No! No! Please -- Not the Apple! Anything but the Apple!
In this, the third installment in Doctor, Doctor, Give Me The News we turn not to another common medical malady or emergent disease process. Imma gonna try'n decode and simplify the malignant beast that is the American Medical-Industrial Complex. I see it as the largest barrier to our long term health and wellness but, at the same time recognize the success in emergent, dramatic, life saving machinations that we depend on.
The forces that have shaped our healthcare system remind me of another dynamic I've watched play out in our society.
The "right to choosers" versus the "right to lifers."
This truly is not an indictment on either side of the debate -- neither the time nor the place, but just my observations and what it has meant for public policy and politics at large, in this country. Afterall, large swaths of voters vote on this item, and this item alone.
Not hard to imagine that the good ol' polly teeshans understand this and use it to their advantage. Do you think that many of these gas bags actually care about abortion? Some. Not many, though.
As is often discussed, many of those who so adamantly oppose abortion, fall into the ranks that vote against policies and laws which protect life outside the womb. Pollution. Education. Consumer protection. Programs for impoverished children. The list goes on.
At least I understand the position of those opposed to abortion.
I understand, to a much lesser degree, current policies which so blatantly trash this place for the next generation. I understand the reasons polluters want to pollute. It saves them money.
I don't understand the voter that is okay with a climate denier and industry shill running the EPA, for example.
In much the same way that there are those in our society which decry abortion, but are all to willing to say "screw 'em" after pulled from the birth canal, so functions our healthcare system.
Modern conservatives have learned how to use abortion as an issue to drive votes. They've also used driven the narrative of the evils of universal healthcare.
What happened to the notion that we can do it better than everyone else? What is stopping us from designing a system that benefits everyone? One where the physicians still get paid, but now can see more patients and spend less time clicking and scrolling. One where access to preventative care is prioritized over the heroic, life saving measures employed at the end of the life.
Luckily, we can have the mistakes and the successes of every other advanced nation on this Earth to learn from.
I also desire a system that has more patient accountability built in. The current system encourages an antagonistic relationship, if the physician is not careful. We are penalized, again, financially and by the ratings the insurance companies give us.
Impaired access to primary care. Food deserts (not desserts.) Impaired air quality. Plastic in the all the water; all of it. This list goes on, too. Are there more barriers to wellness and health than the past? It may feel that way, but there have always been superstitions.
Anti-vaxxer movement is nothing other than a superstition, with shamans who purport to know the "truth" and see behind the "conspiracy."
There have always been those against rationale that challenges dogma. Early evidence of washing hands and the demonstrable decreased mortality were met with derision from within the medical field. I'm sure many of you are aware of Ignaz Semmelweiss, the first known proponent of hand washing/anti-septic technique who was driven mad by the insults and ignorance of his professional peers.
Our system has morphed into one that has bitten off its nose despite it's face. I see fighting against abortion at the same time as working to limit opportunity for the least fortunate among as a nose eating, rest be damn'd kinda move. I see limiting primary care access, which is efficient and affordable and relying on emergency department for basic primary care as a similar nose munching type thing.
We cannot turn patients away from the emergency department. Legally, we cannot. EMTALA was enacted in 1986. We will care for them to the best of our ability no matter the complaint. That is our job. But know this, there is momentum within the medical insurance industry where they will deny payment for "frivolous" visits. The patient will be stuck with the bill. That is a bill you'd prefer not to pay.
This has led to a boom in urgent care clinics. Overall, this is a good and healthy transition, allowing for more efficient medical care.
- Number of visits: 136.9 million
- Number of injury-related visits: 39.0 million
- Number of visits per 100 persons: 43.3 (43.3% of all of us have or will go to the ED this year)
- Number of ED visits resulting in hospital admission: 12.3 million (9%)
- Number of ED visits resulting in ICU admission: 1.5 million (2.2%)
- Percent of patients seen in fewer than 15 minutes: 35.4%
Enough about emergency care.
There is enough to worry about.
How do you navigate and best utilize your face to face time with your doctor? Have you ever thought about this?
I find that engineers make the best patients. They are intelligent, problem-solving oriented people. This means that often they've thought about their chief complaint prior to coming to see me.
I ask them all the questions of OLDCARTS and they have it all ready to go; often written down.
OLDCARTS was taught to me in medical school. There are a lot of other ways that people use to organize their interviews.
- Onset: when did this particular symptom start?
- Location: simple description for the location of the symptom
- Duration: consistent vs intermittent, time frames, etc
- Character: descriptors such as sharp, dull, throbbing, tension can be helpful
- Alleviating/Aggravating: activities or items that seem to help or hurt the issue
- Radiation: does the pain go from your RUQ to your shoulder blade? This type of thing
- Timing: if only at night, only while running, etc
- Severity: pain scale of 0 - 10. Ten being the worst of your life. Seriously, over exaggerating will not help you get pain pills. It will just heighten our suspicion of drug seeking behavior.
Depending on what type of answers the doctor gets, clarification or more questions exploring a certain pattern will be thrown at you.
I know the statistics concerning physicians and how fast and frequently they interrupt their patients. I freely admit I interrupt my patients, but only when necessary as components in their story demand clarification. Sometimes a red flag symptom or scenario is thrown out there and I feel compelled to address it.
But I'm also careful to actually say sorry for interrupting -- and then I quickly get them to address my concerns and let them answer the question. I especially find that patients understand the need for interruption if I explain to them why I had to do so.
Most doctor visits will involve most of the elements above, if the patient presents with a complaint of some kind.
It is helpful to have at least thought about these elements surrounding the issue that brought you to the doctor's office in the first place. Be like the engineers.
