Tuesday, November 22, 2011

Family Medicine: What are We Doing? Why are We Late?

As a Family Physician (FP), I see miserable people every day.  They may be acutely sick with expectations of getting well soon, with some help from me (or just a note saying they can't work for a while).  After clarifying their history and doing a focused physical examination, I make some comments about the natural history of their affliction, negotiate a treatment plan- sometimes just validating their strategy  and congratulating them for knowing themselves so well.  Other times they just want me to be a leader or commander (less than 5% want commands now days- used to be 50-75% in the 70's and 80's- the "old" days) and advise a strategy and watch for their nod of agreement.  The strategy includes plans for any contingencies or follow-up appointment, their next appointment for any prevention or chronic health needs and a comment about an upcoming situation in their life ("I hope you enjoy your Florida trip to see your mother", etc.).

About 25% of my patient interactions relate to these acute illnesses as the primary reason for the appointment, with 98% of those patients adding extra problems of an annoying sort (to the patient) after they are in the exam room.  Those problems seem to be about 25% "reassurable" on the spot and 75% needing a more in depth evaluation, half of them needing another visit to actually evaluate and treat medically.  The patient often wants to push for the extra time immediately, giving me the opportunity to act medically (which has its own set of rules and legal implications) or engage in an often uncomfortable negotiation about the importance of practicing medicine in a medical way as the legal system and the profession expects.

The add on problems constitute the major reason for physicians in Family Medicine getting behind in their schedule, since many of the add-ons that the physician opts to respond to NOW are mental health issues which are complex and require extra listening.  Brain problems and life problems are the next major set of "time in the schedule" challenges.  These and the NOW issues usually relate to depression, anxiety, situational reactions, opiate use or abuse, substance abuse or dependency, chronic pain, grief reactions, marital distress, etc.  Our caring about people as people may often add to the "inefficient" way Family Physicians respond to these complex issues.

Now that Family Physicians are being sucked deeper into the Medical Industrial Complex, by corporate employment, to feed patients into the corporate profit centers, there may be increased efficiency and a lot less response to mental health and life stresses.  The owners of the contracts of those employed FP's are pushing for more numbers and fewer stressed patients. Time will tell if the MIC wins over the health needs of patients, or if the patients educate the MIC to respond better to their needs.  More later about the changing system, much of which is better than our current system, much of which is less safe, all of which seems more expensive to our society.

What do you think about current and future response to your primary care needs?

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