Save Money on Medical Costs - Get Your Old Medical Records

There are many tips to saving money on medical costs like asking your doctor only for generic medications, choosing an insurance plan with a high deductible and lower monthly premiums, going to an urgent care or retail clinic rather than the emergency room, and getting prescriptions mailed rather than go to a pharmacy.

How about getting your old medical records and having them reviewed by a primary care doctor?  It might save you from having an unnecessary test or procedure performed.

Research shows that there is tremendous variability in what doctors do.  Shannon Brownlee's excellent book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer , provides great background on this as well as work done by the Dr. Jack Wennberg and colleagues on the Dartmouth Atlas.  Some have argued that because of the fee for service structure, the more doctors do the more they get paid.   This drives health care costs upwards significantly.  Dr. Atul Gawande noted this phenomenon when comparing two cities in Texas, El Paso and McAllen in the June 2009 New Yorker piece.

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

Doctors apparently seemed to order more tests.  Patients, not surprisingly, agreed.  After all, without adequate medical knowledge or experience, how sure would you be if a doctor recommended a test and you declined?

Would doctors do more because they get paid more or would they simply do the right thing and do tests or procedures when only medically necessary?

I recently had a 55 year old healthy woman join my practice.  She wisely had brought in her medical records and was fairly educated on the care she received.  She told me that her previous doctor had recommended a colonoscopy for this year, five years after her initial colonoscopy at age 50.

Odd. 

For most patients with no family history of colon cancer and a normal colonoscopy, recommendations are to repeat in ten years not five.

Did she have any abdominal pain or change in bowel habits?  No.

Did the doctor say anything about colon polyps or growths?  No.

Did she have the colon biopsied?  No.

Was there a family history of colon cancer?  No.

She was pretty sure she was to have a repeat test five years later.

I reviewed her previous doctor's chart which had her colonoscopy report.

Completely normal colonoscopy.  No polyps.  No growths.  No biopsy.

At the end of the report:  Recommend repeat colonoscopy in 5 years.

I've read news reports over the years where research has noted some gastroenterologists were doing colonoscopies more frequently than recommended by their own professional medical societies either for routine screening or follow-up of colon polyps and growths.  I assumed those stories were outliers and rare.  I would never encounter such an obvious case of overtreatment.

But this patient's report and her memory of what her doctor told her could not be chalked up to a typo or a misunderstanding.  Would doctors do more because they get paid more?  How else to explain this?

After showing my patient the guidelines from the American Cancer Society as well as the American College of Gastroenterology, she was thrilled that she didn't need to undergo the procedure for another five years.  No need to do the prep that Dr. Oz did with the gallon of laxative and the loss of a day getting ready and then recovering from the side effects of IV sedation needed for the colonoscopy.

I saved her time and money and unnecessary treatment.

You should always have a primary care doctor review your old medical record, especially if you move or switch insurance plans.  Another doctor's opinion and insight can be very important to counter this natural feeling of uncertainty.  No one wants to make a bad choice.  Patients aren't medical experts and generally don't want to be.  Doctors who choose primary care do so because they want to care for the whole patient despite the fact it is among the lowest paid specialties and least attractive to medical students.  Medical students are gravitating towards specialty care which are more procedural based and therefore have the opportunity to generate more income.

Unfortunately, this means doctors who can help patients make informed decisions and prevent overtreatment will be in limited supply at a time when we need them the most.

Want more helpful tips? Worry about whether you are getting the best medical care? Does your doctor seemed rushed? Not answering your questions? I have a solution for you!

Colon Cancer Screening Guidelines - Colonoscopy Better Than Sigmoidoscopy? The Truth and the Myth

Colon cancer screening has a particular personal interest for me.  One of my colleagues in residency training had her father die of colon cancer when she was a teenager.

No one should lose a love one to a disease when caught early is often treatable.  Although for both men and women, colon cancer is the third most common behind lung and prostate cancer in men and behind lung and breast cancer in women, it is the second most lethal.

