I like my doctor, but the tart was a little dry

This morning's New York Times has a nice opinion piece about publishing patient ratings of doctors. The editorial board likes it. I like it. Patients like it. Who doesn't like it?

Doctors with low ratings, I suppose. (Note, that could be me; I've never seen patient ratings of me or my clinic.)

Note that the questions used in the Zagat/WellPoint ratings (yes, Zagat) appear to be built, at least in part, around validated patient experience questions from Gordon Moore's research. From the NYT:

Who knows better than patients whether they have confidence in a doctor? Whether they like his or her bedside manner? Or find it easy or hard to make appointments? Or are dealt with on time or kept waiting for hours? Or find the staff helpful? These are the kinds of items covered in the Zagat/WellPoint survey, not anything to do with the quality of medical care provided.

These are similar to Moore's patient experience questions:

1. I have one person I think of as my personal doctor or nurse
2. It is very easy for me to get medical care when I need it
3. Most of the time, when I visit my doctor’s office, it is well-organized, efficient, and does not waste my time
4. The information given to me about health problems is very good
5. I am confident that I can manage and control most of my health problems
6. I feel able to give meaningful feedback to my doctor’s office about ways things could be improved

Wouldn't you feel like you were being well-served as a patient if you could answer yes (enthusiastically) to these questions?

As a physician, I have an obligation to provide the highest-quality medical advice, supported by science. I also have to be a good practicing colleage to other physicians and staff who need my work to be thorough, clear, and timely.

But I also have to keep in mind the perspective of my patients, what they want and need. Doing a good job for them also means responding to the issues surfaced in the Zagat/WellPoint and Moore patient experience items.

It doesn't mean patients will always agree with my recommendations, or that I'll agree with their assessments and requests, if science and common sense suggest otherwise. But the experience ought to be efficient, respectful, and thorough.

I'm glad someone is measuring. Maybe I could be, like, the Nobu of family doctors one day.

Twittering the Future of Family Medicine?

I had the chance last night to meet with some amazing family doctors to discuss ways to use social media to open and sustain a discussion about the current state of primary care and where we're going. And where we should be going. And how.

There will be room for every voice and perspective about how to get from where where we are now to someplace (or places) better for patients, public health, and the well-being of those who deliver primary care.

Primary care is stressed:

• Access is poor: the uninsured don't have access, and if everyone did have insurance, we wouldn't have enough primary care doctors to care for them;
• Costs are out of control, and we don't get much health for our health care dollars;
  
• Reform at the federal level isn't as near as maybe we'd all thought. The white knight of bipartisan reform, Tom Daschle, got knocked out with an IRS body blow. And getting a big deal done on health care seems unlikely, even if it is even more important now than ever.

So what to do? There is tremendous support, in spirit, for better primary care, and it seems now that everyone wants a "Medical Home," though no one can agree on what that means, and the average primary care private practice can't afford to build one.

At out discussion last night, we agreed that there are things family doctors can do right now to move primary care forward at the front lines of practice. And we'll talk about those things in the online forum we're building. We'll blog, podcast, photograph, and discuss the path from here to somewhere better. And we'll make it practical. There's enough rhetoric already.

My assignment: name the project. Eep.

I'm on it.

Stress-free primary care?

When I graduated from medical school in 2005, my friend Liz gave me a label maker and a book called Getting Things Done (GTD). I assumed it was a gag gift, though I knew Liz to be a fan of GTD and its author, David Allen, a productivity swami. I thought it was interesting, so I read it.

And then I labeled everything.

Over the last few years, I have practiced a watered-down version of the GTD process, which advocates "stress free productivity" through effective management of the information that comes to us faster and faster. When the mind is unburdened of the task of remembering all the things there are to do, it is possible to be present for whatever task is at hand.

Through residency, this was tough. The task at hand generally involved some high-stakes activity performed in the setting of sleep deprivation and incompetence-by-design. Delivering babies, for example: you become competent by doing it, they come in the middle of the night, and it's a big deal if you screw it up. There was little about residency that allowed for stress free productivity. I did what I could, but there were limits. Mostly, I just crashed through.

I've been out of residency less than a year, and have been a full time family doctor for a little over six months. I work five full days in clinic, seeing about eighteen patients a day for multiple concerns, acute and chronic. I also manage dozens of lab and study results every day, and respond to patient phone calls and email.

My goal: go in every morning relaxed and prepared for whatever comes my way and leave at the end of the day having acted on every piece of information that came my way. That doesn't meet I've cured everybody, cure is pretty rare in medicine.

But hope that by day's end I will have responded to every item that demanded my attention in a appropriate way:

• Every patient visit ends with a mutually agreed plan;
• Every patient call that came in got an answer, a plan;
• I reviewed every lab or study result and made a plan;
• I updated patient charts to clearly describe the plan to everyone who might need to know.
• I set up reminders to myself so I don't worry that I'll forget about important parts of the plan.
  

When I accomplish all those things, there is an empty in-box in front of me, ready to receive whatever might arrive next.

More importantly, my head is not cluttered with all the things I "should" be doing or trying to remember all the things that might be coming in. Unburdened, I feel much more able to be fully present for patients during the twenty minutes I get with them. We have a lot to do in those brief visits and they expect my full attention. When I'm on my game, they get it.

