. We are also going to be getting ready for our open house tomorrow as it is National Emergency Medical Services Week, so if you get a chance, say thanks to anyone in public safety that does medical work, from 911 dispatchers, First Responders, EMTs, paramedics, emergency room physicians and nurses.

8:36 a.m.: Sure is nice to see the sun, it can get to be a HUGE downer to do ambulance calls when the weather is nasty. I can remember many calls over the years where I was sure glad I had extra winter gloves and hats in my vehicle to hand out to crews on accident calls when it was below zero. Brrrr!

Having nice days just makes you even more excited about how you can help. It’s kind of like an unknown adventure, waiting for the pager to start blaring about an emergency. Are we going to be going to a major accident, transporting a pleasant elderly lady from a nursing home to the hospital, or something else?…  It seems some days you can just sense that it’s going to be busy and some days you wonder if you’re ever going to get a call.

I mentioned intercepts in a previous blog. Since Willmar Ambulance is an Advanced Life Support Ambulance Service, or ALS, we provide advanced care services to all the Basic Life Support Services around Willmar. In Kandiyohi County there are a total of five ambulance services: New London, Atwater, Raymond, Lake Lillian and Willmar. We also work with services outside of our county like Kerkhoven, Clara City, Brooten, Cosmos and others.

We are automatically sent out on calls anywhere in our county if the 911 call is for things like chest pain, major trauma or someone that is considered unconscious or unresponsive. We have a great working relationship with all our surrounding services and always look forward to working with them to help take care of their patients.

9:30 a.m.: We are back to full crews in town. We have two crews on street duty during the day Monday through Friday, with another crew on call either from home if they live in Willmar or at our ambulance quarters located within the Kandiyohi County Rescue Squad building just north of the E. Highway 12 Burger King on Lakeland Drive (very nice facility).

Our two duty crews have assigned tasks to keep them busy during their shifts, like getting the garage ready today for our open house, or working on any number of assigned tasks like data reports, CPR training or just making sure the trucks are looking good. I always remind our staff that we live in a fishbowl and we are driving large blue billboards, so we always need to look and be professional as we are serving the public 24/7!

10:22 a.m.: With our crews today is Jesse. He is a new casual paramedic hired recently by Willmar Ambulance and is doing his field training today. When we hire new staff, we look for candidates that will fit well within our organization and that are already trained to the National Registry EMT standards.

The Willmar Ambulance field training program trains new members how to be an EMT or paramedic on our service. Field training is done by our seasoned Field Training Officers, or FTO staff. Depending on any previous experience in EMS, this training can last up to 30 days. In this time, we schedule the new hire with FTOs for a number of shifts. They spend the day working with the duty crews going through the equipment on the trucks, checking off on a number of different competency tasks during their FTO time.

As they go on calls with us, they initially start by just watching and getting used to our process, paperwork and how we handle calls, as well as learning our medical protocols and working on mapping of the city. As time goes on and runs are accomplished, they move to being the care provider while the FTO watches their care. After each event and the end of every shift, they are evaluated on the day to see where they are at and asked how they are feeling about the position.

Quality assurance is a large part of our work and we always evaluate and make sure our protocols are being followed and reviewing our runs to maintain the best care possible!

12:09 p.m.: Hello, my name is Shar. I have been an EMT with Willmar Ambulance Service for just over eight years. Also a member of Kandiyohi County Rescue for the past 10 years. I got into this profession a little later than most of my co-workers.

At the time I decided to become an EMT I was looking at doing something different with my life, needed a career change and this was something I had wanted to do but didn’t have the opportunity, due to having small children at home.

Yes, we all start out as adrenaline junkies and get a little excited when the pagers start to go off and we hear the sirens, see flashing lights, just like little kids do whenever they see us.

A typical day for myself and my medic partner Carrie is Mon.-Fri. 9-5. We start our day with rig checks, making sure all equipment is stocked and everything is in full working condition.

After that we head into the EMS office which is located in the emergency room where we have a lot of other assigned duties to do each day. My typical duties other than 911 and back-up calls consist of entering all ambulance billings into the computer for the business office, entering our statistics into the computer, maintaining the casual and full-time schedules for all of our staff, ordering equipment and uniforms for all of our staff, making sure we have staff to cover open shifts, fill liquid O2 tank on our truck, assist ER when needed, of course cleaning of trucks, lots of paperwork and all other duties as assigned.

The 9-5 shift is also called the power shift because we cover the hours of the day when we are usually the busiest and we handle most of the daytime transfers that are sent out to other hospitals. We also do some casual calls where you don’t have to be in the office but respond if a call comes in for a third rig.

As EMTs we do a lot of patient care with our medic partners but we also do most of the driving. We have to go through a driving program and must maintain current certification and also clean driving records. We have continued education to keep our skills and certification.

Like all jobs, we have some bad days. Sometimes you have a call that just hits home, but I wouldn’t trade this job for any other out there.

