‘This is where I belong’

Nine months of hands-on clinical training, seeing patients and working with physician mentors at Affiliated Community Medical Centers reinforced the desire of Sarah Eisenschenk, now a fourth-year medical student at the University of Minnesota, to become a rural primary care doctor.

“I guess I found out that this is where I belong!” she concludes in an essay posted this past summer on the Discover ACMC blog.

When you get right down to it, all health care ultimately is local – and you can’t have a good local health system when the right people aren’t in place.

Much has been written about the supply of physicians in the U.S.: how there aren’t enough of them, how specialties such as primary care and geriatrics are in short supply, and the geographic imbalances that leave some urban areas with a surfeit of physicians while rural and/or remote communities go begging.

As someone who lives in rural Minnesota, I’m keenly aware of how much it takes for local providers to attract and retain qualified doctors. They’ve notched up several successes in the past couple of years, but they can’t ever really stop recruiting because they know that a departure or a retirement, or a decision to expand a service – cardiology, for instance – could change the whole situation.

We don’t seem to be alone. The Association of American Medical Colleges projected last year that the national shortage of physicians could reach 62,900 doctors by 2015 (that’s just three years away) and 91,500 by 2020.

I was therefore taken aback when I recently came across some reports suggesting the doctor shortage isn’t as bad as it’s made out to be. According to data released by the Association of American Medical Colleges, there were 258.7 active physicians for every 100,000 Americans last year. More than six in 10 physicians settle in the state where they received their medical education, the report found.

This month the Colorado Health Institute issued a report on the state’s health care workforce and the impact of adding the uninsured to the health insurance rolls when this provision of the Affordable Care Act takes effect in 2014. The report’s conclusion: There’ll be a need for more health care providers but it won’t be as dramatic as many anticipated.

Here’s a final piece of data: First-time applications to medical school reached an all-time high this year, according to the Association of American Medical Colleges. Medical students are increasingly diverse, and the majority start their training with some previous exposure to clinical experiences.

While all of this sounds positive, the picture becomes more complex when you start studying the details.

The Colorado Health Institute report, for instance, is careful to point out that rural areas are, and will continue to be, short of doctors. Nor did the report take into account the impact of an aging population or the increasing trend among physicians to specialize rather than go into primary care.

The situation also varies considerably from state to state (click here to see an interactive map put together by American Medical News). Some states do very well at retaining physicians after they complete their training at one of the state’s medical schools. Alaska, California and Montana manage to keep 60 percent or more of their medical school graduates in the state. New Hampshire is the worst, exporting all but 28.3 percent of its graduates. The Upper Midwest is somewhere in the middle; of the 17,516 medical graduates whose training was in Minnesota, 7,735 – or 44.2 percent – remained in Minnesota to practice medicine.

Dig deeper and you’ll find that although Minnesota has 269.6 active physicians for every 100,000 residents, a figure that puts it among the best 15 states in the U.S., the number of active primary care physicians is 103.8 per 100,000. Moreover, 22 percent of all physicians in Minnesota are over the age of 60 and presumably beginning to think about retiring.

It’s not a time to get complacent, which is why I’ve found it encouraging to read the many physician stories posted at the ACMC blog. One of the most recent comes from Dr. Michelle Cilek of ACMC-Redwood Falls, who describes the rewards of being a family doctor in a smaller town where she can practice quality medicine yet still have time to garden, sew and attend her children’s soccer games. “Redwood Falls is a great community; my practice is busy and I am able to get to know my patients on a more personal level because I see them at church, my children’s activities and more,” she writes.

Dr. Merlin Nelson, a neurologist, likes the challenge of the variety of patients he sees. Being a five-minute drive away from the clinic or hospital when he’s on call is a pretty good deal too. ACMC physicians in Granite Falls, Litchfield, Marshall and Willmar share their stories here, here, here and here.

To the average patient, what matters most is having a doctor quickly available when the need arises. Issues of supply and demand, of geographic distribution, specialty distribution, availability of training slots and even the increasing burden of medical training costs can seem rather remote and academic. But making all the pieces come together is much harder than it looks, and it’s all the more rewarding to see when this happens in your own backyard.

Illustration: “Doctor and doll,” Norman Rockwell, 1929

Matters of experience

It was a bittersweet moment for Liz O’Brien. Dr. Wilson, her longtime dentist, was retiring and turning over his practice to his young associate.

Dr. Riley “looked younger than my own kids,” O’Brien blogged recently at MedPage Today. “I could feel my skepticism rising and my initial smile of welcome turning into a wooden grin. I hoped she didn’t notice. How much experience could this new dentist have?”

