Melissa Young, MD: Are patients expecting too much of me — or vice versa?

Last week, just as I was about to give up on my 12:15 patient, she called — at 12:25 p.m. — to say she was going to be at the office in 15 minutes. My receptionist, knowing full well what I was going to say, asked her to hold, turned to me and asked me if I would see her. See her? Twenty-five minutes into a 45-minute visit? When I had a meeting at 1 p.m.?

I said, “No.” Well, what I actually said can’t be published, but the bottom line was “no.” I listened to her politely explain to the patient that I would no longer be able to see her and that she was welcome to reschedule. I listened to her try to reason with her, saw her put her on hold and turn to me. “No.”
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She tried talking to her again, and then in exasperation asked me if I wanted to talk to her. Of course, I didn’t want to, but fine. Let me interject here that she had already “no-showed” for a new patient visit two weeks earlier and probably should have been given another appointment anyway. So I take the phone and try to explain to her that she was going to be too late, and that, no I would not, could not see her. She insisted that she was “right there,” argued that she was coming “all this way for nothing.”

I reminded her that her appointment was at 12:15, to which she replied “So? It’s only 12:20 now!” First of all, it was by then 12:30, and even if it was 12:20, she was still going to end up at least 20 minutes late. I finally said that she can reschedule or not come at all. To which she replied, “Well then I don’t want you for my doctor. You’re mean.”

I nearly laughed. Instead I said, “That’s fine,” and I hung up. She later called and left a message about how unhappy she is that we would “dare” to ask her to reschedule, and that she doesn’t want me as her doctor. Part of me wanted to say, “No, no, no. I don’t want you as a patient.”

Another patient, one I had yet to see, had called the office numerous times, asking my receptionist things such as, what is my feeling about alternative medicine, will I do a thyroid cyst aspiration on her first visit, can I order this test and that test before she comes.

One day she called and asked to speak to me, and I spent a good 15 minutes trying to tell her that I cannot make any clinical decisions on someone I haven’t seen. So no, I will not plan on an aspiration, no I will not order tests. I don’t care if your other doctor thinks you should have it; if that’s the case, he should order it. Then I finally have the, uh, pleasure of seeing her, and make it through without killing her or me with the sphygmo tubing.

The next day, according to our caller ID, she called at least 10 times. She left a message once asking to please send my notes to her primary. I did so immediately. Then two days later, she called again, and asked to speak to me, to ask me to send my notes to her primary. I said, “I did, why? Didn’t she get it?” Oh, she doesn’t know because she didn’t ask her primary. But she figured she could call and ask me?

Is it too much to ask that patients respect my time?

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

On giving thanks

In the spirit of the holiday, HealthLeaders Media posted 10 Reasons Health Providers Give Thanks.

Here are a few:
- Physicians would be glad that a “significant chunk of their investment portfolio had returned and that inpatient volume has started to go back up."
- Providers would “toast in appreciation that the dreaded predictions of a much more serious season of catastrophic influenza – seasonal or H1N1 – has yet to impact their facilities.
- They would also praise the federal funding for states to implement and test tort reform pilot studies and the funding to support the adoption of health IT.

As we all watch and await health reform in Washington – and while you continue to deal with the day-to-day struggles of practicing medicine – perhaps it’s nice to take a minute to reflect. Check out this story we did a few years ago about building a sense of community and a culture of support in your practice.

And I welcome your reflections on what you are thankful for.

Gerald O'Malley, DO: Speed Racer and my small nervous breakdown

Last year I survived my first trial. It was awful. I walked into the whole ordeal like a lamb to the slaughter. I actually thought that my deposition was going to be a pleasant few hours with the doctor and lawyers talking like professionals about the case and then maybe sitting down to a nice lunch together afterwards. I’m actually embarrassed about my naiveté.

The trial was a joke. Basically it was fixed and we lost the case before it even started. I was devastated and disillusioned and depressed. I was ready to give up medicine and do something (anything) else.

Around about the time that the trial was getting started, a movie called Speed Racer opened. I remembered watching the TV show as a kid and I took my 7-year-old son to see the film. The movie was a flop and received terrible reviews, but my son and I enjoyed it. He wanted all the toys and cars and T-shirts, and I bought them for him. My wife bought the soundtrack and we listened to it all summer driving back and forth to the beach and the community pool.
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During the worst summer I can remember, while I swallowed my frustration and thought about what I needed to do to find peace with myself, Speed Racer was everywhere. The commercials, the toys, the posters, and the beautiful, haunting soundtrack all served as a background for a terribly emotional time. I lost sleep and lost weight and shut out my family and friends and tried to find meaning in what happened. I was filled with rage and disappointment and disillusion with medicine. How could something that I loved so much be so corrupted?

The summer became the fall and I gnashed my teeth all night and sleepwalked through the days. My son’s interest in Speed Racer continued. We bought the DVD the day it was released and watched it that night and several more times.

One Friday night, my son asked to watch the movie again, so I made popcorn and we sat and put the movie on. I was half-watching the movie and half-sorting bills when I realized something that I had never noticed during any of my previous viewings of the movie.

During a pivotal scene, the main character (Speed Racer) confronts another character (Racer X), furious at the betrayal of a third character and lashes out at the corruption and unfair corporate nature of the sport. Racer X takes off his mask, revealing his face to Speed and says something like, “It doesn’t matter if racing never changes. What matters is if we let racing change us. You don’t strap yourself into a T-180 to be a racecar driver — you do it because you are driven to do it.”

I began to see the similarities between my own situation and that of Speed and I realized that Racer X was right. Medicine will never change — what matters is if we let it change who we are. We don’t walk into the ER just to be an ER doctor. We are driven to do it.

Maybe enough time had passed and maybe it was a coincidence, but at that moment, sitting on the couch in the dark with my son and a half-eaten bowl of popcorn, for the first time in months, I felt like I was ready to go back to work. I wanted to go back to work.

I apologized to my wife and family and colleagues for my distant and alien behavior, shook off the cobwebs and ennui and gratefully got back to work.

The fall became winter and on Christmas morning, watching my son running around in his Speed Racer slippers, I decided to share my experience with the makers of the film, two brothers named Larry and David Wachowski. I have never written to an actor or a movie director before and I had to ask a medical student for help in finding out their contact information. But I wrote to them, explained my experience with the lawsuit and thanked them for making a thoughtful and fun movie that helped me get through a very dark time in my adult life.

Imagine my surprise several weeks later when I received a call from the Wachowski brothers’ publicist. Apparently the directors were touched by my letter. They sent a huge package of toys and other Speed Racer merchandise for my son and some autographed items which I thought was entirely unnecessary but very, very nice.

I still occasionally have bad days. I filed an ethics complaint with ACEP against the expert witness in the case from last summer, and I won another lawsuit this spring (unanimous jury verdict for the defense — unheard of in this city).

I still struggle with my feelings of anger and frustration, and I’ll detail some of the consequences of the ethics compliant in another post. Who knows why we do the things we do and why we can be affected by things like children's movies? I just know that it feels really great to sit with my son and watch a hero triumph over the bad guys with tenacity and courage. It makes me want to go back to work.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

Jennifer Frank, MD: Making friends, Part 1

Since moving three years ago, I have struggled to make good friends. Sure, my husband and I know people, attend parties, and discuss the best place to host a child’s birthday party with other parents in the bleachers during Saturday morning basketball at the Y.