The problem is that patients are often confused about which test is the right one.  Is it simply a stool test?  Flexible sigmoidoscopy?  Colonoscopy?  Virtual colonoscopy?  Isn't there just a blood test that can be done? (No.)

In real simple terms, this is all you need to know. 

All men and women age 50 and older should be screened for colon cancer.  Even if you feel healthy and well and have no family history, it must be done.  Note that Oprah's doctor, Dr. Oz, arguably a very health conscious individual learned that he had a colon polyp at age 50 after a screening test.  Left undetected, it could have cut his life short.  This wake-up call caused him to abort his original second season premier on weight loss and instead show the country why colon cancer screening matters.  He admitted that if it wasn't for the show and the need to demonstrate the importance of screening to America, he would have delayed having any test done.

The least invasive test is a stool test.  If it is to screen for colon cancer, then the test is done at home and NOT in the doctor's office.  Either the fecal occult blood (FOBT) or the fecal immunochemical test (FIT) are available to screen for unseen microscopic blood that could be a sign of a colon polyp or cancer.  Research shows that when done annually the risk of dying from colon cancer can fall by 15 to 33 percent.  If you don't want any fiber optic cameras in the rectum and lower colon, this is the test for you.  You must do it annually.

The next two tests are similar but often confused - the flexible sigmoidoscopy and the colonoscopy.

The flexible sigmoidoscopy examines the lower third of the colon, known as the sigmoid and the descending colon.  Patients cleanse the lower colon by ingesting a small amount of laxative the day before the procedure.  If a colon growth or polyp is found, it can be biopsied or completely removed during the procedure.  The test is typically done in 15 to 20 minutes.  Patients are awake for the procedure and can go home.  Research shows this test can decrease the number of deaths due to colon cancer.  The risk of the procedure is very small with about 1 in every 5,000 patients having a small tear or perforation.  This flexible sigmoidoscopy test is done every 5 years. 

Like the sigmoidoscopy, the colonoscopy also requires cleansing of colon, however, a gallon of laxative is require to empty the entire colon.  Colon growths and polyps can be removed similarly.  Unlike the sigmoidscopy, however, the colonoscopy requires that patients be sedated.  As a result, you will need someone to take you to the appointment and drive you home.  Although the procedure itself takes about 30 minutes, it can be a few hours from arriving to going home due to the anesthesia.  Out of all of the screening tests, it is the most risky with an estimated perforation rate and cause of serious bleeding affecting in 1 in 1,000 patients.  A colonoscopy is done every 10 years.

Would checking the entire colon with a colonoscopy be better than evaluating the lower third of the colon with a sigmoidoscopy?  Evidence that colonoscopies save lives from colon cancer is lacking.  This subtle but important point is often not mentioned in media reports.  Even the NY Times perpetuated this belief that colonoscopy is the preferred test in its January 20th, 2011 article, "Why People Aren't Screened for Colon Cancer."  When family medicine doctor and lecturer in health care policy at Harvard medical school, Dr. John Abramson, wrote a letter to the NY Times editor in February 15th, 2011, noting the this fact in an unrelated article, the American College of Gastroenterology (ACG) wrote a letter indicating that a colonoscopy is their preferred test for screening.

No wonder patients are confused.

If one dissects the ACG letter carefully, we note the following language (words bolded for emphasis):

American College of Gastroenterology’s 2009 colorectal cancer screening guidelines recommend colonoscopy as the preferred cancer prevention strategy, and guidelines by the American Society for Gastrointestinal Endoscopy in 2006 also endorse colonoscopy because of its ability to view the entire colon and remove potentially precancerous polyps, reflecting a strong opinion of these experts that prevention should be the primary goal of colorectal cancer screening.