It’s an age-old question: Do patients benefit when their doctor is young, fresh out of training and up to date on the latest skills and knowledge, or are they better off with someone whose wisdom has been honed by years of experience?

As it turns out, the answer isn’t clear. Various studies have attempted to identify the effect of age on physician skills and produced conflicting results. Some found that as the physician’s experience increased, so did the quality of care on some outcomes – but not on others. A couple of studies found that physician performance peaked after a certain number of years in practice and then declined.

The study that perhaps has been cited most often appeared in 2005 in the Annals of Internal Medicine, where it generated considerable stir. The authors reviewed 62 previously published studies and found that in more than half, the results suggested that the longer physicians were out of medical school, the more likely they were to provide lower-quality care.

For example, in 15 of the studies that were reviewed, physicians who were in practice longer were less likely to follow guidelines on the appropriate use of diagnostic and screening tests. In the largest of these studies, physicians who had graduated from medical school more than 20 years previously were “consistently less likely” to follow recommended cancer screening guidelines, the authors of the Annals study wrote.

Perhaps even more significantly, a handful of the studies reported longer hospital stays and worse outcomes for patients whose doctors were farther along in their careers.

Taken together, these findings fly in the face of the usual assumption that the longer physicians are in practice, the more skilled and astute they become.

The authors of the study suggested several possible explanations:

Perhaps most plausible is that physicians’ “toolkits” are created during training and may not be updated regularly. Older physicians seem less likely to adopt newly proven therapies and may be less receptive to new standards of care. In addition, practice innovations that involve theoretical shifts, such as the use of less aggressive surgical therapy for early-stage breast cancer or protocols for reducing length of stay, may be harder to incorporate into the practice of physicians who have trained long ago than innovations that add a procedure or technique consistent with a physician’s pre-existing knowledge.

Another factor might be the cultural shift that has been taking place in medicine, ushering in concepts such as evidence-based care and performance evaluation. What we might be seeing is the “cohort effect,” the study’s authors wrote. “That is, when the current generation of more recently trained physicians has been in practice for a longer time, there may be smaller differences between their practice and those of their younger colleagues than our data would suggest.”

And yet this doesn’t seem to be the whole story.

Many competencies can only be developed by years of experience, one physician wrote in response to the Annals study. “I certainly thought I knew more when I finished my residency than I think I know now. However, like the teenager who knows everything, I could not always decide when best to use the information. Use of that knowledge comes with experience.”

If older doctors can become set in their ways, younger and more inexperienced physicians might be overconfident in their skills and possibly more aggressive in their use of prescription drugs and other therapeutic interventions that don’t necessarily benefit the patient.

What does it all mean for patients trying to decide between an older physician vs. a younger one? Sometimes the considerations are practical. A relative of mine who was looking for a new physician decided to steer clear of older doctors because he wanted a longer-term partnership, not one that would likely end in a few years when the doctor retired. It can also be easier to get an appointment with younger doctors who are building a practice and will take new patients. Often, however, it comes down to personal preference and what patients are looking for in the relationship.

What seems to matter most – and what the Annals study didn’t really address – are the individual qualities that separate an OK physician from a great one: conscientious, willing to listen, open to new ideas, intellectually curious, able to work well with a team, and humble enough to recognize what they know and what they don’t know. This can describe older physicians just as easily as younger ones.

Aside from several weaknesses with the methodology, the real message of the Annals study may be the importance of lifelong learning to ensure doctors stay on top of their game as they progress through their career.

There also seems to be a lesson here about not judging a book by its cover. O’Brien reflects on her first meeting with her longtime dentist: “Dr. Wilson was a young guy, but he had a bunch of diplomas on his office wall. He had been referred by someone I knew, seemed capable, calm, and nice, and I had trusted him.”

He might have been inexperienced but he was determined to be a good dentist, she wrote. “In his case, things worked out fine – very fine indeed. I hope it will work out for Dr. Riley too. I intend to give her a chance.”

Health care bullies

His test results were late, so the patient jokingly asked the doctor whom to blame. The doctor pointed to the nurse and said, “If you want to scream at anyone, scream at her.”

Was this just an offhand comment? A not-very-funny attempt at humor? Or a subtle, belittling insult?

Theresa Brown, an oncology nurse and guest writer for the New York Times, took on the sensitive issue of physician-vs.-nurse bullying in a weekend piece titled “Physician, heel thyself.” She writes:

This vignette is not a scene from the medical drama “House,” nor did it take place 30 years ago, when nurses were considered subservient to doctors. Rather, it happened just a few months ago, at my hospital, to me.

