Finding a Practitioner for Primary Care

September 30, 2010

The shortage of primary care practitioners is here.  For example, 28 percent of people on Medicare who went looking fora primary care doc in 2008 had trouble finding one, according to the Medicare Payment Advisory Commission’s report to Congress.  (This figure has been over-interpreted in a major article, but no matter.)

photo of military physician assistant and colleague

The military has long used physician assistants, as here in Iraq

I want to share a few thoughts with you about what that means for the future of primary care and how we as patients can communicate effectively with practitioners, to get the care we want and need.  Many practitioners will not be physicians.

In February of last year, physician supply guru Richard A. Cooper told an Institute of Medicine conference that “the notion that future patients may experience regular 30-minute visits with a primary care physician is not credible.”  Why?  Not enough family physicians, general internists, general pediatricians, and obstetrician-gynecologists to spend a lot of time with reasonably healthy patients.

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“We Can Take It Out”

September 23, 2010

If you–as a patient or health professional–believe most physicians do a decent job informing their patients about their health care, you’re fooling yourself.  The patient has to take the initiative to learn what’s going on.

Lots of studies show the inadequacy of physician-patient communication. No study that I know shows it’s adequate.

Just this month, for example, the Annals of Internal Medicine published a  study by Michael Rothberg and colleagues showing that most patients undergoing an angioplasty did not understand the purpose of the procedure.  The patients mainly thought the procedure would help prevent a heart attack, but their physicians said the purpose was just to relieve  symptoms.

eye and partial head shot of a young woman looking confused and scared


The authors note, dryly, the “communication gap” between physicians and patients.

On September 20 the Boston Globe published an article by Elizabeth Cooney headlined “What Doctors Say Is Often Not What Patients Hear.”  Cooney writes:

The doctor says: You have cancer, but we’re not sure whether it’s the kind that will spread.  So you’ll have to weigh the risks and benefits of treating it versus waiting to see whether it gets worse.  The patient hears: You have cancer.  We can take it out.

She notes that patients tend to hear the pros and not the cons of treatment, according to Michael Barry of the Foundation for Informed Medical Decision Making.

As a patient, you need to tell your doctor what, as you understand it, the proposed tests, procedures, and care will accomplish. You have to ask questions.

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Alert Patient Prevents Disaster

September 17, 2010

Earlier this month,  the admission of my friend “Don” to a community hospital promised to be routine.   He would be observed in the hospital for three days while a powerful new drug was introduced to address his irregular heart beat, or arrhythmia.

smiling nurse in doorway of hospital roomIf all went well in the three-day hospital stay,  Don then would proceed to take the drug regularly at home,  instead of the less potent drug he’d been taking for a long time.

After going through the hospital’s admission procedure, Don was taken to his room.  There, his nurse, “Karen,” introduced herself .  He said, “I’ve got a question.  I’ve been trying to get an answer from my doctor, but I haven’t been able to.”

“What’s your question?”

“I don’t know whether I’m supposed to be taking my regular daily medication while I’m here,” said Don.

“Are you concerned about something?”

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Our Own Worst Enemy?

September 15, 2010

Patients–health care consumers–can be too clever by half.  Too skeptical of the motives of health professionals, hospitals, insurers, and government, many patients appear to make a habit of ignoring medical advice.  They think they are smart to do so.

a complicated cancer guideline

Example of Cancer Guideline

The gap between the conventional wisdom of the health establishment and the defiant doubt of many patients is explored in a recent article, wittily entitled “Evidence That Consumers Are Skeptical About Evidence-based Health Care.”

There, author Kristin Carman and colleagues suggest it will be hard to persuade consumers to accept treatment based on clinical guidelines, also called “protocols” or “best practices.”  Why?  In a multi-pronged study, the authors found:

. . . there is a fundamental disconnect between the idea of evidence-based medicine and many consumers’ beliefs, which don’t account for variation in quality among providers [that is, the idea that some doctors are better at some things than others] and don’t allow for cost-effectiveness [the idea that some medical procedures are worth what they cost, while others aren’t].

In other words, a lot of patients (are you one?) think any advice to forgo a particular treatment or procedure is based mainly on the economic interest of the source of the advice.  I for one have run into this attitude a lot:

  • Patients and families insist on futile and heroic measures at the end of life, because they think recommendations for hospice or palliative care are intended to save money, rather than improve quality of life.
  • Patients (I’ve seen this in my own family) unnecessarily suffer debilitating medical conditions rather than go to doctors, who they think are just interested in making money.
  • People ignore public health recommendations to get flu vaccines, even during flu epidemics, because they don’t trust the recommendations or assurances that the vaccine is safe.
  • Heavily influenced by ads, many patients insist on expensive new drugs, when their physician wants to use an older, cheaper drug that is safer and just as effective.
  • For years, many HIV-positive African-Americans and Africans refused retroviral treatment, because they believed that HIV was a ruse created by whites to cover up their diabolical role in infecting black communities with AIDS.

The issue is important.  There’s a movement afoot to create and enforce more evidence-based guidelines, which already are often used in cases of heart attack, stroke, HIV/AIDS, and other conditions.  These protocols are called “evidence-based,” because they reflect findings about what happens to most patients who receive a particular treatment as opposed to other treatments.   Resistance to guidelines will forestall improvements in the quality of care.

A vicious cycle will result.  First, people will be sicker for not following the guidelines.  Second, many doctors will take their cue from patients and will ignore guidelines, too (doctors already ignore them far too often).  Third, organizations won’t bother to develop new guidelines, since developing them takes a lot of work, and there’s no point writing guidelines that will be ignored.

What can  you do?  When you and the doctor are discussing your course of treatment, ask whether any clinical guidelines have been developed for your condition.   After all, you want care that meets the most recent, most evidence-based standards.  Why not the best?

Take care.

Photo credit:  sniperslaststand3Attribution.

“All That Matters Is the Person”

September 13, 2010

For eight of the last days of his life, psychiatrist William Gruzenski, a patient in intensive care, was allowed to see his wife Jackie only during tightly limited visiting hours–a restriction  she  found “very cruel.”  Moreover, the hospital staff ignored his request to address him as “Doctor.”

This bad experience was the focus of a commencement speech given at Yale Medical School earlier this year by Don Berwick, now the director of Medicare and Medicaid.  Berwick called on his new fellow physicians–including his daughter Jessica–to temper the massive power they will wield over people’s lives.

commencement speech photoHe explained:

What is at stake here may seem a small thing in the face of the enormous health care world you have joined.  It is as a nickel to the $2.6-trillion industry.  But that small thing is what matters.  I will tell you: it is all that matters.  All that matters is the person.

Berwick spoke eloquently at Yale of the need for compassion in medical care.  He said that physicians aren’t just clinicians:

[N]ow I will tell you a secret–a mystery.  Those who suffer need you to be something more than a doctor; they need you to be a healer.  And, to become a healer, you must do something even more difficult than putting your white coat on.  You must take your white coat off.

There is little to add here to this appeal to humanitarianism in medicine–except that Berwick’s speech perpetuates the notion that physicians have the power.  It suggests that patients are mere recipients of physicians’ advice, care, and communications.

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