Monday, May 31, 2010

Outsiders' perspectives on primary care

You've probably had the experience of going to see a primary care physician and wondering about the many aspects of that visit that just didn't make sense. Why is it so important for me to arrive on time when, in reality, I won't be called back until half an hour (or more) later? What's the point of waiting for another 20 minutes in a chilly examining room for the doctor to show up? Why does my doctor always seem so rushed? And most importantly, why do they always insist that I come for an appointment for a minor problem that could just as easily be handled by phone or e-mail?

Two articles in the current issue of the journal Health Affairs provide outsiders' perspectives on these issues. The first article, an anthropological "field study" of three general internal medicine practices, describes the primary care experience as separated into three "social silos," consisting of physicians ("the frantic bubble"), practice staff ("the flexible team"), and patients ("in limbo"). As I've described previously, family physicians often feel as if they're behind from the get-go:

Their days began with a review of what we dubbed the "fictive schedule," in which the physicians would grab a printed schedule or look at a monitor and see a long string of 15-minute appointments stretching through the morning. They would tap a pen down the list and mutter something like, "This one will take at least half an hour," or "This one's a real nightmare ..." In addition, many unscheduled patients would need to be "fitted in" to these already tight schedules. The fictive schedule showed uniform, precisely measured blocks of time. The "real" schedule in physicians' heads was informed by their knowledge of their actual patients.

The authors go on to observe that little or no time is scheduled for already-harried physicians to perform all of the other essential tasks that go into running a practice (for a nice description of these, see this recent piece in the New England Journal of Medicine).

The second article takes the perspective of a Martian (one wonders if the editors who designed this theme issue of the journal recently read neurologist Oliver Sacks' classic An Anthropologist on Mars) who concludes that primary care physicians' time would best be spent on longer, "necessary" in-person visits, defined as:

1) for a first visit
2) when it may be necessary to engage in some physical maneuver for diagnostic purposes
3) for specific therapeutic purposes, such as injecting a joint
4) when the patient has problems for which lengthy discussion would be helpful
5) when for psychological or emotions reasons it seems better to see the patient face-to-face
6) when face-to-face visits are necessary to build trust

Even with longer appointment times, the author points out, physicians would still end up with additional time in their schedules to devote to coordinating staff activities (such as health behavior counseling) and supervising population-based preventive health and chronic care improvement activities.

The primary obstacle is that a practice redesigned with these principles would rapidly bankrupt itself, since traditional health insurers almost uniformly pay only for in-person encounters with physicians and do not pay for health education delivered by non-physician staff. Only integrated health systems such as Washington State's Group Health Cooperative have been able to thus far afford the changes necessary to transform their old-style practices into what is being called the patient-centered medical home. And though Group Health has already seen their efforts result in improved patient satisfaction and cost savings, for many docs, adapting to the changes hasn't been easy. In a future post, I'll explain why it's difficult for family physicians to transition to being team players.

Friday, May 28, 2010

Comments found in medical records

Here's a completely non-serious post for the start of the long Memorial Day weekend. These are sentences actually typed by medical secretaries (and, presumably, dictated by medical doctors):

1. The patient has no previous history of suicides.
2. Patient has left her white blood cells at another hospital.
3. Patient's medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
5. Patient has chest pain if she lies on her left side for over a year.
6. On the second day the knee was better and on the third day it disappeared.
7. The patient is tearful and crying constantly. She also appears to be depressed.
8. The patient has been depressed since she began seeing me in 1993.
9. Discharge status: Alive, but without my permission.
10. Healthy appearing decrepit 69-year old male, mentally alert, but forgetful.
11. Patient had waffles for breakfast and anorexia for lunch.
12. She is numb from her toes down.
13. While in ER, she was examined, x-rated and sent home.
14. The skin was moist and dry.
15. Occasional, constant infrequent headaches.
16. Patient was alert and unresponsive.
17. Rectal examination revealed a normal size thyroid.
18. She stated that she had been constipated for most of her life until she got a divorce.
19. I saw your patient today, who is still under our care for physical therapy.
20. Both breasts are equal and reactive to light and accommodation.
21. Examination of genitalia reveals that he is circus sized.
22. The lab test indicated abnormal lover function.
23. Skin: somewhat pale, but present.
24. The pelvic exam will be done later on the floor.
25. Large brown stool ambulating in the hall.
26. Patient has two teenage children, but no other abnormalities.
27. When she fainted, her eyes rolled around the room.
28. The patient was in his usual state of good health until his airplane ran out of fuel and crashed.
29. Between you and me, we ought to be able to get this lady pregnant.
30. She slipped on the ice and apparently her legs went in separate directions in early December.
31. Patient was seen in consultation by Dr. Smith, who felt we should sit on the abdomen and I agree.
32. The patient was to have a bowel resection. However, he took a job as a stock broker instead.
33. By the time he was admitted, his rapid heart had stopped, and he was feeling better.