12:57 p.m.: Hi, my name is Carrie Yungerberg. I am a critical care paramedic with Willmar Ambulance.

Every day I come to work, I don’t know what to expect. I may be sitting in the office working on projects, I could be transferring a patient to another facility or responding to ambulance calls in the community. The best part of the job is that each day is different, but the same. I can respond to two chest pain calls and the symptoms for each person, the heart rhythm, and history for each are different.

I initially started college to be an ER nurse, but met a paramedic who told me to become an EMT to see if I liked that type of work. After less than a year of being a paramedic I knew that I loved EMS and would be in it for a long time. After being an EMT for nine years I went to paramedic school at South Central College in Mankato. I was fortunate to be able to continue to work with Willmar Ambulance after graduation. I have been with Willmar Ambulance now for 14 years.

Being a paramedic requires you to think on your feet. For example, when you are treating a patient and the heart rhythm changes, you need to be able to change your thinking and “go down another path” to treat the patient appropriately. Another way you have to think on your feet is to change what you think might be wrong with the patient. For example, if we respond to a car accident we need to determine if the patient had an underlying condition that might have caused the accident – for example, a heart attack or chest pain, or did the car accident cause the heart attack/chest pain.

There are days that we don’t have calls during our shift. On those days we have projects that we do in the office. Some of the projects that I work on are bike helmet safety, CPR classes, Sonshine First Aid tent volunteers, maintenance/coordination of patient care reports for the ambulance and maintaining supplies, handouts for community events as well as setting up staff to attend community events and community education such as taping a segment for the WRAC-8 show, “Willmar 911.”

The hospital has CPR classes once a month for their employees. I coordinate the instructors for teaching. Also if a business, church or community organization needs a CPR class, we work with them to set up a class. Along with CPR, I am part of the AED coalition of Kandiyohi County which helps place AEDs in the community at businesses and churches.

Sonshine Music Festival arrives in Willmar every July. Willmar Ambulance maintains the tent with volunteers from Kandiyohi County and throughout the state of Minnesota. We have over 150 volunteers who take time to help in the first aid tent. We use all types of medically trained staff, from paramedics, EMTs, RNs, LPNs and CNAs. There also are doctors and non-medically trained staff that volunteer.

All of our patient charting is now done on computers. We have a specially designed report that we use to document everything from the ambulance call. Part of my job is to make sure these reports make it to the patient medical chart at Rice Hospital. Also to make sure the reports get sent to the Emergency Services Regulatory Board.

Community education and events are also part of the job. We attend events such as National Night Out, Healthy Kids Day, and Family Fun Night and Safety Days. We give tours of the ambulance to Boy/Girl Scouts, daycare centers and preschools.

If it’s not ambulance calls keeping us busy, it’s the boss!!

1 p.m.: Just got a 911 call to a local restaurant, working with the crews right now.

1:25 p.m.: A large percentage of Willmar Ambulance calls are cardiac-related. Signs and symptoms of cardiac events can vary from males to females, but some typical clues are pain or heaviness in the chest that lasts longer than five minutes, pain radiating into arms and/or jaw. Other signs and symptoms can include unexplained shortness of breath, unexplained sweating and nausea.

Willmar Ambulance, along with the other services in Kandiyohi County, has the ability to detect significant cardiac events by being able to perform a 12-lead EKG and transmit the data directly to a physician in the emergency room. Having EMS involved early in a cardiac event has shown up to a 45-minute decrease in time when a person needs to be taken to a higher level of care like a catheterization lab in St. Cloud or the metro.

How 12-lead EKGs came to Kandiyohi County

2:18 p.m.: Our work today continues as we prepare for our open house events tomorrow. Sounds like the weather is going to be great! We hope to see a lot of families come out and enjoy the evening with us!

Oh, and since it’s going to be soooo nice, we will even cook for you!

So reminder, Wednesday 4-7 p.m. at the Willmar Ambulance garage. See more at http://www.willmarambulance.com/.

3:14 p.m.: Hello, my name is Dr. Scott Abrams, emergency physician at Rice Memorial Hospital.

For the last couple of years, I have provided medical direction for the Willmar Ambulance Service. I basically help with the medical decision-making process or “protocol” that we follow in providing care to the community.

I have come to greatly appreciate the level of care provided by Willmar’s emergency medical technicians and paramedics. They consistently provide excellent care to the community and are always working and training to become better. As medical director and as someone who calls Willmar home, I want to know that when I call 911, I’ll be getting rapid, appropriate care. I can say that we absolutely have that kind of care here in Willmar, thanks to everyone who works with the Willmar Ambulance Service.

I’ve also had the privilege of providing medical direction for several of Willmar’s surrounding communities (Sunburg, Kerkhoven, Atwater, Lake Lillian and Raymond). While Willmar has a professional or “paid” service, these communities rely on volunteers to staff their ambulance services. I have been consistently amazed by the number of people that volunteer their time and efforts to be trained and to work on their local ambulance service. It is a credit to them and to their community that these towns have such excellent services. They truly are wonderful people volunteering to do a tough job and I’ve been fortunate to work with them.