However, what I’m lacking are my own friends. Girlfriends that I call on a Saturday morning to grab a cup of coffee and go window shopping. Kindred spirits that gossip with me about husbands, bosses, and family strife. I know lots of women, but few are friend material.
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I have a lot in common with my professional colleagues — they understand the struggles and joys of being a physician, often wrestle like I do with parenthood, marriage, and a job, and share my interests in science, medicine, and humanity. However, they are also busy like I am. When we do get together outside of a professional role, conversation may be stilted or lead too easily to discussing patients and workplace aggravations.

Another group is moms of my children’s friends and classmates. Because my husband is a stay-at-home dad, he knows these women much better than I do. It is he — not me — who is invited along on their “girls’ night out.” I really like many of these women but it is hard to plan times to get together because our schedules are reversed — daytimes are freer for them and evenings and weekends are better for me. It is also challenging to navigate a relationship with a woman who has more in common with my husband than with me.

I work with a lot of women in my family medicine clinic — receptionists, nurses, administrative staff, and resident physicians. However, in my role as medical director and faculty physician, I find it hard to be friends with women I supervise. My very few forays into this area have inevitably led to sticky situations in which I am laughing with a friend at the gym before work in the morning and then having to give my friend difficult feedback later during the work day.

Old friends are great. I still keep in touch with women I have known in grade school, high school, college, medical school, and residency. They are scattered across the country from Boston to Alaska, Michigan to Texas. We have a history and fabulous memories to share. That makes it fun to get together when I happen to be in town for a convention or when I send them a message on Facebook. But, it is not enough to hold a close friendship together, the kind of friendship that lends itself to spur-of-the-moment phone calls and drop-in visits.

I meet women through other venues, such as teaching Sunday school. We are friendly but not friends. They have kids of different ages and have different interests and different schedules.

I am blessed to have a best friend, someone who knows the intimate day-to-day details of my life. We have much in common — she is a family physician, has four kids and a stay-at-home husband. The times we get together in person are wonderful and she is the type of friend I can call anytime day or night. But, she lives far away and I still long for friends close by. So, my quest continues to find, establish, and nurture friendships with professional moms like me.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Melissa Young, MD: My EMR - I'm getting excited again

I won’t kid you. Using an EMR — even one chosen after hours of research, demos, and site visits — isn’t easy. I still get periodic connection problems and these funky little messages telling me I’ve had an “access violation.” There are still patients who come in with stories or complaints that just don’t fit any pre-made templates (even those made by me), whose history I have to type in manually.

But a few things have happened in the last few weeks that have me all excited over it again.
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First of all, patients are starting to come in for follow-up visits. And with one click (OK, a couple of clicks), I can copy their last visit, and instantly have their HPI, ROS, and exam on the screen. Sure, I have to add new complaints and delete findings that are no longer present, but since my patients tend to complain of the same things every visit, and unless there’s a new issue, their exams are generally the same, I can document the visit with a couple of clicks.

Second, I got a new paper tray for my printer, so now I can print prescriptions instead of writing them out. The patient’s name, address, and date of birth are printed on every one. And if it’s a refill, just click on amount and number of refills and, voila! a perfectly legible prescription — which, by the way, eliminates the calls from the pharmacies because (surprise!) they can’t read my handwriting.

Third, the second point may soon become a moot point, because now I can e-prescribe. With the same number of clicks on the screen, I can electronically send patients’ prescriptions directly to their pharmacies. It (so far) seems more reliable than faxing. And it saves me the expense of both prescription paper and toner. And maybe, just maybe, I’ll get a little stimulus money in the deal.

Yes, I had a connection problem bright and early this morning. But it resolved itself after a minute or two, and by the end of the visit I had e-prescribed two prescriptions, printed a lab slip, and created a consult letter that was faxed to the referring provider. Yeah, I’m all atwitter with excitement.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

MGMA's concerns about EHR stimulus program

The MGMA today raised some concerns about how the EHR incentive program is implemented, and sent a letter of recommendations to Dr. David Blumenthal, National Health IT Coordinator.

MGMA President and CEO William Jessee wrote, “We believe that an inappropriate definition of meaningful use and inefficient administration of the program will lead to failed implementation of the American Recovery and Reinvestment Act of 2009 (ARRA) and result in the needless squandering of resources and significant disruption to the nation’s healthcare system.” Meaningful use, he said, should be verifiable without creating undue burdens on practices.
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MGMA listed a series of recommendations, including calling for a pilot test of the program and before each new phase of the program. Other recommendations include:
- only include criteria for meaningful use that have widespread industry use or have been tested
- have a process for physicians to test their reporting systems before going live
- avoid a pass/fail approach for achieving meaningful use
- monitor the vendor the industry to ensure it can produce high-quality, reasonably priced software

MGMA also called for more physician outreach, suggesting HHS develop a Web site with a FAQ section, toll-free numbers to provide information, Webinars for updates, and direct outreach to trade organizations.

What do you think about how HHS is handling the EHR incentive program guidance so far? For a complete primer on the EHR stimulus program, check out this article.

A little more liability premium relief

The pain of high medical liability insurance premiums continued to ease a bit for most physicians — but perhaps not for long. An annual survey found that 94 percent of premiums are holding steady of dropping this year, according to American Medical News.

But despite the dips, they are still inflated after the rate hikes in the early 2000, insurers say. And this relief could be short-lived.
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According to the Medical Liability Monitor survey, 58 percent of premiums had no change (up from 50 percent last year), 36 percent of premiums fell (down from 43 percent). Two years ago, a full 16 percent of premiums went up, so increases have slowed.

At the same time, jury awards are climbing steadily, so it won’t be long before rates rise again, insurers say.

The news of this survey comes just as I am researching for an upcoming story on how to keep malpractice lawyers at bay. Several pieces of advice I’ve been told so far revolve around treating the patient with respect and setting a tone in the office that makes the patient feel valued and comfortable. Little things mean a lot, consultant Judy Capko said. Even eye contact and friendly body language can go a long way.

Here’s a recent column with 10 ways to keep lawyers at bay, and look for more in the March issue.

Physician payment formula update

The House approved legislation this week preventing the 21 percent Medicare payment cut, and fixing the overall payment formula.
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The bill revamps the formula for basing payments on the sustainable growth rate, which has resulted in potential cuts to physicians for the last seven years. Each year, the Congress has stepped into stop the cuts, but have yet to fix the system.

This step is expected to cost about $210 billion over ten years. That fact, but that the Senate rejected a similar law, makes it unclear if this measure will actually become law.

The new target for payments would be the gross domestic product plus 1 percent. Preventive care and E&M services would be GDP plus 2 percent, according to American Medical News story.

Now the Senate can either take up the House bill or reconsider its own bill which foundered last month after some noted the bill would raise the federal deficit. WSJ blog notes that when the Senate bill failed, Sen. Reid said the Senate would go to a one-year fix instead.

Does your practice have a Web site? Why not?

If I can book a dinner reservation online, why not a doctor’s appointment? I am of the generation that thinks – in general - if it’s not online, it doesn’t really exist, or at least it’s not worth looking into. If I’m looking for a store or restaurant, an article or stat, really anything and everything, I first start with Google.

