Even Specialists Need to be Primary Care Doctors on Occasion

My husband received a phone call from a friend in a panic. She was in a urologist’s waiting room with her son. The son is his early 20’s and previously healthy, was seen in the emergency room the night before with severe flank pain. The ER physician originally thought the young man had a kidney stone although there was no blood in his urine (a classic sign of a kidney stone). While in the ER he develops numbness in his groin and difficulty standing on his right leg. He is also having difficulty urinating. After the family relates this change in condition and since the kidney cat scan(CT) is negative, a CT of the head is performed. It is also negative. At this point the ER doctor shrugs about the difficulty standing and the young emergencyman is given an appointment for a urologist the next day. In hearing the story my husband and I agree—the problem is in the spine, not his urinary tract but the urologist is in the best position to get him further assistance from the appropriate doctor. I reassure the mother. Fifteen minutes later there is another phone call from her. They are in the car (15 minutes later?) with a prescription for his prostate and an admonishment to call their primary care doctor to get the young man in to a neurosurgeon. It is at this point that I lose it. Maybe things have changed since I (and this urologist) went to medical school, but difficulty urinating or defecating from a neurologic problem was taught as a neurologic urgency. The specialist has now put yet another physician in the way of this young man getting an appropriate diagnosis with treatment.

I’ve already texted the patient’s symptoms to my first year medical student daughter who quickly makes the diagnosis of caudal equina syndrome. I’m amazed, not that my daughter made the diagnosis, but that the urologist couldn’t or wouldn’t. I am furious that the patient is made to see another unnecessary physician and that the urologist is unable or unwilling to call another doctor. Are we really that busy? Worried about the young man’s inability to void, I make a quick phone call to a neurosurgeon who agrees to see him within the next hour. The young man receives his MRI in the morning and a preliminary diagnosis of cauda equina syndrome is made. Within 24 hours he is getting the treatment he needs.

This is a classic example of how fragmented our healthcare system has become, when physicians can’t think beyond the silo specialties they’ve created. Sometimes I have to think like a specialist and sometimes the specialist has to think like a primary care doc. That’s why we all attended four years of medical school and studied other organ systems besides the one we might primarily treat. And at all times, we need to think of the patient and the best care for him, not the care most convenient for the physician.

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Be Careful What You Wish For

Physician-to-physician communication has become an increasingly difficult problem and its lack has worsened the fragmentation of healthcare today[1]. The challenge is complicated by many things:

  • Physicians lack the time to call colleagues about patients when their income is patient volume-based 
  • Fewer opportunities for direct physician contact, i.e. the doctor’s lounge
  • EHR systems cannot talk to each other
  • Patients don’t always tell their physicians about other doctors taking care of them
  • Printed EHR records are so full of verbiage that important findings are missed by the doctors trying to scan pages of unimportant documentation
  • Patients rarely carry their health histories with them in any format outside of memory
Another problem, at least in the healthcare system where I work, is the lack of a centralized area where physicians can come together to find community specific information. Blast emails are sent to doctors whose boxes are already full of “junk”, making it difficult to separate the wheat from the chaff. Recognizing this problem I recently approached the IT department at my institution. 

It was gratifying to me that they not only understood the issue, but were excited about assisting in a solution. My vision is to create a Physician Community where providers can go to find answers and communicate in a secure environment about any number of issues–problems with EHR, announcements, medical directors’ updates, calendars with CME and other dates of interest, blogs, CME, vlogs, links to outside trustworthy medical sites, and a place to crowdsource patient or system problems. IT gave me access to build such a community in a Sharepoint environment. 

Of course in addition to the problem of building the environment and populating it with what the doctors need, is getting them to use it. I feel certain that “If you build it they will come” does not apply in this situation. I envision needing to enlist lots of assistance from the President and CMO of the system down to the office managers and EHR superusers. 

I’m a firm believer that Social Media is the most important revolution in patient care today. Effective electronic communication between physician is part of that movement. But today, as I’m reading Sharepoint for Dummies, I can’t help but wonder–what was I thinking and can this make a difference? 

1. Shannon MD MPH, Shannon. peg.org. January/February 2012. http://www.perfectserve.com/resources/docs/ACPE-PhysicianCommunication.pdf
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The Three “P”s of Mayo–Patient-centered, Physician-led and Collaborative Partnership

Last week I attended the Mayo Clinic’s Annual Social Media Summit in Rochester. What most impressed me had nothing to do with the conference. On Tuesday afternoon before the Summit began I toured Mayo Clinic. It was supposed to be for an hour but lasted more than two because our group, consisting of one doctor and nineteen PR professionals, was so interested in the information being fed to us. I don’t know why the publicity folks were so intrigued, but for me Mayo’s philosophy of “patient-centered, physician-led” care hearkened back to a time when the patient-physician relationship was inviolate. It was stimulating to realize that my instincts of how medicine is best-practiced are right on target.

My myopic opinion regarding the fragmentation of healthcare sees the destruction of the patient-physician relationship by multiple entities, who are primarily interested in a piece of the economic pie, as central to our healthcare mess. At Mayo, no project moves forward unless there is a physician who champions it and it is the physician’s responsibility to ensure that every project is dedicated to improving some aspect of patient care. Physicians are salaried so they spend the time necessary to care for patients and are not incentivized to increase the numbers of patients seen or do procedures to enhance the bottom line. 

Every person I met who worked for Mayo reiterated the importance of putting patient care and comfort first. It was incredibly refreshing. The Mayo logo emphasizes a patient-first policy as well. I’d seen the logo multiple times but somehow never thought about what the three shields represent. Our tour guide explained: Patient care, research and education. The educational aspect was obvious as we walked multiple floors of patient care areas. I noticed no TVs in patient waiting rooms but many had computer screens where patients could learn about their conditions. It is a refreshing and calming atmosphere without the cacophony of media noise. There is art everywhere. Waiting rooms are spacious and well-lit. Meditation rooms and educational spaces abound. 