3:36 p.m.: Hi, I’m Jim Kroona and the reason the surprise breakfast wasn’t a surprise. Sorry about that, boss, and congrats on 14 years.

I’ve been an EMT with Willmar Ambulance for 13 years and on the County Rescue Squad for 16 years so the pager is always on. A shift for me is on call from 7 a.m. to 7 p.m. and on duty from 7 p.m. to 7 a.m. Twenty-four hours can go so fast and yet seem so long.

My partner Keith and I started last night with a transfer to Hutch and ended it with a transfer to St. Cloud (which went about 10 minutes before our shift was to end). We had a call where the police assisted us with a patient and did an intercept with Atwater Ambulance. So hardly time to take a lunch break. You learn early on to eat and sleep when you can because you might not have the chance if you wait.

For me it’s about giving back to my home town. Born and raised here and enjoy the sacrifice we make to help those in need.

I have had the joy/terror of delivering a baby in the front seat of a car and the sadness of extricating a relative from his truck as he died.

Please be safe in your day and with what you do. Finally off to bed!! Hope I can fall asleep.

3:51 p.m.: With over 2,600 calls per year, our crews have days of what feels like controlled chaos and some days where it feels like we are just working in the office or the garage.

It typically takes our crews one hour to respond to, transport and do the paperwork on a routine ambulance call. Our service covers 137 square miles within the county and has a response time standard of having to be enroute to calls once dispatched within 90 seconds 90 percent of the time and to be on scene within 10 minutes 90 percent of the time as well.

We use electronic patient care reports so our information about a patient is recorded and uploaded via a secure system where our records are stored and accessible to our hospital health information department as well as our quality control staff. Having the ability to do electronic reports has tremendously helped our service see and respond to our data, from staffing levels to quality assurance.

I tend to still write information on my gloves; old habits are hard to break. Oh, I still enter the data into the electronic system, but other staff members are way better at it than me.

4:33 p.m.: Being paged to a local clinic where someone has fallen, crew responding code 3 now!

4:39 p.m.: Sometimes, depending on the situation, we need to ask for a second ambulance to help on a call. This could be a need for lifting assistance, or because the patient is severely injured and extra hands are required to take care of the patient safely and without causing more harm. We are very fortunate to have backup when we need it to better take care of our patients and help prevent staff injuries when lifting or moving patients in difficult situations.

We communicate with our emergency department nurses and physicians via radio when we are on scene to give them a heads up of what we are dealing with so they can better prepare for the patient coming in. We use portable radios or mobile units within the ambulances. Cell phones are also sometimes used, but radios are simple and are quick access to medical control when needed.

Our reports are quick, with basic important information relayed to the ED about the situation, background and treatments given, as well as asking for any further questions or orders from the doctor in the ESD. We always assess our patient’s vital signs, and depending on the call, may use our cardiac monitor, oxygen, medications or other equipment as needed to make our patient as comfortable as possible and to help ease any pain they have.

4:47 p.m.: Well, as of this posting we have had six calls since midnight, with four of the calls before 7 a.m. It is typical that we have streaks where our main volume of calls comes in on the night shift and some where they come on the day shift.

Our data tells us our busiest times are M-F from 0900-1700 but calls are not always predictable, so to have 24/7 coverage is a must for a town our size.

I will keep you posted until 7 p.m. on what is yet to come. Hope you’re enjoying the weather and the day with the great crews of Willmar Ambulance.

5:41 p.m.: Hello, my name is Jim Bode and I have worked for Willmar Ambulance Service since 1998. I am currently employed as a casual paramedic and also have critical care certification.

Today was kind of a quiet day around here for an ambulance service. When we got to work at 7 a.m. we checked over all the trucks to make sure everything is stocked and ready to go for the day (and night). After truck checks it was time to get something to eat from the cafeteria. Sometimes this does not go as planned; today we got to sit down and enjoy our meal.

After breakfast we went to the garage again and started cleaning it up for the upcoming event tomorrow (come get some hot dogs and see some really cool stuff). After cleaning the garage and running errands around the hospital, we finally decided on lunch, a local pizza joint that is very understanding when we gotta run out the door.

At last we get a call, problem unknown at another restaurant in Willmar. After the run it’s time to restock supplies and clean up the truck for our next run. This usually takes about 15 minutes to get everything in order.

This afternoon was more prep time for tomorrow and enjoying the sunshine which has been missing for some time now. We got a call from the primary crew that they could use some help with a patient they had, so we assisted them on the scene with their requests.

At this time there is nothing more to report on, so everybody stay safe and come see us tomorrow at the ambulance garage.

6:53 p.m.: Well, everyone, not a crazy day and that’s OK! Thanks for hanging out with us and stay safe! This is Brad Hanson signing off for the day.