As we walked out of the patient’s room I asked the doctor if I could quote him in an article. “Sure,” he answered. “It’s a time-honored tradition – blame the nurse whenever anything goes wrong.”

Brown then goes on to lay bare some of the internecine warfare that can take place between doctors and nurses. Much of it, she writes, doesn’t consist of blatant infractions such as surgeons throwing tantrums in the operating room. Instead it tends to be subtle: Sarcasm. Condescension. Passive-aggressive behavior such as not returning calls or pages, or belittling a nurse in front of patients and families.

It matters because patient safety is at stake when health care professionals can’t work well together as a team, Brown writes. And she issues a call for change to start at the top: “[A]longside uniform, well-enforced rules, doctors themselves need to set a new tone in the hospital corridors, policing their colleagues and letting new doctors know what kind of behavior is expected of them.”

As you might guess, the reaction to Brown’s opinion piece has been quite intense, especially from physicians who perceived themselves portrayed in an unflattering light. Uberblogger Dr. Kevin Pho called it “vicious” and “angry.”

“Attacking physicians so personally only serves to drive a bigger wedge between doctors and nurses, when in fact, we need to be working together to solve this issue common to both professions,” he wrote.

Some of Dr. Pho’s commenters thought it was little more than doctor-bashing. But others disagreed. “Should she remain silent?” one commenter wondered. “It would seem to some that to point out any flaws or faults in physician behavior is doctor-bashing. Is the preference to sit quietly and let the misbehavers figure it out for themselves – sometime after an incident comes to light when the behavior results in the death of a patient?”

A number of commenters shared their own stories of doctor-on-nurse bullying, nurse-on-nurse bullying, nurse-on-doctor bullying, nurse-on-medical-student bullying and other variations on the theme.

Other bloggers have weighed in here, here and here. Clearly the topic has struck a nerve – not only among health care professionals but the public as well.

My take? Brown’s essay didn’t come across to me as doctor-bashing, and it certainly wasn’t vicious. Rather, it publicly called out the culture that often silently allows such behavior to take place, sometimes at the expense of good patient care.

I doubt that bullying is rampant in the health care world, at least no more so than in other workplaces. Most studies, including one done here in Willmar a few years ago, suggest this behavior is perpetrated by a small minority. Yet there’s no denying it does happen, and some of the dynamics within the health care culture – the pecking order among professionals, the high-stress nature of patient care, perhaps even the type A personalities who often are drawn to the health professions – may contribute to and reinforce bullying behavior in ways not seen in other settings.

Patient care is filled with risk and complexity. It can’t be carried out well in an environment that’s hostile, unhappy and dysfunctional. Although it may be painful for insiders to see these issues publicly exposed, perhaps that’s what it takes to create enough pressure for all of this to start changing.

Previous entries on this topic: Eating their young; Health care professionals behaving badly.

Blowing the whistle on bad doctors

I admit to some hesitation in using the term “bad” doctors in the title of this post. Physicians can fall short in many ways, often for reasons that are purely human and forgivable. It doesn’t necessarily mean they’re incompetent or that they are somehow bad for their patients.

Medicine is like any other profession, though. Sometimes a doctor is too impaired to safely take care of patients. In these circumstances, colleagues need to be willing to intervene, not only for the sake of maintaining professional standards but also to protect the public. But judging from a newly published study in the Journal of the American Medical Association, doctors are often very reluctant to blow the whistle.

The authors of the study surveyed 1,891 doctors and found a noticeable gap between what they professed to believe about dealing with impaired colleagues and what they actually did about it. The physicians who participated in the survey represented a variety of specialties, from family practice and pediatrics to surgery, anesthesiology and psychiatry. The majority, 64 percent, said they “agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.”

Seventeen percent personally knew of a colleague who shouldn’t be practicing medicine. In more than two-thirds of these cases, the physicians in the survey said they reported it to the appropriate authority. But this still left close to 30 percent who did nothing. Reasons for failing to take action included a belief that someone else was taking care of it, a belief that nothing would be done about it, and fear of retribution.

These findings are actually not too surprising. It has long been known within inside circles that physicians tend to be reluctant to report a colleague. There’s a lot more under the surface than the arrogance of protecting one’s own, however. Medical Economics magazine explored some of the issues after conducting its own ethics study back in 2002, and found that many factors come into play.

There’s the question of how to deal appropriately and compassionately with addiction or physical or mental illness. Should a physician have his or her license yanked because of an addiction, or should the doctor first be urged to seek treatment? Does a mental health disorder automatically mean someone is unfit to practice medicine? If physicians believe they’ll be punished for having a disease or disability, might it not result in a reluctance to seek help and end up driving these problems underground?