While public health experts have recently debated the exact parameters to measure the impact of these screening strategies on mortality, a clinical picture that is muddied by the many variables affecting the quality of the examination, the jury is still out. Indeed colonoscopy’s protective power may lie in a growing appreciation that the biology of precancerous polyps and cancer is different in the right compared to the left colon.

In other words, the recommendation is based on opinion.  There is no language indicating that there is evidence.  The "protective power may lie" in such and such, but hasn't been confirmed.  Examples of when doctors made opinions when evidence was lacking only to change their minds later include hormone replacement after menopause, bone marrow transplant for breast cancer treatment, and prostate cancer screening with PSA.

A study that appeared in the Annals of Internal Medicine in the January 6th, 2009 issue, researchers found that colonoscopies did cut down colon cancer deaths, but it was due to detection of the left sided colon cancers (sigmoid and descending colon) and not to the right side, of which only the colonoscopy can reach.  In other words, a flexible sigmoidoscopy would have detected the cancers as well, which has been observed in previous studies. 

Researchers reviewed health records for persons aged 52 to 90 who received a colorectal cancer diagnosis between 1996 and 2001 and died of colorectal cancer by 2003. These patients were compared to a control group who were selected from the population of Ontario and had not died of colorectal cancer.

According to the researchers, complete colonoscopy was strongly associated with fewer deaths from left-sided colorectal cancer. Conversely, the data showed that colonoscopy seemed to have almost no mortality prevention benefit for right-sided colorectal cancer.

So who do you listen to?  I typically review the guidelines from the American Cancer Society (ACS).  As a group advocating cancer screening and awareness, they should have no bias about what test to use to screen for colon cancer.  For individuals at average risk for colon cancer, ACS notes that to find colon polyps or cancer, either a sigmoidoscopy every 5 years or colonoscopy every 10 years.  Their recommendations don't say the preferred option is a colonoscopy.  The Centers for Disease Control the US Preventive Services Task Force, and the National Cancer Institute also say little about which is preferred. 

What does this mean to you?  For those at average risk and no family history of colon cancer, get screened for colon cancer at age 50.  At the bare minimum, do an annual stool test if you don't want an invasive procedure.  Know that at this time there is no evidence that colonoscopy is better than a flexible sigmoidscopy.

If people tell you otherwise ask them to show you the evidence.
And let me know.

Why Consumer-Driven Health Care Will Fail

The creation of consumer-driven health plans (CDHPs), health insurance policies with high deductibles linked to a savings option and with more financial respnonsibility shouldered by patients and employees and less by employers, was completely inevitable. The American public likes to have everything, whether consumer electronics or other services, as cheap as possible. With escalating health care expenses rising far more rapidly than wages or inflation, it's not surprising employers needed a way to manage this increasingly costly business expense.

In the past, companies faced a similar dilemma.  It wasn't about medical costs, but managing increasingly expensive retirement and pension plan obligations. Years ago, companies moved from these defined benefit plans to defined contribution plans like 401(k)s. After all, much like health care, the reasoning by many was that employees were best able to manage retirement planning because they would have far more financial incentive, responsibility, and self-motivation to make the right choices to ensure a successful outcome.   

How did that assumption turn out anyway?

Disastrous according to a recent Wall Street Journal article titled Retiring Boomers Find 401(k) Plans Fall Short.

The median household headed by a person aged 60 to 62 with a 401(k) account has less than one-quarter of what is needed in that account to maintain its standard of living in retirement, according to data compiled by the Federal Reserve and analyzed by the Center for Retirement Research at Boston College for The Wall Street Journal. Even counting Social Security and any pensions or other savings, most 401(k) participants appear to have insufficient savings. Data from other sources also show big gaps between savings and what people need, and the financial crisis has made things worse.

In others words a lot of people don't have enough money to retire.   The options they have are simply "postponing retirement, moving to cheaper housing, buying less-expensive food, cutting back on travel, taking bigger risks with their investments and making other sacrifices they never imagined....In general, people facing problems today got too little advice, or bad advice."