So why should my doctors be any different?
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Physicians’ offices seem decades behind the times when it comes to an online presence. Topping the results list when I Google my doctor are sites like healthgrades, ucomparehealthcare, and vitals, which rank doctors. No Web site with health information, and of course, no blog or Twitter feed.

Does your practice have a Web site? Now, is it more than just a splash page with your address and phone number, and maybe a picture of the building or Google map? In November’s journal, we have a story about how to trick out your Web site, and it offers some really helpful – and easy – ways to make your practice’s site more engaging. I guess the first step would be to build a site, which these days, is easier than you might imagine.

In our latest annual Technology Survey, we found that 66 percent of you have Web sites, but only 23 percent were interactive, meaning patients could request appointments online.

Even that many practices claiming Web sites surprises me, because anecdotally, I rarely hear of a practice with a sophisticated Web site. But I can’t understand why. Yes, physicians are busy seeing patients and wading through paperwork, but I think an Internet presence is crucial. It’s a worthy way to connect with patients, market your practice, and offer accurate health information.

Just think of the possibilities. Your patient Googles you (or even a phrase such as “primary care doctor, St. Louis”) and up pops your site at the top of the list. There you have information on the seasonal flu and healthy living, and even a way to correspond or request an appointment. What’s the hesitation? Why are medical practices shying away from the Internet?

On the new breast cancer screening recs

Here we go again. I think the NY Times Prescriptions blog put it best: “Call it death panel redux.”

On the heels of the breast cancer recommendations this week, congressional Republicans are saying it’s healthcare rationing. “This is what happens when bureaucrats make your healthcare decisions,” Rep. Dave Camp of Michigan said, according to the Times.

Never mind that the recommendations — to begin routine screenings at 50 rather than 40 and to stop monthly self-exams — are unenforceable and nonbinding for doctors or insurers.
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Never mind that it was not the government making the recommendations, but an independent task force of experts. Never mind the recommendations had nothing to do with the healthcare reform bills in Congress.

Camp and others are saying it’s foreshadowing the role government would play in regulating insurance coverage under the House healthcare bill. He said: “Agencies will be created that will make decisions like this, that some lifesaving screening is not worth it.”

Am I the only one who thinks this sounds like another truth-bender meant to freak people out? From what I have read, many women are already confused and concerned about the recommendation. (Particularly I am hearing from some women at high-risk that they worry they will be denied screening.)

I tend to agree with KevinMD’s blog post on the topic. He writes that the guidelines are a good move, and acknowledge the downside of cancer screening. “In other words, evidence has been introduced into the guidelines, resulting in the recommendation for less testing.”

But because the evidence says less rather than more, some say it’s denying or rationing care. Kevin continues, “The thought that ‘more medicine is better testing’ is so pervasive in the mindset of the American public that it’s going to be extremely difficult to scale back testing in this country. Even if it’s the right thing to do.”

Indeed, many docs are saying they won’t follow the guidelines, in part because their patients wouldn’t understand the risk-benefit analysis on which the recommendations are based. So any efforts for evidence-based medicine will certainly take serious education and outreach for doctors and patients alike.

I would be interested to hear from you on how you plan to approach the guidelines in practice and with your patients.

Gerald O'Malley, DO: Embracing Ambiguity

Today my senior resident, I’ll call him Ricky, wanted to order an ultrasound to rule out testicular torsion. Ricky is a pretty sharp guy and he prefaced his request by saying, “I really don’t think he has a torsion, I think he probably has epididymitis, but I want to make sure he doesn’t have a torsion.”

We talked about the fact that the patient was 27-years-old, sexually promiscuous, and had been seen eight days ago for the exact same complaint (testicular pain) during which he had undergone a scrotal ultrasound. My colleagues that had seen him last week were concerned about testicular torsion, had ordered the ultrasound, ruled out testicular torsion and then sent the patient home with Percocet.

I asked my senior resident, “What does his physical exam show?” Ricky replied that his testicle wasn’t swollen and appeared normal, but was tender to palpation, particularly around the epididymis.

“Come again?” I asked.

My resident sheepishly answered, “His epididymis is tender, the rest of his testicle isn’t, and it really looks like a straight forward case of epididymitis.”

“But you want to get the ultrasound anyway.”

“Well, yeah – how else am I supposed to be sure that it’s not a torsion?”

Variations of this conversation happen every day in my ED (my ED is not so unique that this doesn’t happen everywhere).
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Perfectly neurologically intact kids that fall down get CT scans “just in case” there’s a head bleed; 18-year-old soccer players are admitted to chest pain units “just in case” their two weeks of chest pain might represent an acute cardiac syndrome; otherwise healthy renal colic patients have numerous CT scans “just in case” there is an obstructing stone.

Emergency medicine residents and recently graduated attending physicians have an absolute intolerance of ambiguity.

One time I accepted sign-out from one of my younger colleagues and as we made our way to the twelfth bed of the 18-bed unit (I still like to do bedside sign-out; it tears the residents away from the computer which drives them crazy), I realized that I was being tasked with following up on my fifth chest CT to rule out pulmonary embolus. I asked the assembled group of residents, “What are the odds that five out of the 18 patients in this room all have PEs at the same time? The odds are astronomical!”

My junior colleague pulled me aside and told me that she didn’t appreciate my being critical of her clinical judgment. I replied, “Show me some clinical judgment and I’ll decide if it needs criticism. So far, all I see is a lot of wasteful, time-consuming testing all in the hope of ruling out the worst possible diagnosis. Where is the clinical judgment?”

We are training a generation of residents to not use clinical judgment. We instruct and direct them to not use clinical judgment. We introduce algorithmically driven protocols that exclude the need for disciplined reason and thought. We teach residents to order every test and do everything necessary to exclude a life threat, no matter how irrational, rather than to direct patient management based on what is most likely.

The biggest area at issue in my ED surrounds the use of ultrasound in first trimester vaginal bleeding. At the conclusion of three years of residency (in 1995, thank you), I could count on the fingers of one hand the number of ultrasounds we obtained on first trimester bleeders – and we weren’t stepping over the bodies of young previously ectopically pregnant patients on our way out to the vending machines. Now, pregnant patients with vaginal bleeding routinely get ED ultrasounds “just in case” there is an ectopic pregnancy. The argument always seems to devolve into the “dinosaurs” like myself that trained in the era when the decision to chase the diagnosis was predicated on the ED physician’s suspicion that a ruptured ectopic pregnancy was the most likely scenario versus the “new generation” of ED attendings, all well versed in how to make an ultrasound machine sit up and roll over and that stick a probe on anything that’s not nailed down.

Any criticism of ultrasound application labels me a Luddite. I’ve got nothing against the technology – I think it’s kind of cool, although to me, most ultrasound images look like two polar bears humping in a snowstorm. It’s the overuse and misapplication of the technology that drives me nuts, not just because it wastes time and interferes with patient throughput, but more importantly, because it lets the physician off the hook for having to make the hard decision and it makes us invisible and erodes patient confidence in our competence.

When a patient insists on a CT scan or an ultrasound at the conclusion of my bedside evaluation, I take it personally.

Patient: “I came here to get a CT scan.”

Me: “No, you came here to get an opinion. My opinion is that you don’t need a CT scan.”

Patient: “Well, I’d feel better if you ordered one.”

Me: “Where’s the Maalox?”