A more challenging issue is when a physician has poor skills or chronically exhibits poor judgment or lapses in ethics. Clinical incompetence can be hard to discern, the article notes:

If you assist someone at surgery or some other highly visible activity, you may be in a position to evaluate his competence. But how do you know whether what someone does in his office meets the standard of care, especially if he’s in a different specialty?

Some outcomes information is becoming available in areas like cardiac surgery. But most doctors don’t use that data in deciding on a referral; in fact, they rarely even check publicly available information on sanctions by state medical boards. So their knowledge of whether a consultant is competent comes mainly from patient feedback, hunches, and hearsay.

Truth to tell, it can also be extraordinarily difficult to rat out one of your own – particularly if you don’t have proof or even if you simply empathize with the colleague whose office is next door to yours. Many physicians, says Medical Economics, might wonder how they would feel if the tables were turned:

Craig Wax can testify to that. When he got out of family practice residency two years ago, he would have been inclined to report any physician he suspected of being impaired. But since then, with both group and solo practice under his belt, he’s decided it would be better to approach an impaired physician privately.

“I’d be afraid of ruining the other doctor’s reputation. I’d also be concerned about earning a reputation as a whistle-blower, he says. “Other doctors may think I’m overreacting and say, ‘Oh, it’s just Charley. He’s always done that, and he’s always managed it. It’s silly to report him.'”

In the Medical Economics survey, 4 percent of the respondents said they would do nothing if they became aware of a colleague whose performance was impaired by drugs, alcohol or a physical or mental illness. Thirty-one percent said they would talk to their colleague privately and 65 percent said they would report the physician to the appropriate authorities.

Ideally, there would be systems in place to monitor physician performance so problems are detected sooner and addressed more quickly. But these can be inadequate or dysfunctional; indeed, they can end up being a case of the fox guarding the henhouse, as Dr. Robert Wachter points out in his incisive analysis of a scandal earlier this year involving a Baltimore cardiologist who placed more than 500 unnecessary stents in patients.

Where was the peer review? Dr. Wachter wonders. And did hospital politics allow the cardiologist a free pass, as long as he kept generating revenue?

Cases like this one are terribly troubling, not just because they harm individual patients but because they do violence to the trust that is so fundamental to the physician-patient relationship. Part of the solution must be more robust oversight procedures, such as mandatory second readings of randomly selected cath films.

But these cases also force us to consider the kind of culture that could allow such a fraud to take root and go on for years – a culture that likely prized the hospitals’ and physicians’ financial health over the clinical health of their patients. If the allegations are true, the penalties should be severe, not only for Dr. Midei but also for leaders who knew – or should have known – what was going on, yet remained silent.

Left unsaid in all of this is what patients are supposed to do if they suspect their doctor is impaired or incompetent, or is engaging in unethical behavior. Is there any reason to think patients don’t face some of the same issues about reporting someone? Patients might fear being wrong, or that the authorities will do nothing about their complaint. They might also fear being labeled a troublemaker, or possibly even dismissed from someone’s practice for registering concern about the physician’s competence.

That fact that most of the physicians in the JAMA survey – more than 80 percent – didn’t personally know of an impaired colleague suggests the majority of doctors are indeed competent. The gaps in the profession’s ability to police and regulate itself are troubling, however. It’s not reasonable to think the public is better equipped to be the enforcers, and turning the responsibility over to government opens up a whole new, and probably undesirable, can of worms. If the medical profession wants to do better, it needs to confront these issues itself.

The social mission of medical schools

Few would argue that it’s the mission of medical schools in the U.S. to produce trained and qualified physicians who can provide needed health care to the American population. But do medical schools have social responsibilities that go beyond this basic mission? Is it also their duty to help meet the need for primary care doctors? Should they be working to help increase the number of minority physicians and the number of physicians in underserved areas?

An intriguing report, published this month in the Annals of Internal Medicine, takes a look at how medical schools stack up on this issue and concludes that not all institutions are equal:

The contribution of medical schools to the social mission of medical education varied substantially. Three historically black colleges had the highest social mission rankings. Public and community-based medical schools had higher social mission scores than private and non-community-based schools. National Institutes of Health funding was inversely associated with social mission scores. Medical schools in the northeastern United States and in more urban areas were less likely to produce primary care physicians and physicians who practice in underserved areas.

Social mission scores were calculated on the basis of data on medical school graduates from 1999 to 2001. The researchers analyzed information such as race and ethnicity, practice location and the percentage of primary care graduates at each medical school, then came up with rankings for 141 allopathic and osteopathic medical schools in the U.S.