Though employers were able to manage retirement expenses, employees paid a significant price.  This wasn't intuitively obvious in the 1980's when these plans became more commonplace.  Over the past decade, the less than rational behavior by employees hasn't gone unnoticed by those who study behavioral economics or those in the government.  As a result, more organizations and companies are nudging employees into the right behaviors with auto-enrollment into 401(k) plans and auto-allocation of these funds with protection from any future liability as noted in the Pension Protection Act of 2006.

The analogies to health care and specifically consumer-driven health plans should be clear.  Workers don't save adequately for retirement even when in their best interest.  It's very likely that workers won't save money adequately to fund future health expenses.  After all, if people can't fund retirement, something we undoubtedly all look forward to, which one of us is willing to saving for chemotherapy or open heart surgery, which no one wants?  According to the annual Kaiser Family Foundation Employer Benefits Survey, the average annual deductible for single coverage and family coverage is nearly $2000 and $4000 respectively for health insurance plans that are health savings accounts (HSA) eligible.   The deductibles are slightly lower in health insurance policies that are linked to health reimbursement arrangement (HRA).  About 13 percent of employees are covered under either plan.

Unlike those in retirement planning who can work longer, even if not desirable, employees who are ill may not have an option to work to pay for their medical expenses.  There continues to be evidence that people are curbing their health care due to the ability to pay.

Though experts debate on whether this is a good thing (patients are avoiding unnecessary and expensive therapies and opting for less pricey but equally as effective options) or a bad thing (patients are avoiding the preventive screening tests or therapies that overall can decrease future costs), the opportunities to ensure patients make the right choices should be clear from workers' less than optimal experience with 401(k)s.

If employers wish to help curb medical costs, then they will need to engage workers with programs like employee wellness, assisted decision making (either as second opinions or patient-friendly informed consent), and access to medical experts, equivalent to personal financial advisors, who may be able to help workers make the right choices for their health.  Within the business community, there is some acknowledgment that access to these tools will be necessary to not only manage costs but keep employees healthy and productive.

Done correctly, consumer-driven health care can be what everyone hoped they would be, nudging healthy behaviors and slowing health care costs with workers selecting only cost-effective therapies.  If implemented poorly and organizations simply shift health care costs and financial responsibilities to workers like retirement planning decades ago, the nation will need to accept more than ever that increasingly more people get the medical care based simply on their ability to pay and not on medical necessity.

As a practicing primary care doctor, I hope that day never comes.

What Doctors Wish Their Patients Knew - Critique of the March 2011 Consumer Reports article

First, I'm a big fan of Consumer Reports and even listed their Consumer Reports Best Buy Drugs website in my book, Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System, because of its accurate, unbiased, and money saving information in getting the right treatments for the best price.

So naturally when I saw this month's issues cover story - What Doctors Wish Their Patients Knew, I had to read it.  Overall, it was excellent and made a lot of sense.   Their conclusions were obvious to me, however, might not be as intuitive to the public (after all it is titled what doctors wish their patients knew!).

In summary, primary care doctors matter and having a long-term relationship with one can save time and money.  Respect and being courteous still matter to both doctors and patients.  Thoughtful use of the internet might overcome the resistance doctors have to patients researching information.  Generic medications, which are inexpensive and very effective for many conditions, are excellent and should be used.

A more in depth analysis reveals the following.  Primary care doctors are vitally important.  As Dr. Kevin Grumbach, professor and chair of the department of family and community medicine at the University of California San Francisco noted, "a primary-care doctor should be your partner in your overall health, not just someone you go to for minor problems or a referral to specialty care."  Indeed, that is why I went into primary care.  I prevent problems.  I diagnose problems.  On the occasion I can't solve your problem, then I need the assistance of my specialty colleagues.

I'm not a gatekeeper.  I'm not simply a referral center or an obstacle in getting you the right care.  In fact, I'm the first logical place to always get care and be your partner in keeping you healthy and well.

