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

 
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Monday, September 23, 2013

Adventures in medicine, part 3

So, to pick up from previous posts, Dr. Ron wants to play for Simon Powell on “Doctor Idol,” and Chuck (“Chuck,” I mean) wants to play for the Mud hens. What’s wrong with that? Nothing, actually, aside from their total lack of athletic and musical talent. What’s wrong is the part of the stories preceding these winsome wishes of our dear compadres.

1. The Interaction

Both doctor and patient imagined a simple interaction between doctor and patient, as they are the only two humans physically in the exam room. Unfortunately, there are many others in the doctor’s office and exam room in a non-physical, but very real, sort of way.

The outer circle is comprised of the entities or tasks that are taking Dr. Ron’s mind out of the exam room. These include:

• Insurance companies, with their complex rules (more to follow on this) of payment and ever shrinking payments.• The government, with its growing involvement in the office in areas of measurement, regulations, and (above all else) bureaucracy. Ron feels their ever-growing presence in the office each day.
• The huge amount of paperwork generated by both of these entities (and others).
• The media, with its hype machine built to sell advertising, not truth.
• Denials of claims (and decreasing reimbursement), which lead to …
• The need for higher patient volume, putting Ron further behind and giving Chuck more time to enjoy his waiting room adventures.
• The Internet with its double-edged sword of information/misinformation, leading to patient confusion and decreased patient trust.
• Specialists, who Ron uses to help him manage problems on his patients, but who often don’t send him any information about those visits, do procedures that Ron doesn’t always agree with, and are paid 3 to 4 times more than him (mostly through contracts negotiated by physician groups led by specialists).
• Hospitals, who alternately treat Ron as royalty (to get his referrals and ancillary orders) or dog poo (because he doesn’t generate direct revenue for them like the specialists do).

Sitting in the exam room between Chuck and Dr. Ron are things which are immediately on Ron’s mind, distracting his attention away from Chuck and his back.

While the threat of malpractice is not high for Ron, as a primary care provider, he knows he’s always one exam room away from potential catastrophe. The presence of these distractions make it harder to give the focus needed to avoid missing something important.

Financial pressures, either running the business itself (like Ron does) or cowing to the demands of the hospital overlords (as many other docs do), put finances at the center of the universe in the exam room. Are all the possible charges being entered on each patient? Is he spending too much time with them and therefore decreasing his overall volume?

CPT/ICD codes, whch Ron sees as a trap, with its incredible complicatedness, always seeming to give payers an “out clause.” Patients try to convince him to leave off a diagnosis, while billers want him to include the second digit after the decimal on every one. Ron wonders how digits after decimals became such an important thing in his life.

E/M coding compliance – Like most doctors, Ron realizes two things. That he is paid for documentation, not care. Having a specific number of bullet points in the history, review of systems, exams, and documenting certain thought processes are the things auditors look for when evaluating the records. Ron is forced to either put in a huge amount of information to justify the visit, or to “down code,” charging less for the visit than he deserves to avoid documenting diarrhea. No matter how hard he tries, he is never 100% compliant with documentation requirements. This is the ticking time bomb PCP’s face, as they realize that non-compliance with the impossibly complex documentation rules, in the eyes of hungry auditors has another name: fraud. Ron prays that no auditor with an agenda looks at his charts, as he knows that any doctor could be used as a public whipping-boy.

HIPAA – While Ron likes the fact that HIPAA keeps prying relatives out of the chart, he worries that he will mistakenly talk to someone who is not authorized and get into trouble. More worrisome is the fear of electronic communication or patient records getting out of the office, giving authorities another chance to take him down in public for something he has little control of, let alone understanding of.

Quality measures, while seemingly a positive thing, to reward good doctors, Ron always feels that the real agenda is to go after the “bad” doctors. He’s worried that because he doesn’t get rid of complicated or non-compliant patients, he will be labeled as an “underperforming” doctor, and get on someone’s “doctors to avoid” list. He also thinks it will be used as a reason to lower his payment.

Meaningful Use seems like a classic “bait and switch,” where doctors are lured into using computers with money, only to use the information gathered on him with those computers to increase his chance of being labeled as an “underperforming” doctor, or making the job easier for auditors to hit him with the charge of “fraud.”

All of this surrounds Dr. Ron with a series of barriers that Chuck must unknowingly cross to do the seemingly simple task of telling the doctor what’s wrong. All Chuck knows is that his back hurts and that perhaps buying the Roomba wasn’t such a good idea. He just wants to make sure there’s nothing serious going on, and he wants to feel better.

We’ll address those issues in our next post …

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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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.

Auscultation
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.

DrDialogue
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.

FutureDocs
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.

KevinMD
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).

Prescriptions
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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