Sunday, January 29, 2023

How to Choose a Doctor

For most of my career, I was in a small private practice.  Our staff were like family.  We prided ourselves on providing highly personalized attention to our patients which started at the moment that the patient was greeted by our receptionist.  For a patient to enjoy an optimal medical experience, every member of the team needs to perform at a high level.  The doctor is but one member of a larger team.  Indeed, I have heard personally of patients who have left medical practices who liked the doctors but not the staffs.  Everyone counts.

We saw patients who were self-referred or sent to us by referring doctors or by family members. I have always asked every new patient how they came to see me personally, and I still do.  It is always gratifying when a patient is recommended to us by a medical professional or a family member. You took care of my grandmother and she raves about you!  This not only feels good to the doctor, but the patient arrives already having confidence about the upcoming medical experience. This is a great way for the doctor-patient relationship to commence.

Now that I am employed by a huge medical organization with thousands of physicians, the referral system is quite different.  While I still see some patients who have been sent to me specifically, most of the new patients appear on my schedule by chance. Often, the patients themselves do not even know how they ended up on my schedule.  I had an open appointment slot and a staff member  or a scheduler on the phone filled it.  Having to accommodate tens of thousands of patients requires an impersonal efficiency to keep the trains running.  I understand this, but it doesn’t feel the same to me as you took care of my mom and my sister.  I imagine this feels different for patients also particularly if they enjoyed personalized medical care in the past.  One of the costs of efficiency is intimacy.

Making appointments is like rolling the dice.

There are many benefits and advantages to being an employed physician, particularly at this stage in my career.  But, of course, there are drawbacks.  Luckily for me, many of my patients have followed me from my prior private practice allowing us to perpetuate the warm relationships that we forged years ago.  I’m not saying that relationships like this can’t develop now.  But it takes more work to do this within a system that is designed to promote productivity and efficiency.  As the employment physician model has become dominant, this is a new reality that patients and medical professional need to accept.  And if the current 'roll the dice' system is all you know, then you won't know what you are missing.  


Sunday, January 22, 2023

How to Transfer Medical Records - A Tale of Frustration and Madness

A patient came to see me recently for a second opinion on an abnormal blood test result.  He was accompanied by his parents.  They had driven a considerable distance for this visit. 

The patient’s mother announced at the outset of the visit that she had been assured that all of the relevant records had been transferred.  My forthcoming comment will shock neither patients nor medical professionals.  Nary a single page of records was anywhere in sight.

This vignette illustrates two incredibly frustrating and recurrent realities.

Medical records that referring offices promise they have sent me often never arrive. They are dangling somewhere within a extraterrestrial black hole.  On a regular basis, conscientious patients see me in the office assuring me that they were told that their records have been forwarded.  They may have been forwarded somewhere, but all I know is I don’t have them.  This drives patients to a state of apoplexy, and I don’t blame them.   There are variations on this madness. For example, I may have requested a colonoscopy report but receive a mammogram report instead, which is somewhat less useful to me.  I can’t pinpoint where the breaks in the chain of custody are.  There are occasions when I must dispatch a patient directly to the referring physician’s office to assume possession of the medical papers and to deliver them into my hands only.  Only the strongest among us could take on a challenge of this magnitude. 

The second inexplicable frustration is why I cannot (with a patient’s permission) access other electronic medical record systems from my office computer.  I regularly see patients referred to me from an area emergency room (ER).  If that facility is not in my system, then I can’t access the records.  Conversely, if one of my patients is seen in that ER, they can’t see my records.   Does this sound like best practice in 2022?  It’s downright ridiculous.

Are we still in the age of the abacus?

But this particular case had a fortuitous twist.  The patient’s mother, using her sixth sense, brought a complete copy of the patient’s records with her.  She passed the dossier to me which allowed me to perform the task at hand.