A long-term relationship with a primary care doctor is also important according to three-quarters of the 660 primary care doctors surveyed.  Consumer Reports found some evidence that patients who frequently switch doctors have more health problems and spend more on care.  This seems to make sense.  Having someone you know and trust to get care over a long period of time can keep you healthy and save you money.  The challenge for many Americans is trying to keep the same doctor.  Employers often switch insurance carriers to save money.  Doctors drop out of health plans.  Patients change jobs and have a different health plan or no health insurance coverage.  In other words, a primary care doctor isn't simply a commodity, but rather a vitally important relationship.  Unfortunately the health care system and the general public don't view them that way.  Practicing primary care doctors are leaving the specialty and medical students are not interested in a primary care field even though it is has potential to be one of the best choices in the future.

Respect and being courteous are two traits still valued by doctors and patients.  The majority of doctors polled felt that being respectful and courteous would help get better care.  Patients equated respect and courteousness as professionalism.  Doctors who treated them respectfully, listened to them with understanding, and spent time with them scored high.  Though professionalism scores increased more when patients felt that their doctor seemed technically competent, I find it hard to believe that patients can honestly determine who is skilled clinically.  I think my car mechanic is skilled, but I really don't truly know as I'm not a mechanic.

I'm sure patients believe I'm technically competent as I explain everything I'm doing.  For a knee examination, patients will hear me say -  I'm palpating the meniscus both the medial and lateral aspects to check for arthritis or a meniscus tear.  I'm examining the medial and lateral collateral ligaments of your knee and making sure they are intact and not strained or torn.  I'm looking for fluid in the knee and mechanics of the knee with the range of motion.  I'm checking the health and integrity of the ACL and PCL.  Instead of wondering if I'm simply waving my hands like a magician, the description of the examination demonstrates my value as a doctor.  Patients, and some doctors, have forgotten the value of taking a detailed history and a good physical examination.  There was a time doctors didn't have the imaging tests of xray, CT, or MRI.  Once I explain what I'm doing, then they understand why these tests are often unnecessary, which of course saves money and time. If showing and verbalizing our examination and thought process is professionalism, then we need to do more of it.

Although the article suggested that 80 percent of doctors felt taking a friend or relative to an office visit would be helpful, I believe this expectation to be a little unrealistic.  Unless a family member or relative is particularly worried or if the visit is very important, say a consultation with a surgeon or an oncologist, it isn't necessary to have someone else tag along.  People are incredibly busy.  Taking time out of the day to accompany someone for an appointment isn't going to happen.  The reason for this suggestion is that doctors discover patients don't typically remember everything that occurred in the office.  This point really is about providing patients a strategy to recall important information (using the mneumonic D.A.T.E. can be helpful).  

Suggestions on how to thoughtfully research information on the internet was a plus.  Besides MedlinePlus and the Mayo Clinic, one should also consider Healthcare.gov, which has a preventive app, my health finder, that gives personalized specific age and gender information on what tests are needed and appropriate (it's under the Learn About Prevention tab).  Not surprisingly due to the ease of looking information on the internet, 61 percent of patients have researched their condition.  Sadly doctors were not as enthusiastic.  Half of doctors said that online research was not helpful at all.

Physician wariness to the plethora of online information is due to the lack of respect from some patients who demand certain treatments, medications, or interventions, without understanding the nuance of a diagnosis.  It isn't as simple, though it seems like it, as putting in a bunch of diagnoses and then just then hitting Google search (or worse I'm feeling lucky).  I don't mind patients emailing me links to articles or suggest diagnoses.  In fact, I learn a lot from patients.  I do however find it difficult to treat patients who are insistent on their way or the highway and in those cases will suggest they find another doctor.  It's about a trusting partnership not just about patients who are empowered with small pieces of information.