When I tell the residents that the presence of an ectopic pregnancy is not a medical emergency, they look at me like I have gills and scales. “For crying out loud, OB/GYN sends them home with methotrexate!” Still disbelief. Ectopic pregnancy is not a medical emergency but ruptured ectopic pregnancy is darn sure a medical emergency and one diagnosis that you can’t afford to miss. Of the half dozen or so ruptured ectopic pregnancies that I have personally examined in my career, none of them were subtle.

“Do you think it’s OK to miss an ectopic pregnancy?” they ask. Of course it is. We do it every day. Even patients that have indeterminate early gestational ultrasounds in the ED go home with “early IUP versus possible ectopic pregnancy” as the diagnosis and “clinical correlation required.” Fat chance of that. The possibility of missing an ectopic pregnancy or a hot appendix or an early pneumonia always exists – that’s what discharge instructions are for.

I practice in Philadelphia – ground zero in the med-mal maelstrom. The medicolegal climate in this city is permanently at DEFCON 1 (expectation of actual imminent attack) but I don’t sweat appendicitis or ectopic pregnancy. I accept the fact that those diseases may be present, but are unlikely in a particular patient and explain to my patient and document the absolute need to return if signs or symptoms change or get worse. I think the vogue term these days is “risk stratification.” I call it “using your clinical judgment and common sense.” My Irish mom calls it “using the brains that God gave you.”

Despite Ricky’s objections, we never ordered the testicular ultrasound. We took a urethral culture, gave him ceftriaxone and azithromycin, advised him to have his sexual partners (all of them) treated, and discharged him. As we watched him walk bow-legged out of the ED, I said to my resident, “I wonder if he had torsion of his appendix testis?”

Ricky turned slowly towards me with his mouth open. “I thought you said he had epididymitis.”

“No, I said that he probably has epididymitis. He sure as heck doesn’t have a testicular torsion. Maybe he has a varicocele. Maybe he’s passing kidney stone. Who knows? Dude, relax. Embrace the ambiguous.”

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

Jennifer Frank, MD: How much to share with patients?

In a recent clinic session, I was faced with a familiar dilemma about how much of my own experiences as a wife, mother, and human being to share with my patients.

My first patient of the afternoon was a 2-week-old little girl. Things were going great at home, but her parents had some questions about H1N1 vaccination. Since the little girl’s mom was a patient at our clinic, we vaccinated her to protect her daughter. However, the little girl’s dad was not our patient, so I explained that he would need to contact his own doctor to receive an H1N1 vaccination. My little patient’s father looked at me with an expression like “hey, c’mon.”
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I told him that my own husband (the primary caregiver for our 4-month-old son) had not been vaccinated either since his family physician did not have a supply of H1N1 vaccine yet. I don’t know if my patient’s father felt any better about leaving the clinic unimmunized, but hopefully he respected that I was following the rules for my own family.

A second patient also had an H1N1 concern. She has a 3-month-old daughter at home and was coming in to start contraception. The medical assistant offered her H1N1 vaccination but my patient refused, citing the recent appearance of an H1N1 expert on Good Morning America who stated that he would not get the vaccine himself or give it to his kids.

While I was performing her exam, I gently re-introduced the idea of H1N1 vaccination. “I haven’t heard about any experts opposing the vaccine,” I started, “but I can give it my strongest endorsement by telling you that I received my vaccine and will get my kids vaccinated as soon as it is available to them.” We went on to discuss live versus inactivated vaccine, and she elected to receive the same vaccine I received, as she knew that I was also a mom who is breastfeeding a young baby.

My final patient of the afternoon struggles with multiple medical problems. He and his wife are considering starting a family. After congratulating me on the recent addition to my family, he asked, “Can I ask you a personal question?”

“Sure”, I replied.

“How old are you?”

“Thirty-six,” I responded. He was reassured that I was close to his age and still able to get pregnant. He went on to ask me how I was able to lose my baby weight. I shared my secret answer: “Genetics,” I said. “Both my parents are pretty thin and I was lucky to inherit the right genes.”

I struggle at times with how much of my personal information to share with patients. While I often look for scientifically rigorous answers, I recognize that personal stories or experiences often carry more weight with my patients. I also assume – rightly or wrongly – that I have added credibility when I am able to give both the “doctor” answer and the “mom” answer.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Melissa Young, MD: Paperless office? Ha!

A paperless office? Wait, I can’t stop laughing.

So I am now about six weeks into my new practice. I had visions of being paperless when I started. I realize now that being paperless is as elusive to a physician’s office as being neat is to my house with two small children. You try to keep things neat and tidy, but the kids keep pulling more toys out of the toy box, and their well-meaning grandparents keep bringing them new things to strew upon your floor.
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Patients bring in stacks of lab results, old records, and lists of questions. Drug reps bring in their detail pieces. And the mailman drops off a new stack of junk mail, journals, and EOBs.

Yes, much of it gets scanned. And one day, my secretary and I will be comfortable and confident enough with our EMR that we can shred things as soon as they are scanned.

But for now, we scan, we save, and after the file folder gets full, we survey and we shred. Because I had planned on being paperless, there really isn’t room for paper to be stored. I have one four-drawer filing cabinet and three more file drawers spread around the receptionist’s area. I keep personnel files, instruction manuals (and there are many – one for every component of the computer network, not to mention the phone, the copier, and some of the medical equipment – ok I can probably throw out the one for the sphygmomanometer), and paid bills, but I suppose I could scan much of that too.

There is something to be said for having a tangible piece of paper in one’s hand, and filing it in a folder you can see and touch. And having lived a lifetime reading ink on paper, it is a tough transition. But being able to pull up any document from anywhere in the office, heck, from home even, will make the transition worth it. I’m pretty sure I could even find the sphygmo’s manual online if I tried.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J.

Image isn't everything

After months of contentious wrangling, the House has passed its version of healthcare reform. But to me, and many other observers, healthcare reform has largely become insurance reform. Why concentrate on slowing spending and controlling costs, those issues carry huge political risks. Insurance companies are easy targets. They have high-paid CEOs and they deny people with pre-existing conditions coverage, among other evils. Not surprisingly, polling data suggest that laying blame on insurance companies is safe ground for pols seeking to take a stand on reform.
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In all fairness, the bill contains a variety of changes that focus on quality and health system performance improvements. These include proposals that encourage the development of more primary care providers.
Can that provision get any traction?

Adding more docs isn’t as sexy as bemoaning the fact that millions don’t have healthcare coverage, or those pushed into bankruptcy because medical bills. But anyone seriously concerned about enhancing the health of Americans should pay special attention to this part of the bill. Do the math. How can we cover millions more without adding more docs?

Fact: As few as 2 percent of medical students are pursuing general internal medicine, a trend that could doom efforts at universal health care. According to an article in the New York Times, this death spiral in primary care is due largely to a poor image students have about primary care. But image isn’t everything, money matters too.

Should you discuss healthcare reform with your patients?

One physician distributed a flier in this waiting room answering common questions about healthcare reform (but with perhaps dubious sourcing); another doc posted handouts in his exam and waiting rooms outlining his support for reform legislation.

These are just two examples of how physicians are communicating with their patients about healthcare reform (and where conflicts have arisen). Surely, there have been less formal conversations between doctors and patients about the debate in Washington with mixed outcomes.