Surprise, surprise: Elite Ivy-League and research-oriented schools such as Johns Hopkins and Harvard Medical School fell near the bottom of the list, while lesser-known colleges – Morehouse College in Georgia, Meharry Medical College in Tennessee and Howard University in Washington, D.C., ranked at the top.

Where does the University of Minnesota – a large research institution with an urban campus in Minneapolis and a smaller campus in Duluth – fit into these rankings? Good question. The U of M Medical School was among the top 25 percent of large research institutions in preparing physicians for primary care. The U also was in the top 25 percent for its overall social mission.

The U is among a handful of the larger, research-focused schools that seem to defy the trend, the study’s authors note: “These findings invite questions about what factors influence graduates of these schools to choose primary care and whether those influences might be transferable to other schools.”

It’s one of the first times I’ve seen this kind of data-based analysis to examine how medical schools fare at meeting what could be defined as their responsibility toward society. To be sure, social mission is only one aspect of medical training. It’s also important to prepare physicians for specialties and for research and academia.

The study points out, however, that medical schools cannot afford to shirk their social mission:

Evidence increasingly shows that primary care is associated with improved quality of care and decreased medical costs. However, an insufficient number of primary care physicians has hampered efforts to provide expanded health care access in states, such as Massachusetts, and business groups and insurers have begun to speak out about the need for increased access to primary care.

Rural communities have a chronic shortage of physicians, and federally supported community health centers report major deficits in physician recruitment. African-American, Hispanic and Native-American physicians continue to be severely underrepresented in the U.S. workforce.

The report also takes aim at the prestige factor, noting that national rankings of medical schools “often value research funding, school reputation and student selectivity factors over the actual educational output of each school, particularly regarding the number of graduates who enter primary care, practice in underserved areas, and are underrepresented minorities.”

The authors of the study conclude, “Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation.”

Predictably, the study has been met with negative reaction. “Political correctness and social missions have now invaded the world of measuring ‘quality’ in medical schools,” a commenter lamented online at the Chronicle of Higher Education. A statement issued by the American Association of Medical Colleges concludes the study “falls short” by defining the role of medical schools too narrowly.

An interview with one of the study’s authors, Dr. Candice Chen of the George Washington School of Public Health and Health Services, sheds more light on how the social-mission rankings can be viewed. Research is important but social mission needs to be valued as well, she argues:

… Medical schools have to play their role too. They have to maximize those changes. And medical schools can make a difference. They can make a difference in terms of their recruitment and admissions practices. They can make a difference in terms of their curriculum. And just in the very culture that they support. Unfortunately, there are schools out there that have no family medicine department, and it’s hard to imagine that a student is going to pick family medicine when they’re not being exposed to a family medicine department within the school. There are definitely things that schools can do, and we look at it as things have to happen across the continuum.

Is this just an academic discussion of no real interest to the public? I don’t think so. Aside from the fact that tax dollars are helping subsidize part of the medical education system, communities have a stake here too. This is a discussion that has been long overdue and should be welcomed, controversy and all.

Photo: Harvard Medical School, courtesy of Wikimedia Commons

Bedside manner

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

Why primary care doctors are so busy

During an office visit with your doctor, you might spend part of your 10- or 20-minute appointment discussing your symptoms. The doctor takes notes. A test or a prescription might be ordered. Maybe there’ll be reassurance there isn’t anything seriously wrong with you, or a plan to follow up if there are any concerns.

This is what patients see, and it’s not surprising when they conclude this is how the doctor spends his or her entire day. What they’re seeing, though, is only the tip of the proverbial iceberg. A new study, published this week in the New England Journal of Medicine, quantifies how much time primary care doctors devote to all the extras – extras that are largely invisible to the public and for which they don’t get paid.

The authors asked the question: What’s keeping us so busy? The answer is eye-opening.

The study tracked a private practice in Philadelphia with five internists and an active caseload of 8,440 patients. Here’s how some of the numbers broke down: In 2008 each physician saw an average of 18 patients a day, Monday through Friday and Saturday mornings. Each day they made 23.7 phone calls and received 16.8 e-mails. They reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports, and processed 12.1 prescription refills.

Here’s a further look at just one of these categories, prescription refills:

Each physician processed 12.1 prescription refills per day, not including refills that were handled during a visit or requested as part of a telephone call involving other issues; multiple medications that were refilled at the same time were counted as a single refill. Each refill request required some level of chart review (e.g., determining the patient’s history with the drug and whether any required monitoring had been performed).

