January 31, 2008

Three Vignettes You Won't Understand Until I Explain Them, And Then It Will Be Too Late

Hint: what do the doctors not do?

1.

I say, "Hi, Dr. X?  My name is Dr. T, from University Hospital, we have one of your patients here, Joe Blow, and he says he is on a very large dose of phenobarbital, so I'm trying to verify his doses and his seizure history."

"I know Joe, and his phenobarb does is 500mg per day with Dilantin 500 per day.  He has intractable seizures from several head traumas about ten years ago.  Other than that, he has no other medical issues."

"Wow.  Well, thanks for your help."

"No problem.  Bye."


-----

2.

beep

"Hello, Dr. Alone, this is Dr. Ted, calling you back about John Smith.  According to the chart, I last gave him a prescription on 11/17, and at that time I gave him HCTZ 25mg #30, Percocet #60, and Prevacid 20mg.  If you need any more information, you can call me back at the same number.  Thanks."

end of new messages

-------------

3.

The medical student hangs up the phone.  "That was fast," I say.

She nods.  "I told him I was a medical student at University Hospital, and that we were trying to verify his medical history, but Dr. Block said he didn't remember Mr. Robinson so he said he'd have to have the nurse call me back to read the chart."

"Oh," I say.

----


What these stories have in common is this: the outpatient doctor did not bother to ask why his patient was in the hospital.

That's universal healthcare; or at least Medicaid and Medicare.  Some doctors know everything about their patient, others know almost nothing, there's a variance but what's becoming more common is an apathy and disinterest in the maintenance care, the "across the life cycle" total patient care.

They figure: he's in the hospital, so presumably he'll be managed.  I don't have time for this, I'm busy, I have-- well, patients to see. 

The outpatient doctor isn't a "gatekeeper," he is simply a member of a large, disconnected team of clinicians who each care for a different medical and temporal aspect of his life. We are all consultants now.  Contact between clinicians is usually about the past-- what did you have him on?--- or the short term future-- when can he see you next?  It is almost never about the "total patient," integrating neuro with surgery, derm with endocrine...

The odd exception to this is psychiatry, but only private practice psychiatry.  Community mental health is still a type of temporal consultant: if he shows up, you treat him.

When was the last time you talked to the internist of a patient about why/how you're putting him on Zyprexa?

I'm not any better, I'm afraid.  The system isn't set up to care, it's set up so you care less-- because the less investment you have in being the gatekeeper, the more freedom everyone-- other clinicians who may bump into him down the line-- has in doing what they think is best.  I hardly need to point out that not only are we not paid for consulting with other docs, but we lose billable hours and introduce each other to higher liability because they're now on record as being privy to my crazy Depakote + Cytomel+ testosterone plan.  And no doc dares d/c the meds of another without good resaons-- good reasons that unfortunately no longer include "holy crap, that doctor is an idiot!"








Comments

Interesting, my first thoug... (Below threshold)

January 31, 2008 3:39 AM | Posted by Lexi: | Reply

Interesting, my first thought was there was a lack of exchange of release of confidential information documents.

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Inpatient and outpatient pr... (Below threshold)

January 31, 2008 7:31 AM | Posted by Stephany: | Reply

Inpatient and outpatient private psychiatrists have consulted one another when I asked them to with re: to my daughter. Inpatient medicaid outpatient credit card. If a patient is proactive, and asks and talks with respect and offers up a dialogue, this can happen. But, I do agree with disconnect. Here's a story of mine:

Psych: "well, we could try Geodon to replace her Zyprexa."

Me: "How many patients do you have using Geodon successfully?"

Psych: "One. But I haven't heard from him for a while."

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That's not the first thing ... (Below threshold)

January 31, 2008 8:43 AM | Posted by Aaron D. Ball: | Reply

That's not the first thing that came to my mind when you asked what the doctors didn't do: what struck me was that they did nothing to verify your identity or get the patient's consent before sharing protected health information.