Finally, the best part of the issue was he Best Buy Drugs section which notes that many conditions, like high cholesterol, diabetes, heartburn, allergies, and depression have very good generic prescription medications that are inexpensive and very effective.  Consumer Reports uses evidence based research to back up the claims.  The vast majority of patients I care for do fine with generic medications.  That's what I buy.  You should do fine with generic medicationas as well.  They left out my favorite online pharmacy, Healthwarehouse.com which often has pricing better than Wal-mart and Costco for many medications.

What else do doctors wish patients knew?  Vaccines are safe and underutilized.  Body scans and life line screenings really aren't worth your money.  The fountain of youth really is eating less, moving more, and not smoking, and plenty of servings of fruits and vegetables.  Cancer screening tests are for everyone, not those with family histories as the majority of people who develop cancer are the first in their family.

But of course, that might take more than just a blog post, but an entire book.

Why This Primary Care Doctor Loves his Electronic Health Record

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don't improve outpatient quality.  The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and "doubt [the] argument that the use of EHRs is a "magic bullet" for health care quality improvement, as some advocates imply."

This should surprise no one.  Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes?  Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn't seem to improve outcomes on 20 quality indicators.  First, it isn't clear that the CDS implemented across the various doctors' offices and emergency rooms actually addressed the indicators studied.  Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007).  The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality.  Whether this can be scaled to the national level is the question.

In other words, it isn't just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections.  As most people know already, there is not typically an appropriate antibiotic to use for a virus.  It's a virus.  It does, however, take good bedside manner to inform and educate an ill patient!

As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I'm incredibly lucky.  In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to.  CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time.  It is a safety net.  Understandably some EHRs aren't that good, the CDS is clunky, and certainly the one I use is good, but not perfect.

The real issue isn't finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done.  Indeed, to get into medical school, one has to be self-motivated, persistent, and determined.  Why on earth would we need a computer to help us?

Frankly, because it makes us better doctors.  CDS frees up time and mental energy.  I don't have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia.  Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen. 

Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don't fit any protocol (cognitive medicine) because science hasn't evolved to that level of understanding.  I'm a big believer in the history and physical exam and how the use of HIT can make care more personal.  Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen.  Instead of hunting for lab work in a paper chart or trying to find a specialist's consultation, I can access the information I need rapidly and focus on the patient in front of me.


Sadly, however, many doctors don't feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate.  It might also be, however, our training and tradition which limits us from improving.  If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better.  We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande's New Yorker piece, the Checklist.  Because, really, CDS is essentially a checklist.

In the situation where a patient doesn't fit CDS, then we get to do what we do best and that is use all of our training to get a patient better.   HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before.  In the end, that is what patients really want.

This is why I love my EHR so much.

Why the End of Internal Medicine As We Know It - Might Be A Good Thing!

A recent blog post in the Health Affairs blog proclaimed The End of Internal Medicine As We Know It.  What the article is really asking is the future of primary care in the world of health care reform and the creation of Accountable Care Organizations (ACOs).  While doctors should be naturally concerned about change, I don't completely agree with this article.

ACOs are organizations that are integrated and accountable for the health and well-being of a patient and also have joint responsibilities on how to thoughtfully use a patient's or employer's health insurance premium, something that is sorely lacking in the current health care structure.  These were recently created and defined in the health care reform bill.

Yet, the author seems to suggest that this is a step backwards.

modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions

Not true.  Successful organizations are ones that are tightly integrated - Apple, Fedex, Wal-mart, Disney.

The author talks briefly about how Europe in general does better than the US in terms of outcomes and costs and has a decentralized system.  All true.  However, contrasting Europe and America isn't relevant.  After all, who isn't still using the metric system?  Therefore solutions found outside the US probably aren't applicable due to a variety of reasons.  Americans like to do things our way.

What I do agree on is that doctors need to be part of the solution and ensure that the disasters of decades ago, like labeling primary care doctors (internists and family physicians) as "gatekeepers" rather than what we really do, never happens.