But should you be discussing reform? And how?
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It’s a topic explored on Kevin MD’s blog and a few of the comments struck me. Some said it was just fine for physicians to voice their opinions to patients, while others said doctors are seen as independent, so weighing in on the political debate could erode that trust.

Here are a couple examples:

“Physicians have the right to their opinion and to express that opinion. I don’t openly discuss my views on healthcare reform while seeing patients (and if I did, the newborns would sleep right though it), but if a parent asks me what I think about something, I tell them.”

“Doctors are the most trusted profession in America, and for good reason. They are seen as independent, and focused only on the science of getting you better. As this article illustrates so well, they put this reputation at risk when they start to bring politics into the equation.”

Considering how contentious the debate has been, it seems impossible to offer only the facts and answer a patient’s questions without divulging your opinion. Will expressing your political views affect how your patients feel about you? Should that stuff be left out of the exam room? Or is it unavoidable because it’s on everyone’s mind?

I am curious to find out how you would broach the topic if a patient asked you to weigh in.

Open-access scheduling for flu season

With patients flooding your office with calls or appointments this flu season, you may be considering reworking your appointment scheduling.

“Practices must be ready to accommodate the influx of patients,” consultant Nick Fabrizio told me in a recent podcast on preparing for the H1N1 virus. Fabrizio suggested practices consider a modified open-access scheduling plan, where they set aside 10 percent or 20 percent of the appointments each day for same-day acute patients.
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Open-access scheduling can ease some of the pains of trying to squeeze acute patients in — on top of your normal daily load. But it takes planning, and HealthLeaders Media recently laid out six steps to open access scheduling that I thought would be helpful. Here are a few:

1. Do what is right for your practice. Keep a log of the kinds of calls and appointments being requested, so you can get an idea of how many you should set aside.
2. Be flexible, but resist the urge to fill those dedicated slots with appointments that aren’t same-day.
3. Monitor your success by checking in with staff and seeing if there are any patient complaints. Problems? Just adjust it.

You should also consider calculating your appointment schedule fill rate each month, aiming for an optimal percentage of 90 to 95. For more on open-access scheduling and more tips, check out the Physicians Practice story on the topic.

An analogy for meaningful use

I've seen this photo posted on a few blogs lately, and I thought it needed to be shared. I understand the original source may be Pat Wise of HIMSS.

Gerald O'Malley, DO: What is important to teach

Tonight I worked a shift with an exceptional medical student from a fine school who had never heard of Ignaz Semmelweiz.

My student didn’t recognize his name, but more importantly, this talented and engaging medical student had never heard the tragic story of the great physician who deduced the etiology of puerperal fever (physicians performing autopsies and then delivering babies without washing their hands), who was ridiculed when he proposed that physicians were the fomites responsible for peripartum infection and death, who lost his mind, most likely due to tertiary syphilis (an occupational hazard of 19th century gynecologists), and who died in a mental institution after a savage beating at the hands of other inmates.
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Similarly, this particular student had never heard of Werner Forssman, the German physician who won the Nobel Prize in medicine by demonstrating the feasibility of introducing a catheter into the right atrium of the heart via a peripheral vein — an experiment he performed initially on himself.

Why is the history of medicine not taught in medical schools? How can modern day medical students appreciate their place in the continuum of medicine and their place in history and their responsibilities to past and future generations of physicians unless they learn the great and noble and honorable and not-so-honorable accomplishments of the men and women that have made their marks on our world’s history?

What about the history of medicine through fiction? Sir Arthur Conan Doyle was a physician (many people believe that Dr. Watson was his literary alter-ego). In addition to the adventures of Sherlock Holmes, Conan Doyle wrote numerous short stories about being a physician in 19th century London. Reading Conan Doyle’s “Round the Red Lamp,” one realizes the shared experience of despair at the bedside of a dying patient. Helpless to do anything to stop the inevitable, the great and awful responsibility we have as physicians reaches down through the ages from gaslight to halogen bulbs.

Last year I gave as a graduation present to each of the residents in my department a copy of William Carlos Williams’ “The Doctor Stories” in the hopes that they might see something of themselves in these beautiful stories of doctors and patients from the mid 20th century.

The student that I worked with tonight was born in 1982, which was my sophomore year in college. She grew up in a world that has never not known AIDS. I instruct my residents to consider what it must have been like to practice medicine in the age of polio and rampant tuberculosis and yellow fever, and how the physicians of that age were intimately familiar with those diseases.

Then I ask them to consider the future, when HIV has been conquered and the physician of the next century is dealing with whatever new pathogenic horror has developed. The physician of the future might ponder what it must have been like to practice in the age of AIDS, and I remind them of the awesome responsibility that they have each agreed to.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

Update: AMA keeps support of House bill

The AMA voted yesterday “reaffirming the AMA’s commitment to health system reform,” meaning they decided to retain their support for the House bills.

“H.R. 3962 is not the perfect bill, and we will continue to advocate for changes that help make the system better for patients and physicians as the legislative process continues,” AMA President J. James Rohack, MD, said in a statement.

This vote comes after a group of disgruntled physicians challenged AMA’s endorsement of the House bill, which lacked several key provisions for physicians.The AMA also reiterated several items the organization plans to keep lobbying for, such as Medicare physician payment reform.

Jennifer Frank, MD: What to do about Tamiflu?

We have a young baby at home and as H1N1 started popping up in clinic and in the school system, I cautioned my older children strongly about being extra careful with hand washing before touching their baby brother.

When my husband started complaining of a headache and cough, I insisted he check his temperature. The ear thermometer read 101. “Does this thing really work?” he asked me. I felt pretty confident that he had a fever, having already done the more specific “mom test” of a hand against his forehead. “Yes,” I replied. “You’re sick.”
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My family members almost always develop illnesses and sustain injuries in the evening hours. This was no exception, and I started working my way through the phone triaging system of our family doctor, trying to get a prescription for Tamiflu for our young baby, as I was concerned that my husband was in the early throes of H1N1 influenza.

While waiting for first the nurse and then the doctor to call me back, I checked my young son’s temperature, encouraged my husband to take Tylenol, segregated my other kids in the playroom, and read up on the latest from the CDC. I debated just calling in the Tamiflu myself. However, the more I thought about it and read the emergency use authorization in children younger than 1 year, I started feeling less confident. Maybe my husband had something else going on. Should I expose my son to a potentially harmful medication if I wasn’t sure that he was exposed to H1N1? How many times would I be putting him on Tamiflu this fall and winter if we considered every febrile illness in our family (of which there are usually many) H1N1?

After several frustrating minutes spent discussing feedings and wet diapers with the triage nurse, I pulled out my doctor card. “Listen, I’m a family physician and I’m pretty sure my son has been exposed to H1N1. I think he needs Tamiflu.”

“Oh,” she replied, “I’ll page the doctor on call right away.”

The on-call doctor was busy juggling an evening clinic with my phone call and admitted that she wanted to look up the latest CDC recommendations and speak with a pediatric hospitalist before prescribing the Tamiflu for my son. I watched the clock, trying to judge how long I could wait until our local pharmacy closed for the evening. The on-call doctor called me back about 45 minutes later. “I’m sorry, when we talked before, I didn’t realize you were a physician. You probably know what I am going to tell you, but this is what I found out.”