What many people may not realize is that physician practices don’t get paid for these tasks. The revenue that’s generated must come from actual patient visits to the office. You don’t have to be good at math to figure out that as primary care doctors spend an increasing amount of time on charting, paperwork, communication and behind-the-scenes patient care management, it means less time for face-to-face care and significantly more pressure on the practice’s overall resources.

Is it all about the money, then? Well, yes, it is, in the sense that practices need to generate enough cash to keep the doors open so they can continue seeing patients. And the more time that’s spent on uncompensated tasks, the more challenging this becomes.

Some medical practices are addressing this by charging office fees or service fees – an add-on to help defray the cost of, for instance, taking care of a prescription refill or sending a lab report. One private cardiology practice in California, for example, this year began charging annual fees ranging anywhere from $500 to $7,500. Patients who don’t want to pay the fee can still see the cardiologist, of course, but as NPR’s Shots blog explains, they’ll face some restrictions, such as limited telephone availability except in emergencies.

The situation is arguably worse in primary care. Over the years, primary care has become increasingly cognitive. It involves managing, coordinating, communicating, coaching – important skills that unfortunately are devalued in a payment system where procedures and office visits reign supreme.

I suspect even the authors of the NEJM study were a little taken aback to discover just how much time they spend on all these invisible tasks. It should be eye-opening for the public as well. Now that we know, it becomes harder and harder to come up with excuses for maintaining the status quo.

Photo: Wikimedia Commons

Linkworthy 2.2: the weekend edition

If the weather forecast can be believed, it looks as if we have a perfect spring weekend ahead of us to spend outdoors. But in case you have some down time, here’s some worthwhile online reading:

Had enough yet of health care reform? I haven’t, so I found this to be an interesting commentary by Bob Doherty, who blogs about health care policy for the American College of Physicians. It appeared this week in the Annals of Internal Medicine and explores what we know – and what we don’t know – about the impact of health insurance reform. Doherty suggests "we should all take a deep breath" and try to look at the health reform bill more objectively. An excerpt:

Supporters and opponents alike must humbly recognize that no one knows how this complex legislation will play out. Some effects – like reducing the number of uninsured Americans – might be assessed with a higher degree of confidence than, say, longer-term estimates of the effects on the deficit and health-care costs.

For some online discussion and reaction to Doherty’s article, you can check out the comment thread on his blog.

How will the health reform bill affect the private insurance industry and, by extension, the industry’s customers? The Health Care Blog examines the myths and the facts. Maggie Mahar predicts there’s likely to be a shakeout in the insurance industry: "These new rules will make our health care system fairer and more affordable. But the rules also suggest that for-profit insurance may not be a viable business unless insurers learn far more about what is best for patients."

Challenges, challenges. Then again, this is nothing new in rural health care, which all too often gets overlooked when policymakers start carving out their turf. The Wisconsin State Journal of Madison recently launched an intriguing series of stories that explores the unique issues that characterize rural health. The first story addresses the doctor shortage; the second takes a look at the social and geographic factors that may be responsible for a growing gap in health status and outcomes between rural and urban/suburban residents.

The second story, "Life and Death in Park Falls," appears to have sparked some passionate debate among readers, and the comment thread is well worth reading for the extra dimension it brings to the discussion. Many people thought rural health providers didn’t get enough credit for what they do. Wrote one person, "Here in Park Falls I am not just a number, I am a neighbor. The article made it sound like we have no health care but actually we have a very good hospital and clinic and well-trained doctor and nurses."

How much of this is about being willing to make tradeoffs? "Anyone with a major health problem planning to retire in the northwoods should consider the lack of available quality health care before making that move," one person commented. But someone else countered, "Northwoods culture is not about being a hick (not to say we’re Vermont). It’s about enjoying the outdoors and a lifestyle that can only be found in our state’s natural, rural areas. I agree that rural health is a major issue, but those of us that live here are well aware of our choices."

Most of us have seen those lists of "top doctors" that get published from time to time. But are the top docs really all they’re cracked up to be – and are these rankings a good basis for choosing one’s own physician? Dr. Aidan Charles is skeptical, as he explains on his blog in "Beware the Top Docs":

It is only human to seek perceived leaders. But as sometimes seen in politics, those who have reached the pinnacles are often motivated by ambition, charisma and gamesmanship instead of altruism, sincerity and merit.

Dr. Charles also takes on the online rating sites and the insurance rankings based on quality measures.

What if the rest of life was managed like health care? Would we need preauthorization before ordering a meal at a restaurant? Would we unexpectedly get hit with a high deductible for car repairs? Dr. Rob Lamberts speculates on what it would be like in a pair of entries at his Musings of a Distractible Mind blog. The crazy world he describes is entertaining, absurd yet oh-so-close to reality.