Thanks to Rice Memorial Hospital for agreeing to participate in a live blog; to Sandra Schlagel, communications coordinator at Rice Hospital, for facilitating this project and providing photos; and most of all to Brad Hanson and the rest of the Willmar Ambulance Service for making it all happen.

Primary care’s image problem

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From the doctor’s point of view, is primary care rewarding or is it just plain boring?

Medical student Suchita Shah spent five weeks awhile back doing a clinical rotation at a primary care and general internal medicine clinic.

She blogged about the experience a few months ago. Then her blog entry was picked up at Kevin, MD, one of the leading voices in the medblogging world, which is where I discovered it. It seems to sum up many of the issues ailing primary care these days: namely, that many (maybe even most) medical students no longer seem to find it worth their while.

Shah writes:

It was awesome because I was the “doctor.” I essentially had full responsibility for each patient. From calling him in from the waiting room to deciding what medications he needed and at what dose, and everything in between, he was my responsibility. After I saw the patient, I’d present the case to my attending for a few minutes, we’d discuss and he’d teach for a minute and modify my plan a little if necessary, then the real doctor would go in and say hello and sign the orders I had suggested. I was my patient’s health care provider – a phenomenal feeling and an awesome transition in that I now think of myself as a capable clinician-in-training.

But that’s why I found primary care to be boring. I could do it. As a 3rd-year medical student. The cases I saw were by and large obesity, hypertension, diabetes and hyperlipidemia. A little tweaking of drug doses here and there, lots of education about lifestyle changes, plenty of questioning to assess for target organ damage, referrals for specialist followups… and far too much of “staying the course.”

Medical students and doctors like to be challenged and this wasn’t challenging, she writes. “And if this is what most of family medicine/primary care is like… I don’t want to do it for the rest of my life.”

Houston, I think we have an image problem.

To be sure, there’s a lot that’s frustrating these days for primary care physicians. There’s the paperwork, the crummy reimbursement, the pressure to churn patients through the exam room. But are these reasons to disdain the entire field of family medicine or general internal medicine?

The responses to Shah’s guest blog were interesting. “ALL of medicine is boring. And/or frustrating, time-consuming, aggravating or headache-inducing. Welcome to the real world,” one physician wrote.

From another doctor:

really? as a med student, u really feel like u have mastered primary care medicine? as a professor of medicine, i have a reference point, and i can assure u that u have not.

If you spend much time reading blogs and online discussions among medical students, however, the attitude that primary care is unexciting is far from unusual. And it’s not clear how much of this is based on reality and how much is perception.

It’s true that primary care doesn’t pay as well as most of the specialties. For medical students lumbered with enormous educational loans, career decisions often come down to the financial realities. It doesn’t seem to be only about the money, though; there also seems to be a perception that primary care itself isn’t interesting enough or worthwhile enough to be the focus of one’s career.

An article published a couple of years ago by the Association of American Medical Colleges reflects on why this is so. The devaluing of primary care isn’t new, and it often starts in medical school with a so-called hidden curriculum that devotes fewer resources to learning primary care, fewer good opportunities for students to experience primary care firsthand, and often even subtle discouragement or disdain by medical school faculty, the article explains.

But the article also hits on another factor: the high expectations of many medical students for a career that’s both intellectually and financially rewarding. These students, after all, are quite elite – very bright, very hard-working, competitive and achievement-oriented, with high aspirations for their future – and this sometimes leads to feelings of entitlement. When this is the mindset, primary care often simply can’t compete, especially if students perceive (mistakenly) that it’s easy enough for any rookie to do.

Primary care obviously isn’t suited for everyone. In the final analysis, students need to choose a specialty that’s a good fit for them, and the American health care system needs a good supply of specialists as well as primary care doctors.

But it would be too bad if students wrote off primary care on the basis of a limited experience that may not have been representative.

It looks as if Shah may have completely missed what makes primary care interesting and challenging, a physician commenter wrote: “Every patient encounter is an opportunity to discover something and someone new. I chose primary care partly because I didn’t want every patient of the day to be a life and death situation. I am happy to be brilliant once or twice a day and very much enjoy discovering what makes each of my patients tick, what they love and hate and why they make the health choices they do. I love to hear about their jobs and hobbies and families, their grief and their joy. I can always find a way to plant a small seed of better health in each of their lives. I love my job!”

Update: Results from Match Day on Mar. 17 show an uptick in the number of medical students obtaining residencies in primary care. The National Resident Matching Program reports that the number of U.S. medical school seniors matched to a residency in family medicine rose by 11 percent this year. There was an 8 percent increase in the number of matches to internal medicine and a 3 percent increase in pediatric matches.

The numbers are a little bit misleading because the overall number of residency training slots in primary care has been increased. Family medicine programs, for instance, are offering 100 more positions this year. The number of Match Day applicants for all specialties also is up overall.

According to this year’s Match Day statistics, dermatology, orthopedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery and vascular surgery remain the most competitive specialties for applicants.