She went on to describe the pros and cons of chemoprophylaxis in our particular situation and some of the different ways we could approach the situation. She also acknowledged her own struggle with the Tamiflu issue in her home after one of her children became ill. It was a good conversation and put me at ease as I realized that there was no clear-cut answer, but rather a variety of choices we could make to try to keep my son healthy.

I picked up the Tamiflu that night but held off on giving it to him until my husband’s illness declared itself and our oldest son developed a clear case of influenza. I was glad that I had not made a medical decision on my own but also pleased that I had an opportunity to problem solve with a colleague who respected my role as both a doctor and a mom.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Push to overturn AMA endorsement of House bill?

For those not convinced that the AMA represents physicians’ priorities, there’s this: the AMA may be considering whether to rescind its support for the House healthcare reform bill in the face of pressure from some angry physicians.

The House bill did not have several elements some physicians say are critical: malpractice reform and a fix for Medicare reimbursements, for starters. Now some want the AMA to rescind its support, according to the WSJ.
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“Don’t give a blanket statement to a specific bill that contains provisions that violate AMA policy and interfere with the patient physician relationship,” Donald J. Palmisano, a former AMA president, tells the WSJ.

To be fair, the AMA’s support wasn’t entirely enthusiastic, and the organization said it recognizes “that more improvements are needed before a final bill emerges from a joint House-Senate conference committee.”

But, 10 of the 180 medical societies in the AMA’s voting body submitted a resolution Friday to rescind support. The 544 delegates are expected to vote today or tomorrow.

However, Fox News is reporting that according to one source’s e-mail, the disgruntled members have given up their fight to have the endorsement withdrawn.

Yes, AMA's endorsement was much-touted by Democrats pushing for the bill's passage. But, it passed, so what if the AMA does withdraw support? Perhaps it will affect lobbying efforts to improve the legislation as it goes to conference?

Melissa Young, MD: Getting my name out there

There aren’t many endocrinologists in our area. Well, there aren’t many endocrinologists, period.

There are only about 5,000 board-certified endocrinologists in the U.S., and so even if they all saw patients (as opposed to being in academia, research, or administration) that would only mean an average of 100 per state. Which is probably why, in my experience, in any given hospital, there is only one group of endos who goes there.
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My former practice of three pretty much had a monopoly on inpatient consults at the hospital we worked at. OK, technically there was another endo who had privileges, but she was limited to only seeing her own patients should they be admitted, i.e. she could not see new patients. Don’t ask me how that happened. That was in place before I got there.

The hospital I now have privileges at had one pair of endocrinologists for the longest time. I was told that there was a need for another because the two who were there were so busy. However, I had been “warned” that there was no way I would be able to get in, that they would see to it that I would not get privileges. But as fate would have it, here I am, the first crasher of this private party. And I was told that I was eagerly awaited.

I got a call to see a patient the week before I was officially approved. I apologized and explained that I did not have privileges yet. And I thought to myself, “Yes, consult requests will be flying in.” How could it be easier?

But then the first two weeks went by, no consult. And that was after I gave grand rounds, sent out letters, and hung out in the physicians’ lounge. Then I got one, from a doc who just happened to be a former resident. Another week, one more — from the same doc. I realized that no matter how eager they sounded about my arrival, there’s something to be said for being the guys that everyone know, something to be said for the comfort of using what (or who) you already know.

I did get four consults this week. Maybe, this will be the beginning. In the meantime, I’ll visit the lounge, I’ll attend grand rounds, I’ll smile, and I’ll schmooze (ugh, I hate doing that), and I’ll try to get my name out there.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J.

Podcast: CMS 2010 update

Looking for more information about CMS' final physician fee schedule for 2010?

For this month's podcast, I spoke with consultant Betsy Nicoletti about changes to consultation codes, e-prescribing, and the overall 21 percent cut -- and what it all means for your practice.

Congress to insurers: We're watching you

Regardless of whatever health reform makes its way out of Washington, it looks like Congress has its eyes on the insurance industry. Perhaps it was Cigna’s 93 percent profit jump in the third quarter?

House Speaker Nancy Pelosi called Cigna’s $329 million profit “stunning,” according to HealthLeaders Media. Similarly, Sen. Thomas Harkin on Wednesday brought up the insurance industry’s price increases to small businesses, citing a survey that showed average policies will increase 11 percent to 16 percent (and as much as 30 percent) annually in most states.
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Harkin announced an investigation into the pricing practices of insurance companies that sell to small businesses. He also sent letters to the heads of Humana, UnitedHealth Group, WellPoint, and Aetna asking for information about how they determined insurance rates for small businesses and the percentage of premiums spent on medical care.

The House bill does try to address insurer profits with an amendment to overturn a long-standing act that has antitrust exemptions for the industry, as well as provisions to limit high charges. Insurance companies would also be barred from denying coverage for pre-existing conditions. Voting on the House bill (which the AMA, AARP, and MGMA have all thrown their support behind) is set to begin Saturday.

Yelling and cursing: just another day at the office?

Talk about a hostile workplace environment. Nearly all of the nurses and doctors surveyed recently reported yelling, cursing, inappropriate joking, and refusing to work with one another, according to a Modern Physician story.

The American College of Physician Executives’ survey found that 97 percent of respondents experienced this “treachery and backstabbing” between doctors and nurses.
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Some even reported throwing objects, sexual harassment, and spreading malicious rumors. (Actual physical assaults were reported only 2.8 percent of the time – as if that softens the blow of the other bad behavior.)

This is also interesting: When asked who is behaving badly, about half of the respondents said it was an even mix; 45 percent said it was doctors, and less than 7 percent said nurses.

Insults and degrading comments topped the list of incidents (85 percent reporting that happened in their organization). Yelling followed with 73 percent.

Sure enough, we’ve covered staff conflict before, and in a recent article, we offer a few tips for building a conflict-free workplace. Among them are: discourage blame-casting, set a policy for voicing concerns and resolving problems, and define your office culture with regular staff activities.

And, this: “Remember, physicians set the tone of an office for the staff and, ultimately, patients.”

What do you think? Care to share your stories of conflict and/or resolution?

Maybe it's not so good to be the king

I love Mel Brooks but maybe it's time to rethink his famous line from the movie "History of the World Part I." Maybe it's not that great to be the king -- at least not for physicians who are the kings and queens of their practices.

This month's cover story reveals the results of our annual Physician Compensation Survey. Looking at the numbers, an interesting subplot that emerges is the question of whether it is worth it anymore to shoot for practice partnership or ownership.

There's no question that owners make more money than employed physicians, on average, and there are obvious psyhcological advantages to being the boss, if you're the take-charge type (as many physicians tend to be). Yet the financial benefits, it seems, are narrowing. And the headaches are worsening.

Of course, we've known that for some time. But our data this year offers some new insight into life as an owner, versus that as an employee.



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Consider that owners were more than twice as likely last year to see income declines as employed physicians: 43 percent of owners said their income was down over the last year, compared with 20 percent of employed docs. And here's another startler: More than one in five of owners/partners (of all types of private practices) said they made less than $100,000 last year, a percentage only slightly below that of employed docs. It's hard to fathom a physician accepting all the risk of ownership and the hassles of management only to bring home, say, $80,000 a year.

No wonder most practice owners described their income as "disappointing." And no wonder we keep hearing about more and more practices selling out to hospitals.