Maybe I'll write more about this later. It seems like a good topic to explore further (running a visit, how the day flows, setting reminders, updating care plans, teamwork and communication, cross-covering for colleagues...)

But it's time to get started with the day, so off I go.

A path of endless bickering

The health care reform effort won't get far if doctors whine like toddlers instead of being realistic about the need for payment change. An article in the recent American Academy of Family Physicians NewsNow newsletter online began like this:

A recent editorial by AMA Board of Trustees Chair Joseph Heyman, M.D., has led AAFP President Ted Epperly, M.D., of Boise, Idaho, to emphasize the importance of the AMA working with primary care physicians to ensure they are fairly and adequately paid for the services they provide to patients with Medicare coverage.

Heyman's editorial, which was posted Jan. 26 to American Medical News online and published in the Feb. 2 print version of the publication, urges payment increases for primary care physicians, but he emphasizes that the AMA would not support such increases if it means there would be corresponding reductions in subspecialists' payments.

"Payments to primary care physicians must increase," said Heyman, an OB-Gyn. However, he added, the AMA "absolutely opposes applying budget-neutrality rules that confine offsets to the physician payment pool."

"Congress should not rob Dr. Peter, the surgeon, to pay Dr. Paul, the primary care physician," said Heyman.

So, if primary care doctors earn more (encouraging more medical students go into primary care to fill the gap), and the specialists still get paid a lot to do procedures that may or may not be helpful to patients' health, then were does the savings come from?

We know that a good primary care system saves money by decreasing complications of chronic disease, so there's an argument to be made there, but I think we should act less like children fighting over who gets more M&Ms (or BMWs), and frame the debate around questions that matter.

Doctors should get paid for delivering care that works. The payment system we have rewards procedures and discourages talking to patients. Not everyone needs a colonoscopy to look for colon cancer (very few people do, actually), but we put a lot of cameras into a lot of bottoms for a lot of money when a $10 screening study you can do at home is equally effective at preventing colon cancer mortality.

As the Dartmouth Atlas of Health Care points out, where there are specialists, there are is more specialty care. Live in a town with lots of gastroenterologists? Predict lots of colonoscopies. It has nothing to do with evidence or effectiveness. Doctors have to pay the bills like everyone else, so you do what you're trained to do and bill accordingly.

I agree that physicians should be paid fairly for the work they do, procedure or not. But we should only be paid for care that works (i.e. has a measurably positive effect in patients' lives). Elective colonoscopy for colon cancer screening? Medicare shouldn't pay for that (or should pay $10, which is what it costs to screen for colon cancer). Eventually the payments to specialists would be driven down using good outcomes-oriented science, fewer medical students choose lucrative lifestyle specialities.

Reframe the debate around what matters, what works, instead of bickering about cost neutrality. Health care costs too much. Some of us have to get less in order to make it work. And we'll all do just fine. Maybe our patients will, too.

Plan B?

"There was no Plan B." So said David Axelrod yesterday following the abrupt end of Tom Daschle's bid to be the white knight of our failing health care system.

I think Daschle did the right thing in bowing out. It was the first right and non-stupid thing he did in a little while. I'm not sure how on earth someone avoids more in taxes than most people earn in in salary and thinks it won't get in the way of a senate confirmation. I also don't understand why taking $5 million in fees from the health care industry (my people, admitted) and thinks that won't come up as a legitimate conflict.

But we're all in agreement now, right? Daschle acknowledges the problem and dropped out. Obama acknowledges the mistake in allowing it to go this far, which created what even the most love-struck Obamanite would agree is an inconsistent rule: no lobbyists or murky ethics in the new administration, except when it suits the administration's needs. I feel better knowing that people in DC can do the right thing, even when it screws up the plan.

And as for the plan--meaningful improvement of how we deliver health care in America? Well, according to David Axelrod, Daschle was it. "There was no plan B."

Super. I'll be Congress will have a plan B, and it won't include universal coverage, guaranteed primary care services (prevention and chronic disease management), nor any kind of incentives for more students to enter primary care.

We've arrived at the time we've been talking about, when our health care system is unsustainable. Companies can't afford to keep the lights on, much less pay huge health care premiums for employees. Employees lose benefits or just lose their jobs. Patients come to me asking for six months of medications because they're losing coverage, and ask for hard copies of their scripts to take to WalMart for the $4 medication plan instead of filling for a few dollars more at our clinic pharmacy.

And there is no plan.

Having the federal government cover 30% of COBRA costs for out of work families is kind of like giving them a buck to help with the rent. Not enough. Out of work is out of work, zero income doesn't cover 70% of a health care premium.

That's not a plan.

There will be some kind of change, but I worry it won't actually help anyone. Those who spend a good part of the year shelling out cash while they wander around in the Medicare Part D donut hole understand meaningless change.

Let's hope for a good, solid plan B, and fast.

And by the way, Mr. President, good for you for admitting your mistake. I expect the learning curve in your job is steep. If you learn from the mistakes, we'll all benefit.

Hope lives on.