American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, November 25, 2015

The high cost of high cost

“You don't charge enough.”

I've heard this from a lot of folks. I've heard it from my accountant (of course), other doctors, consultants, and even some of my patients. I've had some patients who are especially complex offer to pay me more because of the difficulty of their care. I think they feel guilty and worry I'm upset that they are being “too demanding” for what they are paying. I don't ever take extra money.

When I recently told an elderly patient's family that I was willing to do house calls if/when the woman needed it, their question was: “how much extra does it cost?” No extra charge, actually. They were delighted at how “old fashioned” I am. Yep, Dr. Smartphone is certainly old fashioned.

Doesn't this seem like a stupid move for a guy who did a major life change while three kids were college age, who spent most of his retirement money after he turned 50, who has lived the past few years doing a balancing act with both work and home bank accounts? Shouldn't I charge more? Shouldn't I try to get more money now so I can sustain the business better?

I don't think so.

I recently had a conversation with a friend who has a practice that is very similar to mine. He complained to me about how “high maintenance” his under-30 patient population is to him. I was surprised, as this same population in my practice is nowhere near the label of “high maintenance.” After further investigation, the big difference between our practices (besides location) is that I charge only $30 per month for folks under 30, while he charges $50. Then everything made sense.

I initially came upon the $30 price when I considered the young families I had taken care of in the past, and the likelihood they would tolerate a price of $50 per month. It seemed to me that people would be much more willing to pay a dollar a day for access to my care than they would a higher price. Since my model of practice (a monthly fee without copay or other profitable procedures/products) benefits most from people paying for my service without heavy use of those services, this seemed to be prudent. It seems that I was right about this, when comparing experiences with my colleague. People are much less likely to pay $50 per month (or more) unless they have significant need, so a higher price essentially selects for more complex and/or demanding patients.

This is why I can reasonably handle 640 patients today with only two nurses (one of whom is away on vacation). Yes, I don't get as much money as I would for 640 patients at a higher monthly rate, but I wonder if I could actually handle that number of patients with only two nurses if I selected out for more demanding patients with that higher rate. I doubt it. The longer I consider this, the more I'm convinced of its truth, and the less I am inclined to raise my rates (much to the chagrin of my accountant).

But this doesn't just apply to my practice model; it applies to all of health care. I have family members who don't get routine care for their blood pressure or undergo routine screening tests because of the cost (and yes, they do have insurance). I've had many patients who wait until the value-proposition becomes overwhelming to seek care. Treat blood pressure? Not worth it. Treat congestive heart failure? I guess I can fork out the money. This is not out of stupidity or carelessness, necessarily, but instead it is an ignorance of the potential long-term harm of seemingly small, treatable problems.

So what's the point of all this? Am I suggesting we make primary care really cheap for everyone? Maybe. But the bigger points are that the economics of healthcare is not always straightforward, and that our emphasis on paying more for high acuity, high complexity patients yields exactly what we are paying for. Somehow we need to find a way to lower the barrier for people to seek care when it has the biggest economic benefit: early. On the other side, we need to somehow reward providers for engaging patients in early intervention and disease prevention. Finally this all needs to be done without penalizing or discouraging the care of complex problems or diseases.

Like I said, it's hard economics. But I've been able to show it is possible in my growing sample. There is still a lot of work to be done, as I try to grow the practice into something that is a viable alternative to our fee-for-service (using the word “service” lightly) payment model. None of this is easy, but at least I (and other docs doing what I do) are trying to show there are viable alternatives.

Many folks initially told me this practice model couldn't work. Many said that I would cater to the rich, excluding the poor. Many said I'd avoid complex patients or time-consuming diseases. Many say my prices are too low. Yet here I stand, 3 years sober from taking insurance, with a growing practice filled with people from a wide variety of economic backgrounds, with a good mix of healthy and sick, and with an ever improving personal economic future. I actually put some money back into my retirement accounts recently.

There. At least that gives something for my accountant to be happy about.

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Tuesday, November 24, 2015

Mammograms: find your sanity

Fairly typical week in health news: Mammograms.

