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

 
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Monday, September 30, 2013

Adventures in medicine: part 4

In the last post we saw how complicated the visit is from Dr. Ron’s perspective, and how many things were working to pull him away from our hero, Chuck. So what about Chuck? What about his perspective? I ended the previous post with the statement: “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.”

In other words, Chuck is interested in two main things: quality of life and quantity of life.

What he wants to avoid is: death, disability, disfigurement and pain. Please note that I could have used “dysesthesia” to keep with the “D’s,” but chose to speak English (a talent which many doctors lack).

Now, when Dr. Ron listens to the story of a patient like Chuck, there are three main tasks he focuses on: 1) Ruling out serious problems (or assessing risk), treating symptoms and making a diagnosis.

He does this by listening to Chuck’s story (his symptoms), looking for objective findings (via physical exam, labs, or other tests), and looking over Chuck’s back-story (his past problems, symptoms, and risk factors).

From Chuck’s vantage point, as long as Ron has ruled out bad stuff and makes his back feel better, he doesn’t benefit from making a firm diagnosis. That’s what Chuck thinks he’s paying for (both from his wallet and from the precious moments of his life wasted in the waiting room). But here’s where things start to get complicated: Ron doesn’t actually get paid for the two things that Chuck wants the most (ruling out bad stuff and treating symptoms), instead he’s paid for:

1) Coming up with “diagnosis” (problem) codes to describe Chuck’s situation.

2) Coming up with “procedure” codes to describe what he did in the office.

3) Doing his medical record in a way that “justifies” his codes to insurers (in case he’s audited).

4) Paying a bunch of staff to make sure this information is submitted exactly right, as any mistakes could result in denial of payment.

Ron’s new fancy-schmancy computer record program is built to make sure all of the information needed to justify the charge is put in properly, and that the diagnosis codes and procedure codes are also properly entered so they can be electronically submitted to the insurance company. Ron likes the fact that it makes this easier, but it bothers him that so much of the note is just “packaging material” that obscures the most important part of the note to both doctor and patient: the plan.

To make matters worse, Ron has to find a code from the ICD-9 code list, which are specific codes that the insurers accept for treatment. This is sometimes hard, as the codes for common things (like weakness of the arms) are mysteriously missing, while codes for strange things (like being injured by a space ship) are on the list.

To “improve” this situation, the government is soon to introduce ICD-10, which will increase the number of codes by 500%, now including the important code for “burns incurred from flaming water skis” (it’s about time).

Ron’s EMR gets to these codes (relatively) easily because they are essential to be paid.

Additionally (and worrisome to Ron), the insurers are taking these diagnosis codes and problems on the list to measure the “quality” of Ron’s care. Ron worries about this because payment is increasingly being linked to quality measures, and the folks doing the measuring are the ones doing the paying, which means they would benefit from measuring low. Another negative of having problems accumulating on lists is the all-inclusive nature of the lists, which include:
• Chronic disease (like diabetes, hypertension)
• Past events (heart attacks, cancer)
• Symptoms (back pain, fatigue)
• Risk factors (family history of heart disease, cancer)
• Abnormal test results (high cholesterol, low sodium, abnormal chest x-ray)
• Exam findings (heart murmurs, skin lesions)
• Minor problems (allergies, baldness)
• Acute problems (Viral infections, sinus infections)

This makes these lists grow quite large, which is often made worse if the acute problems are don’t drop off of the list, which is often the case. Taking the time to clean up and organize records is something most doctor’s offices don’t have time to do.

What does this have to do with Chuck’s Roomba-assisted back injury? Nothing good. Unfortunately, it makes Ron focus on the least important thing: the diagnosis (remember, Chuck really just wants to rule out bad things and feel better). It rewards doctors for finding problems and doing procedures to fix those problems. It also rewards Ron for putting things into the chart that makes it jumbled and confusing. Since Ron’s pay is dependent on his documentation, he spends much of his time and energy putting information into the record, as Chuck sits and watches him type.

So, for the 10 minutes in the exam room together, the majority of time is spent inputting information and finding diagnosis codes. Ron feels bad about this, a feeling that tempts him to do what many doctors do: order X-rays, MRI scans, and prescribe medications for a simple back strain. But Ron knows that these do nothing useful for Chuck and just raise the cost. Ironically, Ron’s decision to do the right thing makes Chuck wonder about how good of a doctor Ron is, as he leaves with nothing to show for his time and inconvenience other than a sympathetic look, instruction to take ibuprofen, and a back exercise sheet. It seems like a waste of time and money.

Ron agrees with this assessment, wishing that he was rewarded for doing the right thing, not penalized. Both Ron and Chuck leave the visit frustrated. Chuck goes home to plot against his cat, while Ron moves on to the next patient, hoping for something a little more satisfying.

To be continued …

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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