Which brings me to my questions for commenters. Owners, would you recommend partnership to younger physicians, or tell them to just "get jobs." Are you considering selling out/retiring/closing shop at some point soon? I'm very interested to know your current thinking on the idea of selling to a hospital. Does it feel like a "way out" or a sell out? How do you think you'll feel having a boss, vs. having (potentially) fewer money worries?

And employed docs, are you reconsidering your long term career plans? Do you want to be a partner or owner someday? Did you ever?

Comment below and e-mail me your thoughts at bob.keaveney@cmpmedica.com, if you have any interest in being interviewed for a possible upcoming column.

Reimbursement for prayer treatments?

Should payers treat prayer treatments the same as medical treatments? If a little-noticed (until now) healthcare provision passes, then yes.

Tucked into the Senate reform bill is a provision that would require insurers to consider covering Christian Science prayer treatments as medical expenses, the LA Times reports.
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The provision was included by Utah Republican Orrin Hatch and backed by Massachusetts Dems Kerry and Kennedy – home to the Church of Christ, Scientist. Christian Science prayer treatments would be on the same footing as clinical medicine.

Whatever happened to the separation of church and state? And doesn’t this open the door for other religious groups to demand similar reimbursements for spiritual healing. The cost impact is small, as Christian Science is a small church and treatments are as little as $20 a day, the Times notes.

Blogger and physician Val Jones wrote about this recently and had picked up on their efforts before, calling their medical approach “quackery.” Referring to the church’s hefty and loud lobbying efforts, she notes, “This tells me that determination trumps both common sense and science in the political arena. What a sad state of affairs.” She also notes that President Obama promised to re-elevate science, and clearly this measure goes against that effort.

As it turns out, the Christian Science Church has worked hard for official recognition of its prayer practitioners, and about 90 years ago, private insurance companies began paying for prayer treatments. More recently, managed-care insurers have declined reimbursements. The IRS allows the costs to be itemized medical expenses, the LA Times reports.

Surely religion, prayer, spirituality (however you would like to define it) has a place in wellbeing and health (I am not convinced enough to go as far as to say in “healing.”). But where does it stand when it comes to reimbursement and government support? It seems to me this measure is opening the floodgates for reimbursement for all kinds of spiritual healing, some of which might be pure quackery and some perhaps less so, but all not necessarily rooted in science.

Similarly, we recently did a story here about what how medicine and religion can collide, focusing on how practices can deal with the sensitive subject with patients. It’s certainly complicated, and you may have patients whose religion dictates their thoughts about treatment. As we found, it’s all about communication.

Gerald O'Malley, DO: Why I'm Not Getting the Flu Shot

I’m not getting immunized against the flu. I’m not immunizing my kids either. Sue me.

I’m not a Luddite – I know the science, and I know the statistics, and I know the professional recommendations. My kids have been fully immunized against measles, mumps, rubella, diptheria, varicella, tetanus, and all the other typical childhood diseases. I can explain some of the technical aspects of vaccine preparation. I’m still not snorting the vapor or taking the shot.
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Call it stubborn or call it stupid – I don’t care. I know that there are a lot of physicians that agree with me, but they are afraid that if they refuse the vaccine they will be labeled paranoid or a conspiracy theorist, or they simply don’t want to stand out or be seen as a problem employee or be ridiculed.

I’ve had to sign attestation statements for several of the hospitals in which I work explaining why I’m refusing the flu vaccine. My home base hospital grants me the right to decline the vaccine provided I give them an explanation. The reasoning isn’t terribly important – just so long as they have some kind explanation for the refusal. The last few explanations have implicated the worldwide vaccine-industrial complex and global warming as reasons for my refusal. They don’t seem to care too much.

Some hospitals, on the other hand, care a lot about the reasons why I don’t want to vaccinate myself or my kids. In my opinion, the administrators at some hospitals are intrusive, obnoxious, coercive, and bullying in their insistence that I accept the vaccine. I do a lot of consulting work through the Philadelphia Poison Control Center, and at least one hospital has insisted that since I am a consultant member of the medical staff, I show proof of vaccination or lose medical staff privileges and face being reported to the National Practitioner database. I’ve explained that all my patient interactions involve telephone consults and I never actually set foot in the hospital, and that despite the virulence and general scariness of H1N1, I’m pretty sure that you can’t transmit it over the phone. So far, the secretaries in the medical staff office have granted me an exemption, but I’m pretty sure that when the actual administrators get around to evaluating my telephone – transmission explanation, I’ll be on the receiving end of some e-mail nastygrams.

All this attention on vaccines seems a little forced and staged, doesn’t it? How did the human race survive and prosper for centuries without absorbing a $30 vaccine every year? Is it me, or does anyone else get the distinct impression that someone is making huge bank on this flu hysteria and the concomitant insistence on mandatory vaccinations for everyone?

OK – this year we need to take two different vaccines. What about next year? Will we be required to take three? When will this end?

My colleagues that actually work at the 100 percent mandatory vaccination hospital tell me that their ED census has exploded, the waiting times have tripled, and everyone is frazzled. Would it be worse if there wasn't mandatory vaccination? It's impossible to prove a negative, but I can't imagine that it would be. At my hospital, we don't have mandatory vaccination and the patients are spilling out into the street from the waiting room. Most of them go home. Most of them don't need to be there in the first place. I worked last Thursday and overnight Saturday night and last night and probably 90 percent of the patients I saw had the flu. I think I put two pregnant women on Tamiflu, and the rest went home with Tylenol and orders to rest and drink fluids. Nobody was admitted. The overwhelming majority of patients that I see with the flu (and they ALL have H1N1, according to our ID guy) do perfectly well with supportive care.

How did we get here? Why do doctors beat up on each other to the degree that we do when the external forces decreasing access to care (lawyers, reimbursement, bureaucracy, paperwork) are so oppressive?

I’ve heard all the arguments about how mandatory vaccination is a public health issue, but so is access to care and nobody seems to care a bit about improving that, especially not in Pennsylvania, where we have seen 17 maternity units and 40 healthcare delivery centers close in the past decade, all under the watchful eye of Governor Ed Rendell. In 1992, approximately 60 percent of graduating residents stayed in this state to practice; in 2008 only 20 percent stayed. That is the public health issue that nobody seems interested in talking about.

It’s easier to manipulate a doctor’s conscience and inherent sense of moral goodness (and if that doesn’t work, threaten and coerce) to try to achieve vaccination compliance than it is to lobby the corrupt state and federal legislature to provide the resources to actually deliver health care.

Instead of focusing on me and my declination of the vaccine, why don’t our professional leaders ignore the low-hanging publicity fruit and tackle the hard job of taking the fight to the legislators and improving access to care?

My daughter is home right now. She has H1N1 and has been home since Saturday with fevers and coughing. Forty percent of her school is out sick, and my wife just called to tell me that our son is in the nurses office with a fever, so I guess he will be laid up for the rest of the week. Then he will get better and go back to school and life will return to normal in a few days. My daughter is already over the worst of it and should be back to school tomorrow. Thankfully, my kids’ pediatrician has been in practice almost 40 years and he doesn’t see the need to vaccinate all his patients. At least I won’t need to come up with a creative explanation for him.