She was the hero of the day, if not the week or maybe even the month.  But should patients and their families have to work this hard?  Shouldn’t the system be designed to facilitate and not hinder their care?  When will this perennial conundrum be resolved?  Why does the medical establishment tolerate this?   If medical billing were similarly flawed, and payments arrived late or not at all, do you think that the medical establishment would remain indifferent?

Sunday, January 15, 2023

Should Doctors Charge Patients to use the Patient Portal?

My employer,  a rather large and well known medical behemoth based in Cleveland, recently announced that patients may be charged for medical advice solicited on the patient electronic portal.  This has generated an array of opinions ranging from accusations of corporate greed to defending physicians’ right to be compensated for practicing medicine.

Implementing this new program violates the following reality of human nature.

Folks will not support losing an established benefit. 

Consider how organized labor reacts when management aims to reduce worker benefits.  How would any of us feel if our employer cut back our vacation allowance?   How might homeowners feel if their mortgage interest is no longer tax deductible? 

You get my point.  Over the past few decades, I have provided thousands of hours of free medical care on the phone and electronically.  I never felt that I was being ripped off since this was the only system I knew and I accepted it.  Similarly, patients never felt they were stealing my time since for them this was simply how the system always operated.  It never entered their minds that these interactions were compensable.

But is it fair to ask a physician to dispense medical advice without being paid for it?  If a reader maintains that medical advice offered electronically should be gratis, then kindly explain why.   Legal clients are well aware that many law firms invoice every phone call or e-mail exchanged.  Indeed, we joke about hearing a ticking clock when we phone our attorney.

'You mean water isn't free anymore?

The proposal will not charge patients for mundane issues including medication refills or setting up appointments.  But, if the communication involves a specified level of medical complexity, then a charge may be issued.   If patient sees me in the office for my advice on stomach pain, of course, I will put a charge through.  If another patient wants the same advice through the electronic portal, shouldn’t a charge also be issued?  

Keep in mind that when I give free advice, I am still medically liable and can be sued for this.  Doesn’t basic fairness dictate that if I am legally responsible for a medical recommendation, that I should be compensated for it?  If not, then why not?

Is the aim here to create a new revenue stream for medical establishments and doctors?  Or was the objective to decrease the deluge of patient electronic requests that have become an increasing daily burden for physicians?  (Ask you own doctor how much time he or she spends on these electronic communications each week.)  My suspicion is that charging for advice on the portal will be uncommon events.  In my case, for example, if a patient sends me an electronic message that has medical complexity, then I am likely to respond that an office visit is necessary.  The electronic portal is not a vehicle to conduct ‘office visits’.  Yet, I typically receive messages from patients I haven't seen in over a year asking my advice on abdominal pain and vomiting.

This new program does not apply to phone calls, an activity that takes up hours of my time each week.  Might this be the next target for billers? Should it be?

No one likes to pay for anything that used to be free. I still can’t believe that I now have to pay for a bottle of water. 


Sunday, January 8, 2023

Upgrading the Electronic Medical Record!

After 30 years or so, there is still much joy for me in the practice of medicine.  Electronic medical record (EMR) systems doesn’t make the list.  Chances are that if you asked your own doctor to assemble a Frustration List, that EMR issues would be among the top five entries.  Over the past 15 or 20 years, I have struggled through several of them.  At one point, I was using 4 distinct systems: 2 different hospital EMR systems, our office practice EMR and our endoscopy center’s software.  Does this sound like fun? Think of all the passwords I kept track of! 

There is a recurrent EMR event in every system that brings doctors to our knees. Here’s the simple phrase that transforms even a stoic doctor into a sweating and trembling practitioner:
The EMR system will be upgraded overnight.

Let me explain.  One might think that a computer upgrade would be a desirable event. For example, Merriam-Webster’s dictionary definition of upgrade is to replace something with a more useful version or alternative.  What actually happens is that the system that you have clumsily managed to operate, once upgraded, now seems to have more bugs crawling through it than an ant colony.  The computer tasks that you formerly performed with practiced mediocrity no longer seem to work.  Glitches pop up everywhere.  Frozen screens.  Lost data.  (well, it’s not really lost; it’s just now nestled in some deep EMR layer that you don’t even know exists!). 