Another aspect of how doctors think and understand various issues surrounds the depth of understanding of the human body that we come to over time. The patient who is hundreds of pounds overweight complaining of lower extremity joint pain probably does have osteoarthritis. I code it as OA secondary to morbid obesity. This is perhaps the simplest of relationships. Gravity works. All the time and everywhere -- those knees take a pounding and the cartilage will wear down.
Another good example is erectile dysfunction for men. It often works as the proverbial 'canary in the coal mine' in that untreated diabetes or peripheral vascular disease can cause ED. In younger men, more often than not it is a psychological issue, stemming from life stressors. Nothing gets people motivated than a loss of sexual prowess and libido.
One of the main complaints about doctors is that we don't spend enough time with our patients. It is important to know that most of us actually spend more time than we get paid for with the patients. See, becoming a doctor is not something one does with the intention of screwing over patients in favor of the dollar. Do some end up this way? Sure. In this day and age, with all the restrictions and laws regulating the business of the doctor, we're just trying to stay out of jail, the courtroom and debtor's prison. Don't get me wrong, but of all the things that doctors get blamed for, the only one that really rings true to me is this: doctors have not stood up against private medical insurance encroachment on practice autonomy and profiteering.
One day I'll write my dissertation on how in the 1980s the doctors blew their chance to save a functioning system of health care. They couldn't organize and it's been every doctor for themselves since. I digress.
Paperwork and electronic silo EMRs add to the immense time we already spend documenting. We document for patient safety, of course, but if that were the case solely, we'd spend a fraction of the time we do now. We document because the insurance companies want to pay as little as possible. Of course they do, especially considering these are publicly held corporations that must produce profit for the shareholders. That is the reason for its existence not insuring patients and ensuring their best outcome.
Your insurance company is contracted with the doctor to provide a service. We document what services we give and bill the company. How much the company pays dictates how many patients must be scene during the day in order to keep the lights on provide bounce-free paychecks.
For most it breaks down into 15 minute appointment chunks. 15 minutes is fast. Multiple serious issues? The morning is off track, guaranteed and there goes the lunch hour.
All I can say to the patients who end up waiting too long, just know it wasn't done frivolously and that almost every time, it was because a patient needed more than anticipated attention.
For those that grow weary of this model, and not only having your time but the medication and procedure options significantly limited by the insurance companies, there are options.
Direct Medical Care is a cost efficient model. Concierge Medicine is often a pricery but viable option for some. With the ridiculously high cash deductible many of these plans have, it is no wonder that these other models are taking off.
In brief, these are subscription services -- so much per month, for example, to see your doctor so many times. I've seen as cheap as $25 per month for a plan, and I'm not sure there is an upper limit of cost.
For those that find themselves frustrated with their appointments I bring these up only to encourage exploration of alternative models of health care delivery.
Be proactive in your healthcare.
Ask questions.
Don't fear to ask for clarification of a diagnosis, test result or recommended procedure.
As the years go by it is extraordinarily easy for us doctors to forget that the most mundane parts of the day may be a terrifying experience for the patient. Sometimes it's old hat for the patient -- sometimes they have no idea what is going on. I hope everyone that passes by under my care at least feels a base understanding of why, what, how, when and where for whatever the issue at hand is.
I also recommend being honest with your doctor. Tell him or her that you're nervous. It's okay. Or, it should be. I recognize that some don't have the luxury of changing a physician, with insurance pre-authorizations and networks, and all that, and much of this is written with you in mind. Sometimes life demands that we adapt and make the best of a situation.
For those who are frustrated and are fortunate enough to be able to choose their doctors, just do a little looking around before choosing, and don't be afraid to keep looking if unsatisfied.
Insurance companies may want us to be all encompassing to all patients and penalize us financially depending on patient satisfaction surveys. In general, I think we all know who will spend more time on something like that -- those who feel wronged somehow. Yelp, Amazon reviews, and such are a testament to this. A patient may hate the parking lot situation and complain about it. The doctor is paid less depending on how the patient answers the survey. I'd like to see what would happen if nurses were paid less depending on patient satisfaction. The nurses union would squash that idea with a vehemence that physicians can't seem to muster.
As a side note, concerning nursing unions, in relation to the recent NRA vs physician social media dispute, where the NRA basically told doctors, in general, that gun ownership was none of their business and they should basically stay out of the debate, or that we should "stay in our lane."
If this "stay in your lane" message was leveled at the nurses, we might actually get sensible firearm reform in this nation. Again, I digress.
I'll leave you with this:
My job exists for a few reasons. First, I want to keep you out of the hospital. Now, and definitely decades down the line -- hospitals are super dangerous -- infectious disease (superbad ones, too), sleep disruption, bedridden, medication given (hopefully the right one at the right dose), foley catheters, crazy people in the same room or down the hall (hopefully down the hall, at least) and truly, hospitalization can be a very traumatic experience. Understandably so. I also exist to help with the "smaller" problems in life. Maybe not life-threatening, but life style inhibiting. Sprained ankle to the chronic asthma control, I can do it.
And perhaps most importantly, most of us do this because we feel like we can, and should help people; I've worked with a lot of different doctors at this point, as I near the end of training. Including those I've observed but not worked with, I have a large sample size from which to conclude that almost all of us really do want to help you. Part of the reason this series exists is to bridge the gap of patient expectations and limitations of medical science. Sometimes we don't have the answers. A lot of us feel like we can't let that come across, if for no other reason than the comfort of the patient and family.
Despite all the barriers, headaches and frustration involved with seeking medical care that currently exist, I have hope for a day where logic, pragmatism and the elimination of the insurance companies as we now know them.
Please be patient with us. I mean, isn't that why we call you the "patient" after all? Or is it our patience? Just depends on the people involved, I guess. Patience and patients galore. This is my life.
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