Oh dear. Oh dear. Is it OK for doctors to Google their patients? Dr. Kevin Pho wonders on his blog about the ethics of doing this. As long as the information is publicly available, why should it matter? Patients can Google their doctors, after all. It might even be helpful in, say, the case of a psychiatric patient who’s posting threats online, or someone who arrives unconscious in the emergency room. There appear to be few guidelines that address this, Dr. Pho writes, but he suggests that ferreting out online information about a patient isn’t something physicians should routinely do. He himself has "never Googled a patient and can’t see any reason to in a primary care setting."

The lesson for patients, I guess, is to be careful about your online persona. If your physician can Google you, so can everyone else. Just thinking about it has made me decide to end this post right.now.

HealthBeat photo by Anne Polta

Politics in the doctor’s office

Dr. Jack Cassell, a urologist in private practice in Florida, is very, very disgruntled with the passage last month of the federal health reform bill. So disgruntled, in fact, that he has posted a notice on his door, telling patients who voted for President Obama to find another doctor.

The story has provoked a firestorm of public opinion ever since appearing late last week in the Orlando Sentinel:

A doctor who considers the national health-care overhaul to be bad medicine for the country posted a sign on his office door telling patients who voted for President Barack Obama to seek care "elsewhere."

"I’m not turning anybody away – that would be unethical," Dr. Jack Cassell, 56, a Mount Dora urologist and a registered Republican opposed to the health plan, told the Orlando Sentinel on Thursday. "But if they read the sign and turn the other way, so be it."

The sign reads: "If you voted for Obama… seek healthcare elsewhere. Changes to your healthcare begin right now, not in four years."

Dr. Cassell’s politics apparently aren’t limited to a sign on the door:

In his waiting room, Cassell also has provided his patients with photocopies of a health-care timeline produced by Republican leaders that outlines "major provisions" in the health-care package. The doctor put a sign above the stack of copies that reads: "This is what the morons in Washington have done to your health care. Take one, read it and vote out anyone who voted for it."

The story hit the New York Times this weekend, where at last count more than 300 readers had weighed in with comments. Some were sympathetic. "Three cheers for this doctor!" someone wrote. But many were dismayed and highly critical. "His patients should be thanking God that Dr. Cassell has given them advance warning of his character," one person wrote. "If I were his patient, I’d be running away like the wind. Turning people away based on their beliefs is one mm away from giving them bad care for the same reason."

As of this morning, the original story in the Orlando Sentinel had more than 3,300 comments.

So is Dr. Cassell a villain (or at least a jerk)? Or is he a hero for standing up for what he believes?

Nowhere is it written that physicians can’t express their personal opinions or that they can’t be politically involved. Nor are they necessarily compelled to treat every patient who walks in the door. Physicians in private practice can and do dismiss their patients, although usually this is for clear reasons, such as abusive behavior, noncompliance, prescription-forging, refusal to cooperate in paying a bill, and so forth.

Dr. Cassell appears to be walking a very fine line of professionalism, however. It’s one thing to have political opinions; it’s quite another to impose them on unsuspecting patients. I’m not sure how to interpret Dr. Cassell’s actions as anything other than hostility toward those who don’t share his views. It’s hard to imagine patients who disagree with him politically wouldn’t feel coerced or unwelcome in his practice (the sensitive specialty of urology, no less), and that this wouldn’t somehow spill over into their interactions with the doctor, possibly to the detriment of their care.

From the Orlando Sentinel:

Cassell may be walking a thin line between his right to free speech and his professional obligation, said William Allen, professor of bioethics, law and medical professionalism at the University of Florida’s College of Medicine.

Allen said doctors cannot refuse patients on the basis of race, gender, religion, sexual orientation or disability, but political preference is not one of the legally protected categories specified in civil rights law. By insisting he does not quiz his patients about their politics and has not turned away patients based on their vote, the doctor is "trying to hold onto the nub of his ethical obligation," Allen said.

"But this is pushing the limit," he said.

It’s not clear if the Florida Board of Medical Practice is going to take a look at the case. There doesn’t appear to be any medical licensing statute that specifically addresses activity such as Dr. Cassell’s. Is he being unprofessional? Probably. Immature? Absolutely. But has he done something illegal or discriminatory? Probably not, at least according to the letter of the law. Whether he’s violating the spirit of the medical ethos is another issue altogether, and one I’m not sure he and his supporters are capable of grasping.

If action can’t be taken against his medical license, here’s another idea: Make this guy go back to junior high for a week. Maybe he’ll learn something about how not to be such a sore loser.

The medical trivia quiz: the answers

On Tuesday, you may have checked out the trivia quiz posted here in honor of Doctors’ Day. As promised, here are the answers (and no fair peeking first).