Match Day helps determine where fourth-year medical students will spend the next three to five years completing their residency training. It’s usually predictive of the student’s ultimate choice of specialty.

Photo: Wikimedia Commons

Rx for primary care

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When primary care doctors openly admit they wouldn’t advise medical students to follow in their footsteps, it does not bode well for the future of patient care.

A couple of weeks ago I attended a local meeting on the future of primary care. It was one of several that were hosted around Minnesota this past month to gather ideas and perspectives on the issues surrounding primary care.

On many levels, the discussion was truly depressing. Among the concerns I heard: There’s too much paperwork. Aging and chronic disease have made patient care much more complicated. Doctors are overburdened and dissatisfied. The primary care workforce is shrinking.

There was some talk of potential solutions, such as bringing in scribes to reduce the burden of medical charting or finding ways for physicians’ work time to be more flexible.

But what I didn’t hear was where patients might fit into all of this.

For better or worse, there’s a lot of frustration in health care these days. Consumer Reports recently published the results of an online survey of 660 doctors and the findings are revealing:

- 70 percent of the respondents said they were getting less respect and appreciation from their patients.

- The top complaint was failure by patients to follow advice or treatment recommendations.

- The volume of insurance paperwork was the No. 1 barrier to providing optimal care, followed by financial pressures that force doctors to see more patients for shorter visits.

If health care providers are frustrated, so are patients. Consumer Reports also surveyed 49,000 of its subscribers and found that although the majority were very satisfied with their doctor, they were less so if they felt their doctor rushed them through a visit, dismissed their symptoms or were too quick to whip out the prescription pad.

By now you’ve probably connected some of the dots. No one’s happy with short visits, unappreciative patients, harried doctors or tons of paperwork. Whether we realize it or not, patients are deeply enmeshed in what ails primary care, and if the ship is going down, patients are going down with it.

It’s all the more unfortunate, then, that many of the so-called solutions to primary care often are formulated and implemented with little, if any, input from patients. Take medical scribes. On the surface, it sounds like a great idea: someone who can take over the burden of charting and documentation so the doctor can concentrate his or her attention on the patient. But how do patients feel about this? Will it change the dynamics of the encounter? It’s one thing, after all, to have someone transcribe the doctor’s notes after the visit; it’s quite another thing to have a third person in the room, during real time, taking notes on the visit.

Evaluations of demonstration projects to implement the medical home concept found that patient satisfaction actually eroded. Assumptions that patients don’t mind having their care turned over to mid-level professionals also can be mistaken.

For what it’s worth, I think patients and doctors still value the relationship-building that lies at the heart of primary care. In fact, when the Consumer Reports survey asked doctors what patients could do to obtain better medical care, establishing an ongoing relationship with a primary care doctor was at the top of the list.

Unfortunately the ability to form and sustain those relationships is being seriously fractured by multiple pressures from the outside. There’s a very real danger that in the rush to come up with solutions, we overlook or devalue what makes primary care unique, what draws physicians to primary care in the first place. Who benefits from that? Not physicians, and certainly not patients.

This is a discussion in which patients need to participate. I hope someone out there is listening.

Photo: Wikimedia Commons

The efficiency factor: One visit or five?

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It’s game show time: Behind Door No. 1 is a 30-minute visit with the doctor during which you’ll be allowed to address multiple issues. Behind the other door is a series of three 10-minute visits addressing one issue apiece.

You chose the 30-minute visit? Bzzzt! Wrong answer.

It’s an unfortunate reality that most doctor visits are short, and patients who want to bring up more than one concern will likely be asked to make another appointment.

The issue came up awhile back in a guest column by Dr. Danielle Ofri which appeared in the New York Times health section, lamenting an encounter with a patient who arrived with a long laundry list of problems. How do you sort through them all without becoming overwhelmed – or, as in this patient’s case, possibly missing something critical? Dr. Ofri says she learned a lesson:

When a patient presents with so many complaints that it’s not possible to cover them all in depth, I openly acknowledge the limits and say, “Today, we are going to review three of your concerns: you pick two and I pick one.” This allows the patient to select the two most concerning issues, and allows me to home in on the one I think might conceal a serious illness.

If there are other issues that haven’t been addressed or resolved, the patient presumably would be told to make another appointment.

On many levels this is a reasonable course of action. After all, doctors have other patients who need to see them too. And patient volume, rather than time spent with individual patients, essentially is what supports the practice’s overhead costs.

Is this really better, though, for overall patient care? Dr. Ofri’s column was picked up this week at Kevin, MD, where the online discussion quickly grew interesting. The comment that most caught my attention came from a medical office practice manager who wrote, “Patients… resist numerous shorter appointments as they feel they are getting less for their co-pay, and want the most bang for their buck.”

Whoa… what?