Tuesday, May 25, 2010

Why I'm a doctor and not a pharmacist

One of my favorite patients in residency was a lady in her seventies who had longstanding high blood pressure, high cholesterol, and diabetes. Each time she visited the office, I would recommend that we start multiple medications to control these conditions, and every time she would politely decline. Her previous physicians had left frustrated notes in her chart littered with terms such as "non-compliant," "against medical advice" and expressing wonderment why she even bothered to show up. I wondered, too - for show up she did, never missing an appointment but always turning down every drug we offered.

This type of patient drives most doctors nuts. I took a more philosophical approach: at least I knew exactly where she stood. Other patients, I suspected, simply accepted proffered prescriptions without protest and then never went to a pharmacy to fill them. Later, as an attending physician, the first thing I'd tell students who wanted to reflexively increase the dose of an apparently ineffective drug was, "Make sure that they're actually taking the meds."

The extent of the problem of "primary medication non-adherence" (not filling the initial prescription for a new drug) became much clearer with the publication of a study in the April 2010 issue of the Journal of General Internal Medicine that found that a whopping 28% of new prescriptions were never filled. What were the most common types of drugs that patients never picked up? Those for high blood pressure, high cholesterol, and diabetes.

There are many potential explanations for why patients don't take prescribed drugs, ranging from cost to convenience to the patient's not being totally convinced that the drug is necessary to treat an asymptomatic condition. But many doctors aren 't really interested in talking to patients about it, asserted surgeon Pauline Chen in a recent New York Times column:

While anyone who has ever tried to complete a full course of antibiotics can understand how easy it is to skip, cut down or forget one's medications altogether, bringing the topic up in the exam room feels more like a confession or inquisition than a rational discussion. Few of us want to talk about medication nonadherence, much less admit to it.

Fair enough. But there are plenty of good reasons to change this mindset. Prescriptions that aren't filled can't do any good, but they can easily do harm: for example, in the diabetic patient who is hospitalized for an infection and given his "regular" insulin dose, only to become comatose from low blood sugar because he never actually took that dose (which his puzzled physician kept increasing) in real life.

The patient I mentioned earlier eventually suffered a stroke, the unfortunate consequence of not taking medications for her conditions. Had I assumed that she had been taking her medications, however, my colleagues might have pursued a more aggressive - and totally unnecessary - workup to explain the cause of the stroke. Instead, she returned to my care a changed woman, resolved to take the drugs that she'd previously avoided, and her blood pressure, cholesterol, and blood sugar rapidly returned to normal. An interesting finding in the non-adherence study was that patients were less likely to fill prescriptions of specialists than those of primary care physicians. It goes to show that a family doctors know that their job isn't done once the prescription is written. If that's all it took, we - and the specialists who often have more tenuous relationships with patients - might as well be pharmacists.

Friday, May 21, 2010

Finding good primary care: beyond "best doctors" lists - Part 2 of 2

Aware of the limited amount of reliable data about physicians online, many practices have decided to cut out the middleman and market their services to patients directly. Increasingly, practice websites contain more than basic information such as contact phone numbers and hours of operation. For example, Maryland's Potomac Physician Associates maintains separate web pages for each their three offices that contain physician biographies, a list of accepted health insurance plans, and FAQs such as guidance for caring for a child at home with H1N1 influenza.

Patient First, which operates multiple offices in Virginia and Maryland, displays each doctor’s schedule and offers links to news items about the practice and the websites of authoritative government and private health organizations. A primary care house call practice for the homebound elderly in Washington, DC posted an award-winning YouTube video describing the benefits of its services on patients’ lives.

Even for family physicians who don’t have the time or resources to incorporate many bells and whistles into a practice web page, it is a simple matter to refer patients to social media sources that can help them to stay healthy. The various institutes of the National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality all maintain active Twitter and/or Facebook accounts to rapidly disseminate breaking news and other information relevant to patient care.

Preventive counseling to promote healthy and discourage unhealthy lifestyle behaviors lends itself especially well to “micro-blogging.” Smokers who are seeking support to quit the habit can exchange tips with thousands of fellow nicotine addicts at; patients with alcohol problems can join a “virtual AA group” at; and anyone interested in improving their physical fitness can find lifestyle coaches and personal trainers at

While it is difficult to forecast the directions in which online patient-physician interactions will evolve in the future, one lesson is already abundantly clear: establishing an interactive, informative online presence is far more likely to recruit and retain satisfied patients than leaving one’s reputation to the mercy of doctor rating websites.