1. The word “doctor” stems from the Latin “docere,” meaning “to teach.” In the earliest examples of written English, appearing in the early 1300s, it was used to describe “doctors of the church,” i.e. scholars who were learned in Scripture. The first use of the term in reference to medical doctors is believed to date to 1377.

2. c) Hippocrates. Born in ca. 460 B.C.E. on the Greek island of Kos, he rejected the notion that disease was caused by evil spirits or the displeasure of the gods, believing instead that illness has a physical and rational explanation. This observational approach became the foundation of modern medicine. Hippocrates, who was recognized by his contemporaries as one of the foremost physicians in ancient Greece, also promoted ethical and moral standards for the practice of medicine. These teachings may have inspired the Hippocratic Oath, which is still a part of many medical school graduation ceremonies.

3. The familiar symbol of a winged staff entwined with two serpents is known as the caduceus. In ancient Greek mythology, the winged staff was carried by Hermes, messenger of the gods, as a sign of peace. Through its association with Hermes, who was also reputed to be an alchemist, it became linked to medicine some time in the seventh century. Another version links the caduceus to Asclepius, the Greek god of healing – except that the Asclepian staff was entwined with a single snake, not two, nor was it winged. The Asclepian staff and the caduceus of Hermes are now used interchangeably, although most purists would probably consider the staff to be the more accurate form of the symbol.

4. Many terms used in modern medicine have their roots in Latin, the language of scholars in medieval and Renaissance Europe. This era is when much of the terminology of basic anatomy and prescription-writing was established. Modern language began to take over some time after the 16th century but Latin continues to survive in medical nomenclature, especially in the study of anatomy.

5. The oldest medical school in the United States can be found at the University of Pennsylvania in Philadelphia; it was established in 1765 as the Medical Department of the College of Philadelphia. The forerunner of what is now the medical school at Columbia University was founded in 1767. Harvard Medical School, 1782, is the third oldest. Queens College had a medical school that was established in 1787 but was dissolved in 1816 and no longer exists. The fifth-oldest medical college in the U.S. is at Dartmouth, 1797.

6. Dr. William J. Mayo and Dr. Charles H. Mayo, along with their father, Dr. William Worrall Mayo, founded the now world-famous Mayo Clinic in their home town of Rochester, Minn., in 1903. Initially the Mayo Clinic, a branch of St. Mary’s Hospital, specialized in surgery. It became a full medical center in 1915 and soon began to attract top-quality physicians from all over the world. The Mayo brothers’ philosophy of a patient-centered team approach was dubbed the “Mayo model of care”; it led to one of the first integrated group medical practices in the world. 

7. Sinclair Lewis (1885-1951), the first American to win the Nobel Prize for literature, was born in Sauk Centre, Minnesota. His home town was the inspiration for Gopher Prairie, the setting of his classic novel “Main Street,” the story of an independent young woman who marries the rather dull and practical Dr. Will Kennicott and struggles to adapt to small-town life. Lewis was awarded the Pulitzer prize in 1926 (and turned it down) for “Arrowsmith,” whose idealistic hero, Dr. Martin Arrowsmith, is tempted by wealth and prestige and eventually finds redemption in pursuing his own path.

8. In 2009, students graduated from medical school with an average of $156,456 in educational debt. Medical education debt has been rising steadily, and most students owe a significant amount of money by the time they complete their training. Increasing tuition costs for medical school, on top of the increasing cost of undergraduate education, are primarily to blame. Many observers worry that the prospect of educational debt is steering students away from careers in primary care, where salaries are generally lower, and may be discouraging bright young people from even considering a career in medicine.

9. “Marcus Welby, M.D.,” made its debut on ABC in September 1969 and ran until May 1976. During the 1970 season it was the most popular series on TV, according to the Nielsen ratings. The show starred Robert Young as a kind and fatherly primary care physician. Dr. Welby became somewhat of an icon but the character also sparked some controversy, both for his perceived paternalistic attitude toward his patients and for creating unrealistic expectations for how physicians should ideally behave.

10. The field of hospital medicine is one of the newest and fastest growing. The term “hospitalist” was coined in 1996 to describe physicians who specialized in the care of hospitalized patients. More than 20,000 hospitalists currently practice in the United States; this number is expected to grow to 30,000 within the next year.

10-14 points: Excellent! Have you ever considered going to medical school?

5-9 points: Not too shabby. You’ve been diligent in watching episodes of “House.”

0-4 points: Ouch! Better stick to handing out the occasional Band-Aid.

Photo: Wikimedia Commons