Money certainly enters into the equation. There’s no getting around the fact that two office visits and two co-pays are more expensive for patients, especially if they’re uninsured or underinsured or have a large deductible. Sometimes this is the main reason patients show up with a long, and frustrating, list of issues that need addressing: They save up all their concerns and bring them to one visit because they can’t afford to come in more often.

But I can think of many other reasons why patients wouldn’t be thrilled with a system that requires them to make multiple appointments to get all their issues addressed. For working-age adults, it means taking more time off work. For adults who are caregivers or who have small children, it means making arrangements each time to reorganize their personal responsibilities. What about older people who no longer drive and must find transportation for each of those additional doctor visits? What about people who are frail or not very mobile, for whom a trip to the doctor can be an exhausting logistical challenge?

There are many times when a face-to-face visit is necessary, regardless of the hassles it might entail. Nor is it reasonable for patients to expect unlimited time with their doctor. But from the patient’s point of view, being asked to restrict their visit to one or two issues and make additional appointments to deal with the rest is a fragmented and inefficient way of doing business – and providers should not be surprised that patients sometimes “resist.”

It would be interesting to speculate on how this practice might be contributing to the escalating cost of health care in the United States and the increasing burden on the health care system. Ten-minute visits can help churn patients through the process more quickly, but if many of those patients have to keep coming back, what has been gained? How does it save money or help the system operate more efficiently?

Much of this goes back to how doctors, particularly in primary care, are paid. They’re rewarded for volume and procedures, not for diagnosing, problem-solving, coordinating and managing. There’ll be little progress until this changes.

In the meantime, how about a little more mutual understanding? Patients aren’t villains for resisting multiple short appointments when a single longer appointment would do, any more than doctors are villains for asking patients to keep it short and come back another day.

Rethinking the medical home

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There’s a lot about the medical home concept that makes sense. Coordination and continuity of care, teamwork, more focus on preventive care and the management of chronic disease – what’s not to like?

Lately, though, I’ve been rethinking whether the medical home is truly going to improve the delivery of primary care. Apparently I’m not the only one; Dr. John Schumann, who blogs at GlassHospital, recently came right out and declared, “It’s never going to work.”

Dr. Schumann lays it on the line:

… While the PCMH sounds good conceptually, individual doctors and patients are finding it less lofty than its rhetoric. For one thing, the model presupposes the doctor as the center of a “care team,” consisting of nurses and “mid-levels” (i.e. nurse practitioners and physician assistants). Under the PCMH model, doctors would only see the “complex” patients, leaving the “simpler” issues (like sore throats, colds, sprains and urinary tract infections) to the rest of the team.

In theory, the doctor (really the doctor’s team) has the ability to handle many more patients, improving both practice revenue and efficiency (attributable to the new informatics tools and data pooling). The obvious problem with this is that the patient has to buy in to the model. Some folks are fine seeing the nurse practitioner for their acute complaint, but how does the Medical Home model improve the doctor-patient relationship, especially if you already have trouble seeing your actual doctor?

Worse yet, with all of this restructuring, the PCMH has yet to be shown to be cost effective. Reorganization costs money, as do the startup costs of the electronic tools. Integrated systems like Group Health in Seattle and Geisinger in Pennsylvania have shown cost savings when doctors are salaried, networked, and have a captive audience of insureds to analyze. Unfortunately, the vast majority of practicing doctors still operate outside of these networks. Encouraging them to transition their practices into “homes” will be disruptive to say the least; the real question is whether the disruption will be transformative toward the ideal or cause the destruction of individualized doctor-patient relationships.

I wouldn’t go so far as to say it won’t work (at least not yet). But I’m starting to doubt whether it’s the solution to primary care that many people think it is.

Last month I blogged here about the results of some early demonstration projects to implement the medical home concept. One of the lessons was that it’s incredibly hard work to adopt this model – much harder, in fact, than anyone realizes. Nor is there a great deal of evidence yet that medical homes do indeed save money, result in better care and are more satisfying for patients.

I hesitate to draw conclusions on the basis of first-generation data. It stands to reason that the learning curve will be steeper during the early stages of exploring any new model of medical care. Now that we know, for instance, that too much focus on implementing the information technology of the medical home can hurt patient satisfaction, other providers who want to adopt this model can try to avoid the same mistake.

There are a lot of assumptions, however, that the medical home model will somehow automatically make things better for patients, and I’m not convinced this is necessarily so.

If patient care is going to be coordinated by teams, good communication is critical. It’s one of the things in  health care, though, that’s notoriously difficult to do well. Are care teams prepared to step up their game? Or will the patient’s care become increasingly fragmented as he or she is handed off to a series of mid-level professionals? How many nuances of someone’s health will get overlooked or missed?

How clearly are the roles delineated? There are many things a mid-level professional can do better, or more efficiently, than a physician. But this isn’t appropriate in every situation, nor with every patient. Moreover, someone still needs to be the captain of the ship and have responsibility for the overall care of the patient.