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I'd argue that community me... (Below threshold)

January 31, 2008 4:42 PM | Posted by Demodenise: | Reply

I'd argue that community mental health isn't treating people; all they seem to do is refer them back to inpatient care.

Then the patients beg and plead at discharge not to be referred back to mental health, to send them ANYWHERE but mental health, and the discharge planners are all "We HAVE to send you back to mental health, cause nobody (in private practice) takes Medicare or Medicaid anymore. . ."

I think that's a kind of apathy, too. "It's just our job to make sure you have appointments. . . ."

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The phrase trying to form i... (Below threshold)

February 6, 2008 12:29 PM | Posted by Anonymous: | Reply

The phrase trying to form in my mind to sum up what you've said here is "medical assembly line." I imagine that in the context of urgent care or treatments that are "supposed to be one-time deals" (making them even more like an assembly line), doctors are even more likely to actually be annoyed by repeat visits rather than simply apathetic.

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I don't get why this is a p... (Below threshold)

February 26, 2008 7:02 PM | Posted by Paul : | Reply

I don't get why this is a problem specific to medicare/universal health care.

Up here in Canada, the only difference I see with our system is single-payer.

How would these _not_ be problems if an insurance company replaces Health Canada?

The problem of physicians not being paid for time consulting with other doctors is very much a real concern, but having physicians on salary, instead of a fee-for-service model solves that problem nicely. That option is increasingly being offered to younger doctors in Canada, and the younger doctors love the idea.

After all, we don't pay prosecuting lawyers/district attorneys based on how many cases they take to trial, so why do we pay doctors based on how many patients they see?

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"he system isn't set up to ... (Below threshold)

April 9, 2008 12:14 PM | Posted by growing freedom: | Reply

"he system isn't set up to care, it's set up so you care less-- because the less investment you have in being the gatekeeper, the more freedom everyone-- other clinicians who may bump into him down the line-- has in doing what they think is best. I hardly need to point out that not only are we not paid for consulting with other docs, but we lose billable hours and introduce each other to higher liability"

Um, wow? When you put it that way it becomes even more clear that the economics of modern healthcare are broken, from the patient's (cash cow?) perspective. Being paid not to create long term plans, cooperate with other professionals, or criticize others in the profession. Paid in the sense of not getting sued, only being paid for certain billable activities, etc... Negative reinforcement of a lousy process. Its worse than design-by-committee. Its design by blind and isolated committee of indeterminate size.

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That`s not the only 3 thing... (Below threshold)

September 30, 2010 7:48 AM | Posted by Mutuelle santé: | Reply

That`s not the only 3 things that doctors dont do, there are loads of many stuff, they don`t seem to show any care towards the patient and also instead of examining someone all they do is just ask them wht`s wrong.

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That`s not the only 3 thing... (Below threshold)

September 30, 2010 8:20 AM | Posted, in reply to Mutuelle santé's comment, by mutuelle santé: | Reply

That`s not the only 3 things that doctors dont do, there are loads of many stuff, they don`t seem to show any care towards the patient and also instead of examining someone all they do is just ask them wht`s wrong.

Vote up Vote down Report this comment Score: -1 (1 votes cast)
Why copy my comment, make u... (Below threshold)

September 30, 2010 8:42 AM | Posted, in reply to mutuelle santé's comment, by Anonymous: | Reply

Why copy my comment, make ur own.

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This attitude is true of wo... (Below threshold)

April 17, 2013 1:29 AM | Posted by mia466: | Reply

This attitude is true of work in any large American corporation; No one cares because someone else will pick up the slack. It doesn't surprise me that it's leaked over into hospitals as well. I think when you point the finger at socialized health care, you are maybe barking up the wrong tree. Diffusion of responsibility doesn't automatically mean that no one will care (although it can). Those are values already in place. You seem to suggest that doctors will only take care of the patient if taking care of a patient directly contributes to their income, as if financial gain were the only reward for being a good doctor. Sadly, I think many doctors think this way.

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