The big story is that the American Cancer Society issued an updated guideline recommending that women undergo mammography less frequently than before.

This announcement was denounced on both “sides” of the perennial debate. Those in the “mammograms save lives” camp are outraged that a scientific society dedicated to cancer prevention and treatment would issue a proclamation that seems to run counter to the notion that “early detection saves lives.”

Those in the “putting scientific evidence in the forefront” camp are actually somewhat pleased that the ACS is finally ”moving in the right direction,” but displeased that the society didn't get all the way to the vicinity of, for example, the U.S. Preventive Services Task Force, which has the most heavily-weighted (and least stringent) screening mammography recommendations: for women at average risk (i.e. those that don't have a mother or sister with breast cancer), start breast cancer screening at age 50 and get a mammogram every 2 years until age 74.

The new ACS guideline: start screening at age 45 (well, 40 if you want to) and have mammograms annually until age 55, at which point you can go to every other year.

If a woman at average risk for breast cancer follows the USPSTF guideline to the letter (and is lucky enough to avoid a “call-back,” i.e. further looks for a possible abnormality), she'd have 13 mammograms over 25 years. If she follows the new ACS guidelines to the letter, she'd have 20 mammograms, possibly more. Of course, every mammogram not only increases the cumulative total of lifetime radiation exposure, it increases the odds that an abnormality will be found and a call-back will be issued.

The best analysis regarding the new ACS recommendation (and actually, 1 of the best pieces about the whole breast cancer screening issue in general) is from FiveThirtyEight's lead science writer, Christie Aschwanden, whose piece is titled, “Science Won't Settle the Mammogram Debate.” Aschwanden correctly points out the “right thing” depends on you, the patient, and your values. There is no right answer.

For some, not getting mammograms annually (or even at all) is the right choice. For the rest, following the “rules” such as they are provides the best piece of mind.

And that's OK.

Here's the thing: because choosing to have mammograms or not is a personal decision, we should refrain from blaming people who choose 1 way or the other. People have their reasons. As with many social and medical issues, the personal has become very political, because people's beliefs are strongly held. Ultimately, a lot of economics is impacted by the politics here. Pro-screening partisans are always uneasy when edicts cutting back on screening are issued, because the fear is that the health care “establishment” (i.e. insurance companies) will stop covering the tests.

That's simply not going to happen with mammography.

If we strip the emotion out of the issue and just try to stick to facts, what, at heart, is undergoing a mammogram like?

The video below comes from the UK's Cancer Institute. It's just more than a minute, and is very matter-of-fact. It shows an actual woman undergoing an actual mammogram, and thus includes bare breasts.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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Monday, November 23, 2015

So not a provider: part deux

I wrote a piece about the word “provider,” and how physicians have been a bit blindsided to what's fast becoming their new title. It started something of a social media wave. For anyone who hasn't read the article, it can be found here. It was good to see the article encouraging lots of healthy debate, and I was also grateful for the large volume of supportive messages. As we continue this important discussion, I wanted to specifically address 5 follow-up issues:

1. This is not about ego or turf wars

My own dislike with the word provider doesn't come from an egotistical perspective or some desire to inflate my own position. Neither do I feel this is the case for most physicians. Speaking personally, it was my childhood dream to become a doctor. I enjoy what I do, consider the physician-patient interaction sacred, and strive to perfect the art of medicine each day I'm on the medical floors. A good doctor is what I always hope to be. Seeing a different job description and name creep into the equation, one where I'm known as the “provider”, is just as disheartening to me as it would be to any professional who strives to be the best at what they do and takes pride in their work—be it a pilot, an attorney, or even an actor—who wakes up to find they are being called “transport provider”, “legal advice provider” or “entertainment provider” by the people that employ them. Rightly or wrongly, I do consider it a bit of an insult when I'm addressed primarily as a Provider to my patients. I'm quite relaxed and informal, don't insist on being called “Dr.”, and don't mind being called by my first name. But I do insist that my job description is that of being a physician. Period.