There’s a very real concern that the adoption of the medical home model is more focused on meeting the requirements than on the actual provision of care that’s patient-centered. A clinic might have an electronic medical record (check!) but this doesn’t guarantee it’s being used in a meaningful way. Likewise, some practices might have a well-developed philosophy of teamwork and patient-centered care but not be able to document it so that it satisfies the bureaucratic standard.

Then there’s the patients themselves. What do they think about this?

Patients, in fact, seem to have been left out of the loop altogether, Dr. Pauline Chen contends in a thoughtful column this week in the New York Times:

Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it’s hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.

Farther down in the column, she notes that many patients who participated in early demonstration projects were unhappy with the results:

Yes, they were getting into their doctors’ offices more quickly and were being followed more closely than ever before, but many patients reported feeling disoriented. Some felt displaced as they saw the old one-to-one doctor-patient interactions replaced with one-to-three or one-to-four relationships involving not only the doctor but also a whole host of other providers. As offices switched from paper-based to electronic medical records, other patients reacted to the distracted clinicians who seemed more focused on learning the new computer system than on listening to them. Satisfaction fell because, like my friend, few patients were cognizant of, much less involved in, the changes going on around them.

It’s worth noting that one of the online commenters who responded to the column was a participant in one of the medical home demonstration projects. Her reaction wasn’t positive:

During the 18-month period, I saw 7 different providers, only one was my primary care physician. For one medical issue, I saw 5 different providers. One of the PAs I saw failed to prescribe the appropriate treatment and for my return visit, I saw a different PA who suggested I needed another appointment with “my doctor” because I hadn’t seen “my doctor” for over a year.

On top of all this, she relates, all of these well-meaning professionals somehow completely missed a problem that required treatment.

Does this mean the model is flawed? Maybe this particular clinic was just floundering with how best to implement a medical home strategy. Maybe, given the passage of time coupled with feedback from patients, these processes could have been smoothed. Then again, maybe not.

On paper, the concept of a medical home still sounds good. But there are clearly issues with how it’s executed in real life, and it seems too soon to know whether these can be overcome. In the meantime, my opinion of the medical home has been cooled off with a healthy dose of skepticism.

Image: Wikimedia Commons

The medical home: some early lessons

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The medical home, or health care home, is being touted as the direction in which primary care in the United States should evolve. Getting there is not easy, however, and it might take a very long time to see any measurable benefit, a report released this week in the Annals of Family Medicine has concluded.

These findings come from a two-year national demonstration project, carried out in 36 primary care practices, that studied the implementation of the patient-centered medical home. They’re significant because they represent one of the first times the medical-home model has been rigorously evaluated for feasibility and outcomes.

What was the experience like for the clinics who were part of the demonstration project? Which strategies worked and which ones didn’t? Were patients better off as a result of having a medical home?

The answers, as it turns out, are neither simple nor obvious. For instance, practices that were randomized to receive intensive coaching from a facilitator to help them through the process tended to adopt more components of the medical home concept than those that didn’t have a facilitator – but it came at the cost of a slight decrease in patient satisfaction. At the same time, though, many practices were able to accomplish a majority of their goals without intensive outside help.

The main lessons can probably be summed up this way:

Six key themes emerged from the qualitative analysis. These themes, illustrated and then explained below, are (1) practice adaptive reserve is critical to managing change, (2) developmental pathways to success may vary by practice, (3) motivation of key practice members is critical, (4) the larger system can help or hinder, (5) transformation is more than a series of changes and requires shifts in roles and mental models, and (6) practices benefit from the multiple roles that facilitators play.

The experiences of the participating clinics suggest it’s going to take far more than anyone envisioned to transform a primary care practice into a comprehensive patient-centered medical home. Independent evaluators of the demonstration project concluded, “It is apparent that for most practices, the process will take a high degree of motivation, communication and leadership; considerable time and resources; and probably some outside facilitation.”

Significantly, five practices dropped out of the pilot project before the two years were up. In two of these cases, it was because the participating practices were part of a larger system that closed or restructured their office; in another, competing demands for time and attention caused one of the clinics to withdraw from the study. One of the participating practices also went out of business during the study because of financial difficulties.

Although the concept of a medical home contains a number of core principles – coordination of care, medical teamwork and use of information technology, to name a few – it appears there’s no easy instruction manual for how primary care practices can implement them. Indeed, one of the biggest hurdles may be the fundamental shift in mindset that the medical-home model requires, particularly for physicians who are trained and conditioned to view the doctor-patient relationship as paramount:

Permitting other practice staff members into meaningful patient interactions for team care meant expanding that special relationship, and for many physicians, doing so required a substantial change in their identity as physician. This shift required not only a change in roles of both physicians and staff, but also substantial changes in the way physicians thought about themselves.

Evaluators also found that primary care practices need to undergo a paradigm shift as an organization in order to successful make the transformation to a patient-centered medical home:

Rather than seeing itself as an organization that processed patient visits for the convenience of the physician, the practice needed to see itself as primarily meeting the needs of patients and planning proactive population-based care for groups of patients. This shift involved substantial change in roles of staff members, time spent in new activities, and rethinking the overall practice processes, values, and mission.