Now, as you might expect, these upgrades elevate staff morale and create a peaceful aura that bathes the entire office.  

Depiction of Doctor Whose EMR was just Upgraded. 

And physicians, known for our patience, are completely understanding when our IT technical support team advises us that they will try to amend the situation in a day or so.

In my current job, I do confess that the EMR system called EPIC is the easiest of all of the prior systems that I’ve endured.  Thus far, it has never crashed and burned, and it operates more intuitively than other competitors.  I have achieved my goal of learning only those skills that I truly need.  I am content to soar at a low cruising altitude.  But, on a regular basis the system is upgraded.  This is when I can learn a bunch of new ways to do stuff even when the old ways worked fine. 
Have computers introduced absurdity into your life?  Kindly share. 

Sunday, January 1, 2023

Colonoscopy in the Elderly. How Old is too Old?

I am frequently asked what is the upper age limit for offering screening colonoscopy.  Patients today are often more informed on certain medical issues than their doctors are.  I support their empowerment.  Of course, we physicians, as actual medical professionals, presumably have more credibility in opining on the practice of medicine.  In my own life, I always give great weight to the folks I hire, whether they are tradesmen or professionals.  Why would I not give consideration and deference to one who has years of training and experience?  If I needed an attorney to litigate an issue, would I presume to advise on the optimal trial strategy?  He who represents himself has a fool for a client.’

Patients can acquire a great deal of medical knowledge, but they are not as easily able to exercise sound medical judgment.  This takes us professionals years to develop.  Consider this weighty maxim:  It takes 10 years to acquire 10 years of experience.   Indeed, I am still trying to advance my skills after decades on the job.  As I have posted in this blog more than once, honed medical judgment is a seasoned physician’s strongest asset.  Consider the following 2 examples and decide which would be within a patient’s grasp to understand and which would be beyond reach. 

Research a drug to determine if the medicine might be responsible for a side effect.

Decide that a CAT scan of the abdomen is not necessary.

See the difference between knowledge and judgment?  One of the above tasks requires a professional and the other doesn’t.

So, how old is too old for a screening colonoscopy?  Although there are published guidelines addressing this, I do not have a firm cut off.  I think that the upper threshold must be individualized to the patient with consideration of their views and their medical status.   For example, a 65-year-old individual who is ‘due’ for a colon exam but is navigating through various medical struggles might not be an appropriate candidate for a routine screening exam.  But should an 80-year-old in great health who was last screened at age 70 be denied a screening test?

Elderly Woman Contemplates a Screening Colonoscopy.

Medical care is not simply following a checklist.  If it were, then you wouldn’t need a doctor.  You could just do it yourself as a DIY medical professional.   Instead of simply blindly following published colonoscopy guidelines (which often conflict with each other), kick the issue around with your doctor.   You can bring the knowledge but leave the judgment to the professionals. 

Sunday, December 25, 2022

Whistleblower Holiday Cheer 2022!


The Dems were all nervous

Back in October.

The Red Wave was coming!

Would their blue reign be over?

The tables had turned,

After November,

This midterm result

Will be long remembered.


Deniers fell short,

One by one,

And the public ensured

That democracy won.


With the House barely red,

And the Senate still blue,

Might we move beyond

‘I win so you lose’?


The last 2 guys standing

Were Raphael and Herschel.

We were finally spared

Their endless commercials.


On his own time,

Trump did announce,

While a new special counsel

Is ready to pounce.


Lurking in waiting,

A stealth praying mantis,

Eyeing his prey

Is Ron DeSantis.


Biden is 80

Is he the Dem’s best shot?

If he steps aside,

Who else have they got?


Wishing you all,

Good health and good cheer,

And prayers to enjoy,

A much better year.