2. All health care professionals should get on

Many online comments came from other professionals, including NPs and PAs. As I said in my original piece, this is not about them or what they do. We must all get on at the frontlines of medicine, because our ultimate mission is always the same: to serve our patients. By the same token, why any Nurse Practitioner or Physician Assistant would like the term “provider” also eludes me!

3. This is not just another fight with administration or the government

Although it may seem like the push to use the word “provider” comes from faceless administrators, having talked to (and being friends with) many of them, I don't think administrators necessarily realize the problem with use of the word Provider and might be caught up themselves in a wave without knowing where it all started. Neither would any of them ask for a “provider” when their sick child or elderly parent needs help. There's no “big evil empire” out there wanting to define physicians. Our fate is in our own hands and all ships that have sailed can be brought back to port.

4. Don't forget the power of words

Physicians are on the whole not the most linguistic people (no offense intended), and should understand that words have immense power. Talk to any marketer, business-savvy person or even any attorney—and they will tell you all about this. There's a lot in a name, and physicians can be a bit naive about this compared with other professionals.

5. Our patients don't want to know us as providers

I'm yet to hear of any patient who likes hearing or using that word. If, in the end, we all agree that the patient comes first—let's listen to them on this too!

We face some huge challenges in healthcare. In the overall entirety of things, this may not seem like a major issue. But I personally think about and face these healthcare challenges from the perspective of being a physician who wants the best for my patients. So should every other colleague who values what they do and the honor bestowed upon them of being a physician. The U.S. Bureau of Labor Statistics estimates that there are around 700,000 practicing medical doctors in the United States. Other estimates, including retired and non-practicing physicians, are around 1 million. That's an awful lot of people. Maybe, just maybe, a sleeping giant can be awoken.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Friday, November 20, 2015

Getting diagnostic help through sharing the patient's story

Recently, we had a new patient admission whose presentation confused the entire team. We developed a differential diagnosis, but really did not have great confidence that we were moving in the right direction. We thought we had a good idea of what diagnoses we could not afford to miss. We ordered a few tests to exclude those can't miss diagnoses, but all the tests did not provide an answer. We accomplished this strategy within a few hours.

My resident and I happened upon 2 physicians in the physician's lunch room. One was a resident; another, a subspecialist. Being confused, we shared the story with our colleagues.

The other resident suggested a possibility that we had not considered. I immediately pulled up DynaMed Plus (disclaimer, I am on the editorial board and all ACP members get DynaMed Plus for free for the next 2 years) to investigate this possibility. I think that I had heard about the possibility, but unfortunately had not really learned enough on that subject.

The research confirmed the suggestion. We proceeded to make this possibility our #1 diagnostic target, because it is very treatable and potentially deadly if we missed it.

Of course, the resident was correct. Our lunch conversation made a potentially long and hazardous hospitalization much shorter and with a great outcome for the patient.

As I think about diagnostic dilemmas, I realize that I often “run the story” by colleagues, residents and even students. Sometimes the process of telling the story helps me better understand; sometimes the listener asks a key question; often the listener expands the differential diagnosis.

A couple of months ago, a former student (now an intern) approached me after a teaching conference. He wanted to share a patient story to see if I had any good ideas. His resident and he told me the story. In that instance, I had the proper knowledge to help, and once again the patient benefited.

In both cases, I have told the stories multiple times since. In the first case, most physicians go down the same paths that we originally did. Yesterday, I presented the story to a chief medical resident who had seen a similar patient as a student. He got the answer immediately.

For the second case, few people know the information that allowed me to point the team in the right direction. The presentation was 1 that I particularly had thought about and studied because I have a passion for acid-base and electrolytes.

Our sports role models should not be individual sport champions, but rather the “glue guys” in team sports. ”Glue guys” strive at all times to do whatever is necessary to help the team. The enemy is ignorance of the correct diagnosis. Victory is getting to the proper diagnosis. We cannot afford to have ego about how we get there, rather we must take advantage of interpersonal “crowd sourcing” if that helps the patient.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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