Children’s waiting area

Mayo has always represented excellent healthcare in my mind. Patient reports that come to me after a visit there are extraordinary due to the extent of the integrative care the patient experiences from multiple medical disciplines coming together. I expected to be impressed. I did not realize I would also be reassured. Putting patients first is what I’ll continue to strive to do, despite insurance interference, governmental policies or EHR dysfunction.

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The Need to Blame the Doctor, not the System

Maureen Dowd wrote a thoughtful and thought-provoking article in the New York Times this morning entitled “The Boy Who Wanted to Fly“. I had read about the incident in a twitter-linked article earlier in the week and my heart ached for everyone involved–the boy, the parents, the pediatrician, the ER docs and the staff treating him at the hospital. I know from professional experience how gut-wrenching this outcome is to the doctors and staff involved. As a parent I prefer not to imagine what the personal experience would be. It was hard enough to have stood beside friends as they moved through it.

Many of the comments below the article demonize the physicians involved in the care of this boy. That is an easy thing to do and seems to be a particularly American way of approaching a problem–find someone to blame and sue them. Unfortunately, this will do nothing to fix what is an increasingly common problem in our healthcare system today.

I don’t know the specifics of what happened in this case. On the surface of it, the article and remarks about it emphasize many of the issues of our broken healthcare system. The comments engendered begin with ‘hard-hearted doctors” and “sue the jerks”. Perhaps the most thoughtful was the comment by Infectious Disease specialist Dr. Jonathan Rosenthal who said: “The average physician will never see a case of florid Group A Streptococcal septic shock such as this one in her entire career. One of the reasons these rare cases can be so lethal is that is can be enormously difficult to pick them out from among 10000 cases of viral illness in a Pediatric ER. Herculean efforts are made every day not to miss early sepsis. We can learn from cases like this but not if we are distracted by looking for the person to blame. This poor child was seen by a number of physicians – were they all incompetent?”

As a primary care physician some of my thoughts are: How busy was the pediatrician? How busy was the ER? Did they have the time and experience to pick up on those “soft signs” of sepsis that Sully Sullenberger alluded to? As an aviation safety expert he understands the importance of fixing the SYSTEM that is causing the problem, rather than placing blame on the individuals involved.

Patients live in a world where physicians are pushed to see more and more of them to pay the bills; where technology substitutes for stopping and really “seeing” a patient as more than a disease state; where the patient is seen only as a dollar sign by the healthcare administrators, insurance executives, employers, lawyers and politicians who crowd into the examining room as if they had a sacred right to be there; and where time, the most important commodity for good patient care, is stripped from those on the front lines because it is not valued highly by their own peers.

This case should be a rallying cry for patients (and we are all patients) to fix a badly broken, fragmented healthcare system where volume and technology substitute for care. Since this involves a political fix from a system equally broken and fragmented, a fix that must involve compromise from both sides of the aisle, I fear for the future health of my patients and my profession.

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Reducing Fragmentation and Patient Care NOW not Next Year

I do not recommend doing this, but today I attempted to listen to two Webinars at the same time. One was also tweeting the discussion and the other had very detailed slides which made it easier to follow but as studies show, we are not really capable of that kind of multi-tasking. The topic of the first suggested it would discuss Primary Care and its future. However, what the expert proposed was a “How to” plan for bringing more customers into a healthcare system. This was boiled down to a recommendation that these system open small clinics, run by NPs, in competition with drug store and grocery store clinics of similar ilk in order to funnel patients into the listeners’ systems. The other Webinar was a discussion by three mobile health leaders (mHealth) on the future use of their products in the global mobile health arena (wow, that rhymed).
It’s is a good idea to know what is going on in the minds of healthcare system development teams and as I listened to the expert’s remarks I could not help but ponder on what, in my humble opinion, would build the kind of “team loyalty” that hospitals and other healthcare systems are dreaming of. What is it that patients want? I agree that they need healthcare access in their busy lives at more convenient times of the day than traditional physician offices offer. What my patients tell me (and what people tell me at cocktail parties) is that they would prefer access to their very own providers, those individuals who know them best. No insult intended to NPs because they are essential to the healthcare team, but they are physician extenders, not physician substitutes. What about developing systems that give patients greater access to their own providers? This would really engender loyalty to a healthcare system, especially one in which physicians are employees, more and more the norm these days. I believe mHealth can do that. What if you could access your physician after hours via Skype? Or text your doctor just for a quick conversation about whether you should seek immediate care or be seen the next day? Gee, what if the physician had access to their schedule and could book them on the spot?!? What I’m advocating here is a “concierge” type practice without the concierge price. Of course there would have to be some sort of reimbursement procedure to give already overworked primary care doctors the incentive to take care of patients in this way but wouldn’t that be a cheaper investment than opening the equivalent of “Little Clinics” everywhere?
Along with the cost, the second complaint I routinely hear from patients about their medical care is its fragmentation. From a patient and a primary care perspective, no one on the health care team is talking to each other. In fact, frequently the word “team” is a misnomer. Using tools like Doximity physicians can employ a HIPPA compliant platform to discuss cases and improve care. Of course the phone always works, but with the ability to ask questions and respond in a timely but convenient fashion, doctors and other providers like NPs, PTs, etc. can reduce the fragmentation patients feel from their healthcare team.
Of course I realize that ACOs (Accountable Care Organizations) are supposed to be developing this kind of care. But does the bureaucracy that surrounds these systems bother anyone else but me? Do we really have to wait for the lumbering movement of government sponsored programs in order to improve communication, fragmentation and access to care when the technology is already here today? 
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