Saturday, November 20, 2010

Family Medicine: Could Curious George Be a Family Doctor?

"If you don't have a label,  you don't exist" .. undiagnosed patient with chronic condition.
Persons with some conditions that don't  get a medical diagnosis can feel lost in the Medical Industrial Complex grinder, so they try to avoid it and often enter through the "wrong door".  Starting with their chiropractor, massage therapist or neighbor who is an EMT, they get referred or go from doctor to doctor until they finally might get a pamphlet for a pain management center from someone in the third ED they enter in a two month struggle with "spells", "seizures" or muscle spasms.

After four months of back injections at the pain center, they come in for a post air travel ear pain and we may get to hear the story of their misery adventure.  The eustachian tube dysfunction causing the ear pain after air travel is a chip shot for the family doctor who gets curious when the patient says, "while I'm here, can I get a refill on my Vicoden?"

The time allocated for their acute illness is 15 minutes, not including time with check in, MA for vital signs and clarifying their chief complaint, but including time with physician and prescriptions, forms, referrals, and the usual doctor's office stuff.  It is already gone at the moment the word Vicoden crosses their lips.  The family doctor knows that it'll take another 15 minutes to clarify how and why our patient is taking an opiate without our involvement.  How do we clarify that we don't have the time to get the history and physical examination to arrive at an opiate level decision for the problem they decided not to involve us in until they accidentally came in for the ear pain.  The "incidental" issue is about four times more challenging to effectively explore, diagnose and treat than the ear pain.

Will our curiosity pull the family physician into making the next patient wait another 15 to 30 minutes (confusion sometimes abounds with the self referred chronic pain person who doesn't believe in "citizenship" in the medical system)?  Or will the FP comfortably respond to the request with, "I'm happy to explore that with you in another appointment, since we're out of time and opiate prescribing implies a complex situation with added risks."?  Stay tuned.  Stay Curious.

"Curious George" sees another patient scheduled for an acute visit: Patient called this morning for a visit today acutely ill with sinus pain (see other blogs noting that Dayton, OH area is the worst allergy city in America- Numero Uno for total allergic mucous per capita), and moans a bit when describing pain in face and right ear for 3 days off and on.  Now they have coughed up some yellow mucous (Yes, it is the "Yellow Victory" noted in one of my April blog posts) and wish relief for sinuses, ear and upcoming Thanksgiving holiday with family (is it going to get worse? Am I going to get pneumonia?)

After my examination of the affected areas,sharing my perspective on diagnosis and ideal treatment and answering questions, the moaning stops and my patient energetically asks, "can  you take over prescribing my Wellbutrin, I don't think I need a psychiatrist any more?"  I notice the moaning somewhere again, oops-it's me.  When is your next appointment for your diabetes, hypertension and acid reflux?  "I don't have one."  States the patient who agreed to have an appointment for those conditions two months from when she saw our family nurse practitioner four weeks ago.  The room feels too warm.  "Excuse me a second while I check the heat control right outside the door, it feels too hot in here, I said warmly." 
"Doctor, your next patient just called to reschedule, her mother is having a stroke".  I turn the heat down two degrees, re-enter the room with renewed energy and curiosity.  I think, I wonder how many problems my patient will drive through this visit if I just go with the flow, Wellbutrin and all.  SEVEN!  We had seven diagnoses and four more prescriptions and a blood test conquered before I started to close by noting the number of problems we've dealt with in the time allotted for the acute visit plus the rescheduled patients time.

Sometimes I feel like Curious George and get carried away with curiosity about people.  They are all interesting and different, but I have to remember the flow of the schedule and how to relate to acutely ill persons and differently to chronic disease management folks (different rhythm, flow and focus).  The patient agreed to schedule a chronic problem visit for the other four problems that I deferred.  We could have done ELEVEN problems, we get paid as if we handled four at the most.  So my curiosity gave away payment for treating three problems or so.  Not the best behavior for the business side of the practice, which is squeaking.

We love our patients and the interaction with them.  Sometimes that doesn't balance well enough with the financial survival side of things in family medicine.  Now we face the planned Medicare reimbursement reduction again for the fourth or fifth time this year (21.2%) soon to be followed by a 5 or 6% reduction in reimbursement in 2011.  The other four times, Congress extended current payment levels at the last minute or retroactively when in May (or was it April or June?) they passively instituted the cuts for two weeks before reinstating the former reimbursement, which is 2001 levels of reimbursement.

All notes on Medicare Advantage Plan patients are reviewed by an outside reviewer, so we do a lot of copying so they can tell if we're defrauding the  government.  Patients covered by Medicare are generally older and have more complex problems per visit than any other patients, but their reimbursement per problem is generally less than all other patients.  And we expect the reimbursement to be slashed.  Hmmm, should I try to recruit more Medicare patients?  How curious am I?

We have concerns about _______ (insurance) company and we're not sure what our relationship with them will be after January 1, 2011.  This sign is in all our exam rooms and our waiting room with the name of an insurance company in the space where the blank is.  Some times one company or another scares us with their behavior and we drop back or out of a business relationship with them.  It's a sign of the times.  Hopefully, we're not curious enough to go out of business financially by relating to the wrong folks.  Stay tuned.  Stay Curious, just like George.


  1. I found online for Findrxonline, in hospitals there is a spinal cord stimulator, which is a major departure for chronic pain because it prevents you use painkillers such as Vicodin, hydrocodone, norco, which is the alternative that gives us pain management doctor but I think now people in the United States have a better option for health care.

  2. Pat, In the midst of describing the real concerns of being able to balance being a caring physician with getting paid in a system of declining reimbursements, you maintain the humor that endeared you to so many of our classmates at West Point. Once again while reading your blog, I found myself laughing out loud...this time in paragraph six when the moaning returns (oops-it's me). As I read these blogs that deal with real and significant concerns facing all of us in medicine, I find myself wishing I had gone through med school with you as well as the Academy. Laughter goes a long way, just like curiosity! Keep up the good work!

  3. Thanks for the comments. Joan: you're correct about the spinal cord stimulator which is a miracle for a tiny number of chronic spinal pain folks. Further advances will be forthcoming.

    Alan, thanks for the humor appreciation and other empathies about the "system". I guess I did OK writing fall-out skits for Plebe year appealing to the "non-adult" side of upperclassmen and it carried forward to medical chuckles and lamentations. I hope Congress enjoys humor and gives the healthcare system a "fall-out" so we can move forward with adult strategies for health system upgrades. Peace and Best Wishes for a great Thanksgiving with family.

  4. I loved Curious George :)

    Thanks you for posts like this that let patients see things from the doctor's perspective.

  5. LOVE IT! I live it everyday....of course you already knew that. I TRY to approach this like George and not like ANGRY BITTER FP. It's hard. LIke today Monday. First pt. Short week. Here's the CP: Physical, Diabetes, HTN, Depression, refills, Health question about the HCG diet. Sweet LORD. You've got to be kidding me. And she's united health who only pays 1/2 for the Mod-25 visits. Whatever. I like this patient and the one that's next and was 20 min late, not so much. Guess he'll have to reschedule or see the NP. :)

    I love my job.

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