Welcome Our Newest Blogger

Please allow me to introduce our third physician contributor to Practice Notes, Jennifer Frank, MD, FAAFP.

Dr. Frank is a mother of four, whose husband (also a physician) is a stay-at-home dad. As a family physician in Wisconsin, Frank will be writing regularly about her experiences in practice and in life - especially trying to balance being a mother and a doctor.

If you, too, are a physician interested in blogging for Practice Notes, e-mail me at sara.michael@cmpmedica.com. We're looking for physicians able to commit to at least one blog post a week about your own experiences in practice, observations about the state of healthcare, your efforts to have a balanced life, etc.

Jennifer Frank, MD: The Kid Who Really Needed Me

I hate missing my kids’ important school events. Recently, I received an invite to chaperone my kindergartner’s first field trip. Unfortunately, it arrived about a week before the field trip was scheduled, and I already had a fully booked clinic that day.

A couple years ago, I was upset to discover that our son’s preschool Mother’s Day program was scheduled for a Thursday morning and we had been given only 10 days notice of the event. I wasn’t able to attend (another fully booked clinic) and felt like the ultimate mom failure. I imagined my little guy searching the audience and not finding me. What would he think when his mom wasn’t there for the program?
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My tearful lament led my husband (a stay-at-home dad) to discuss the situation with the preschool teachers. They promised to give parents more notice in the future (although it didn’t help me then), but were surprised that this was even an issue — they had mostly stay-at-home moms in the preschool.

Gloomily, I went to work that morning. My heart was not in patient care as I struggled with a job that sometimes asks more than I am willing to give. My last patient of the morning was a 6-year-old little boy with brittle diabetes. Undocumented immigrants from Mexico, his family could neither afford insulin nor regular medical care. The school nurse sent him to us because of daily episodes of severe hypoglycemia.

While I was speaking with his mom about his insulin regimen, his eyelids started to droop and he slumped forward in his chair. I started to evaluate and treat him for hypoglycemia. While managing this acute issue, I worked with our clinic staff to come up with a plan that would assure safe care for this little boy. After two hours of intermittently checking on my patient, calling our tertiary care children’s hospital, and speaking with our local social service agency, we formulated a plan that included an urgent evaluation with pediatric endocrinology, a free supply of insulin from a pharmaceutical company, and a ride to the children’s hospital (90 minutes away) by a local volunteer.

Decompressing from this hectic and emotionally charged clinic visit, I was reminded why I continue to do (and mostly love) a job that is so demanding. While I was disappointed to miss my son’s preschool program, on this particular day, my instincts as a physician and a mom enabled me to provide comprehensive and potentially life-saving care to someone else’s son.

When I got home from work that evening, I sat down with my son at his little table while he ate his dinner. “I’m sorry I missed your program at school today,” I began, “but I had to take care of a little boy named Marco who was really sick.”

Since that day, I share with my kids what I am doing that takes me away from the important events in their lives. I tell them about the patients in the hospital who need me to help them get better, the babies I deliver, and all the little boys who need a doctor — sometimes at inconvenient times. But, I also make sure that I know the date of the Mother’s Day program, the holiday concert, or the school play well in advance, so that I can make every effort to be in the audience watching my favorite little people.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Red Flags enforcement delayed again

The Red Flags identity theft rule enforcement has been delayed once again — for the fourth time — until June 1, 2010.

The FTC announced the delay late last week, saying members of Congress requested it. Congress is currently considering a bill, passed by the House and now with the Senate, that would exempt entities with 20 or fewer employees.

The Red Flags rule requires entities considered creditors, which includes most medical practices, to develop policies for preventing, identifying, and responding to identity theft. For much more on the rule, check out our resource page.

More on the CMS fee schedule and a payment fix

On the heels of CMS’ release of the final physician fee schedule for 2010 on Friday, AMA renewed their cries for a permanent fix to the flawed payment formula.

“Permanent repeal of the payment formula is an essential element of comprehensive reform to improve the health system for patients and physicians,” AMA’s President J. James Rohack, MD, said in a statement.

But before you decide to stop taking Medicare patients, a fix could be on its way. Read more

Congress has historically stepped in and passed legislation stopping the drastic cuts, and it looks like this year is no different. The House Ways and Means Committee introduce legislation on Thursday that would stop that 21 percent reduction in 2010 — and “replace the physician payment formula with a more stable system that ends the unrealistic cycle of threats of ever-larger fee cuts followed by short-term patches,” according to a committee statement about the bill.

The bill would replace SGR (the Sustainable Growth Index, which Medicare rates are based on), with a formula that, according to the committee:
- Removes items such as drugs and lab services not paid directly to practitioners from spending targets;
- Allows the volume of most services to grow at the rate of GDP plus 1 percentage point per year (compared to GDP without any adjustment today);
- Allows the volume of primary and preventive care services to grow at GDP plus 2% per year;
- Encourages coordinated, innovative care by allowing Accountable Care Organizations to be responsible for their own growth paths, irrespective of reductions or increases that apply elsewhere in the system.

A permanent fix has been batted around in Washington for the last couple weeks, and fizzled in the Senate, so it remains to be seen if this time it will move forward.
Still, many physicians are getting off the rollercoaster and saying no to Medicare patients.

Meanwhile, the Medicare rule also formalizes the removal of physician-administered drugs from the formula, according to AMA, and Rohack called this “a long overdue step on the road to permanent reform.” CMS says this will reduce the number of years in which physicians may see a negative update.

CMS also will stop making payment for higher-paying specialists’ consultation codes. The savings would be redistributed to increase payments for E&M services, with an eye toward increasing payments to primary-care physicians.

Among other changes, the fee schedule also includes changes to the PQRI program. For 2010, participants can earn 2 percent of total allowed charges. CMS will add 30 individual PQRI measures and add an EHR-based reporting mechanism. For more, check out their fact sheet.

There's a lot there, so I welcome your thoughts here on the changes.

Melissa Young, MD: I survived the first month

So I officially left my old practice eight weeks ago, and opened my doors four weeks ago. I have neither broken down sobbing nor screamed hysterically at my receptionist, patients, or husband. I have seen patients, paid bills, borrowed money (to pay said bills), and learned a lot of things that no book, seminar, or conference could ever teach me. There have been days that I’ve sworn under (and over) my breath, but for the most part, it has been a fulfilling month.

A word of advice to anyone who is planning to leave one practice to start another:
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While I thought I had the timing planned perfectly, you really can’t expect to transition quickly as far as payers are concerned.

In general, the insurance companies (and particularly Medicare) won’t even entertain your change of address/change of tax ID number any sooner than 30 days before your effective date. Yet, it takes longer than 30 days for them to process the changes. So I had naively thought that I could start my new practice two weeks after leaving my old one, but no. And at week four, the new practice was only credentialed with a couple of payers, even though I had participated in nearly 20 at my old practice, and I had only moved a couple of towns away. I hadn’t even moved out of the county. I didn’t worry do much about Medicare (which took the longest, by the way) because I figured I could back bill as far as 90 days.

After seeing patients for two weeks, we finally were able to submit claims, and guess what? Checks came in yesterday! As an employed physician, I never saw the money come in. I got my salary and at the end of the quarter, got my share of collections (which was regularly a source of contention). For the last four months, as a new business owner, I had only seen the money go out. And now, happy day, remittance. Now, to figure out who’s paying me how much.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.