demonizing doctors, doctors are human too, patient satisfaction, primary care

There’s a shortage of primary care doctors. Who is responsible for solving this problem?

According to Medical Economics, in their article “How can physicians combat industry shortages and meet patient demands,” the existing primary care workforce bears sole responsibility for this.

The article doesn’t start off too badly.  It says that by 2025, there will be a shortage of 46,000 to 90,000 primary care docs. It then states that one of the reasons for the shortage is the relatively low pay that primary care docs get. This is true. Most primary care practices are consistently in the red due to low insurance payments, which is why there are very few independent practices anymore. Most are owned by hospital systems, who can absorb the loss.

That’s about where the sanity of this piece ends.  According to it, the second reason for the shortage is that we have not “embraced technological advancements.”  The article tells us that we need to deliver services via telemedicine and apps.

No matter that technology for this is still substandard.

No matter that there are serious concerns about cybersecurity and the safety of patient info.

No matter that using these technologies requires a substantial financial investments, of which no primary care doctor can afford.

No matter that there is absolutely no guarantee that insurers will actually pay for these services.
The article then goes on to give this sage advice:

Expand Office Locations: Research market trends and population changes across surrounding areas. Opening office locations in underserved areas experiencing population growth asserts your presence before other practices follow suit.”

And who the heck is going to staff these other locations? I thought they just said we’ve got a shortage of doctors! Maybe the staff of Medical Economics has discovered the secrets of cloning and can be in two places at once, but I haven’t figured it out yet.

It goes on to say:

Reevaluate office hours. Take a look at appointment patterns. Do most of your patients prefer appointments later in the day or earlier in the morning? Should you offer weekend hours? What about extending services later in the evening, when people are out of work? Instead of becoming complacent with standard office hours, test new hours and see how patients respond. Tailoring hours by office location will better serve patients while maximizing your staff’s time and resources.

See, here’s the thing.  My schedule is full during standard office hours. Do I have patients that would love evening or weekend hours? Sure. But am I supposed to work 24 hours a day, 7 days a week? It’s not like I sit around twiddling my thumbs from the hours of 9-5. I’m seeing patients for just about every minute of that time, and doing paperwork during any time I’m not seeing patients (and after hours and on weekends, too).  You can’t claim that there’s a shortage of doctors and too many patients to go around in one breath, and then claim that the doctors are the ones that need to be more accommodating in the next.  Supply and demand, people.

 

Here’s the thing, Medical Economics. The reasons for the primary care shortage are many. Low pay. Low prestige. Too much paperwork. Every-increasing government and insurance regulations and requirements. And, most important of all, not enough residency spots for training doctors.  There are only a certain amount of residency spots a year to train graduating MDs. If a doctor graduates from medical school but does not complete a residency, they can’t practice. They can’t get a license.  Their education is, in essence, wasted.  These are not bad students. There are just not enough spots.  Every year, almost 10,000 doctors do not match! Most of these doctors have gone to international schools.  All of them would do just about anything for the chance to practice medicine here.

It takes a 3 year residency to train a primary care doctor.  If those 10,000 doctors a year were able to do an internal medicine, pediatrics, or family medicine residency, our shortage would be non-existent in less than a decade.

Medicare needs to fund more residency spots.  Period. The way to solve a physician shortage is to make more physicians. It’s that simple, really.

The way to solve a physician shortage is not to place the responsiblity for it on the backs of those already bearing its brunt.

 

patient satisfaction, Press-Ganey, surveys

Are we taking patient satisfaction too far?

“Patient satisfaction” has become quite the buzzword for us in the medical care field.  Of course we want our patients to be healthy, and if possible we would also like them to be happy.  However, sometimes the two are mutually exclusive, or at least mutually elusive.  Patient satisfaction is even starting to be factored into how we’re paid- starting last year, Medicare started making incentive payments to hospitals based on how they did on surveys.  Some doctors are even having part of their salary based on how they score in surveys.

On the surface, this sounds like a pretty good idea, right?  If someone is satisfied, they must have gotten good care.

Not so fast.  Press-Ganey is the largest company involved in making patient satisfaction surveys.  But even they admit that the response rate on surveys is so low that it does not produce meaningful results.  Even more disturbing is that physicians who are a minority race are more likely to receive low scores.

And the worst part of this whole thing?  Patients who are more satisfied have worse outcomes.  They have more hospitalizations, more health care expenses, and a higher death rate!    If you think about it, it’s easy to see why.  A patient wants a stress test, just to “make sure” his heart is OK.  It’s not indicated, as he has no cardiac risk factors and no chest pain.  If he doesn’t get it, he’s unsatisfied.  If he does get it, he’s happy.  But what if the stress test is positive?  Then he gets a cardiac catheterization- a procedure with definite risks.  The cath is normal.  So, now this patient has added at least $10,000 to the nation’s health care tab.  He had a risky procedure.  Luckily, there was no permanent harm done.  The patient is satisfied, and thinks, “I’m so glad we made sure everything was okay!”  But in reality, he received bad, expensive, and risky medical care.

Anyway, this is what has triggered this little rant of mine.  It’s an article on NPR written by an emergency physician, detailing a patient’s experience.  In a nutshell, the patient had a heart attack at a restaurant.  He refused an ambulance and his wife drove him to the ER.  Once there, he received exemplary, fast care.  He had an EKG within 3 minutes, an immediate diagnosis of a heart attack and was taken to the cath lab.  In 22 minutes, the clogged artery in his heart was opened with a balloon a stent was placed.  The patient recovered perfectly- so perfectly, in fact, that he was back at work and exercising again in 2 weeks.

But the story doesn’t end there.  The patient and his wife then lodged a complaint with the hospital that there was no communication and he didn’t even know that he had a heart attack until his second day in the hospital.

Well.  I have to say that I find this pretty hard to believe.  The husband signed a consent.  Unfortunately, the anesthesia given can often cause amnesia for the events preceding it.  As for the wife, I would venture to say that given the panic of the situation her recall might not be that great.

In my experience, when I was doing hospital medicine, I would always introduce myself to patients.  I’d see them, examine them, and review the plan with them. And often, a few hours later, a nurse would page me and ask when I was coming to see the patient.  I’d already seen the patient, but they  thought that I was the nurse or a therapist, even though I had introduced myself.  Or they just forgot the visit all together.  A hospital is a disorienting place to be, and that can be made worse by medications and illness.

But let’s say that in this particular case of the heart attack patient, the patient and his wife are correct.  The ER staff didn’t explain to them what was happening.  They treated the disease only.  But was their sin so bad?  Seconds count in a heart attack.  Every second wasted is more dead heart muscle.  This story makes me wonder if we’ve gotten so used to the every day miracles that modern medicine performs that we have forgotten how things used to be.  Heart disease deaths in the United States peaked in 1968.  Since then, we’ve added 6.6 years of life expectancy, and 70% of this increase is due to a decrease in heart disease.  The estimate is that 1.7 million lives are saved in the USA annually that would otherwise be lost to heart disease.  1.7 million.

I’m sorry the patient and his wife were unhappy.  But, I have to say, I also think they are terribly ungrateful, and I’m more sorry for the doctors and nurses who had to deal with the inevitable fall out from the complaint.  They busted their butts and saved that patient’s life, and for their amazing efforts they were called on the carpet.

For me, personally, if it comes down to a life-or-death situation, I want a doctor who can kick ass, not kiss ass.  Niceties and hand-holding be damned.