In view of this deep structural change that needs to take place, it’s perhaps not surprising that patient outcomes didn’t show dramatic improvement by the end of the two-year demonstration project. As the evaluators point out, “… It takes time and additional work to turn a new process into an effective function.” In addition, two years simply may not have been long enough to begin reaping measurable outcomes for the better. And on top of this, there were some limitations in the data, such as no control group against which to compare.

These are all important lessons as policymakers push for the adoption of the medical-home model of primary care. It’ll be critical not to push too hard or beyond the capacity of individual medical practices without also giving them the support they’ll more than likely need to be successful. It’ll be especially critical to allow sufficient time for the process to take hold. There can be a tendency to quickly scrap something, or to conclude it’s too flawed to work, if it doesn’t yield an immediate payoff. It’s a tendency we’re going to have to try to resist.

Health care is complex, intricate and unique. It’s not a place for quick fixes or the idea du jour. Fundamental change of the type that policymakers and the public profess to want for the health care system is hard work, and everyone needs to understand up front that it’s not going to happen overnight.

Photo: the Fred Harlow House, Troutdale, Ore. Courtesy of Wikimedia Commons

Bedside manner

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Thank-you notes to the doctor are nice. So is paying your bill on time. The icing on the cake, though, is for patients to have a chance to nominate their family doctor for the Family Doctor of the Year award, hosted annually by the Minnesota Academy of Family Physicians.

The award is a big deal. One of the rules is that nominations have to come from patients. Entries detailing the accomplishments of outstanding family doctors are submitted from all over the state. Finalists are selected by a panel of judges, which also chooses the winner.

One of the comments I’ve heard most often about Dr. Rick Wehseler, who was honored this past month as Minnesota’s 2010 Family Physician of the Year, is “He so deserves this award.” Dr. Wehseler is a family doctor at Affiliated Community Medical Centers in New London-Spicer. He’s obviously well loved by his patients and respected by his colleagues.

It’s notable that this is the third time in less than a decade that a local family physician has received this award. Dr. Dennis Peterson, of Family Practice Medical Center here in Willmar, won in 2004. Dr. Darrell Carter, of ACMC in Granite Falls, was Minnesota’s family doctor of the year in 2001 and was named the national family doctor of the year in 2003 by the American Academy of Family Physicians.

What makes a doctor “good”? Is it just a matter of being clinically competent, or is it something more than this? It’s a question many people have tried to answer. A few years ago the British Medical Journal sought input from its readers on what qualities make someone a good physician. Among the responses: Respect for the patient, regardless of who the patient is. Support for the patient and family. Promotion of health as well as treatment of illness. Courtesy and a willingness to answer questions. Providing the best information available while respecting the patient’s individual values and preferences.

These are the things that tend to really matter for patients and families. In an interesting study published in 2006, Mayo Clinic Proceedings took a more formal look at this whole issue of how to define a good physician:

Is technical proficiency sufficient to be a good doctor? Clearly, a physician cannot lack necessary technical knowledge and skills and still be a good doctor. Less clear is whether a technically proficient physician can lack interpersonal skills necessary to relate well to patients and still be a good doctor.

The authors of the study interviewed a random sample of 192 patients seen among 14 specialties at Mayo Clinic in Rochester and in Scottsdale, Ariz., and asked them to describe their best and worst encounters with a physician in the Mayo Clinic system. The interviews resulted in a list of seven ideal behaviors physicians should possess: confident, empathetic, humane, personal, forthright, respectful and thorough.

If clinical skills don’t appear on this list, it’s probably because most people see the physician’s knowledge and skill as something that goes without saying. They expect clinical competence, but what they want and value are the human skills, the collection of qualities that often are grouped under the heading of “bedside manner.” When these are absent, it does not go unnoticed. Sure, there are patients who insist their doctor should be a good mechanic and nothing more – but I’d be willing to bet most of these folks have either a) never had to receive bad medical news, either for themselves or someone in their family; or b) never had something go wrong with their care.

Indeed, the physician’s bedside manner can make a big difference in how well the patient manages a chronic condition or fares during a health crisis, the Mayo Clinic journal explains:

Most patients want a strong relationship with a primary care physician. Not surprisingly, strong physician relationships appear to assume even greater importance during periods of serious illness. The quality of a patient’s relationship with a physician can affect not only a patient’s emotional responses but also behavioral and medical outcomes such as compliance and recovery.

Bedside manner and its impact on patients can be hard to measure. It’s easy to regard it as a “soft” skill that’s perhaps not as critical as being knowledgeable, well trained and technically competent. But patients know it when they see it, and judging from the letters from patients that are sent in each year for the Family Physician of the Year award, they value it tremendously.

West Central Tribune photo by Gary Miller