I love primary care.  I've worked at Kaiser Permanente (KP) in Northern California since 2000.  I have long term relationships with my patients.  They see me when they are well.   They see me when they are sick.  They have me as their personal doctor.  There are no mid-level practitioners (nurse practitioners or physician assistants) in my unit.  I'm supported by information technology, staff to help those members with chronic conditions, and collegial specialist colleagues.

In other words, I'm doing what almost every primary care doctor wants: long-term meaningful relationships with patients, no hassles from insurance companies, the ability to retrieve information quickly and easily, and support for specialty colleagues who are equally focused on the well-being of the patient and who respect me as much as I respect them.

Perhaps the death of primary care as it currently exists with crushing administrative hassles, loss of work-life balance, increasingly short office visits, and paper charts which often has inadequate information or are unavailable isn't a bad idea after all.

Now I understand that KP looks very much like an ACO.   I also know it isn't for everyone, doctors or patients, and isn't the only solution for the country.  Certainly doctors should be wary of if every self-proclaimed "ACO" is really that or more of the same in the fee for service world but simply disguised in the ACO term.

However, for primary care doctors looking for a better way to care for patients, it is a very viable and sustainable solution.  If the future for primary care looks like what I see and do everyday, then I believe the future will be bright.

Primary care doctors looking for a better future in primary care and willing to move to Northern California should do more research here. 

Patients in the end may benefit from ACOs.  I know my patients do.

Patients Lie. Why Doctors Should be Like Medical Students. A Good History is a Checklist.

The most common question first year medical students ask me is how do they become efficient at taking a patient history.  Can they skip certain parts of taking the patient history and avoid asking about a social history, whether a patient drinks, smokes, uses drugs, or is sexually active?  When can they stop asking about the review of systems, a list of questions asked about each organ system?  A comprehensive history is used in the emergency room, hospital, or during an annual physical, not in urgent care or an outpatient appointment, right?

Wrong.


Patients lie and don't even know it.  It's not that they mean to.  In fact, they are trying to be helpful when giving a history of their symptoms.  Medical students concerns about taking a fast history reflects two things.  First is the reality of the limited amount of face time with patients, which unfortunately seems to be even less than the past.  Second, more importantly, is their fascination and desire to get started on real medicine -- what are the diagnoses, treatments, and tests that must be learned to be a good doctor.


In fact, what they realize after working with me is that the most important part of being a doctor is talking to patients and listening.  Taking a good history is the essential part of being a good doctor.


Here are two examples of patients who I saw during the winter.  The practice is busy this time of year.  I'm often running late.  Like many encounters, I've never met these patients before.  In many ways, it can feel like an urgent care practice.  Which patient is lying?  Can you tell?

Young woman wanting a work note for the flu.  She was complaining of a three day history of diffuse muscle pains, headache and high fever.  That's it.  She had no other concerns.  Just anxious to get home and go to bed.


OR


A young man with an ankle injury after playing soccer.  As an aside, he also asked about stomach flu which occurred a few days prior.  He had nausea, abdominal pain, and vomiting for a day.  He still had abdominal pain.

Which one was lying?  Both.

A medical student or doctor recently out of training might have not missed the diagnosis in either patient because they are still working on how to hone down their questioning.  In other words, they haven't take the shortcuts yet and still ask comprehensive histories.  Yet, they aspire to just ask the vital questions to be efficient.  A more seasoned doctor who is stressed and busy may have taken mental shortcuts and moved on.

In other words, how do you know what is and isn't vital until you ask?

Patients also have fallen into this trap believing this tradition of talking to their doctors is simply unnecessary, worthless, and an obstacle to getting to the truth.  With increasing out of pockets costs for office visits, I'm seeing more requests from patients to simply get a MRI or blood test instead of seeing a doctor not only to address the problem, the real reason for the tests, but also if testing is usually necessary (it isn't in the vast majority of cases).

A good history is very much like the checklists pilots use and what Dr. Atul Gawande advocates in his book.  Taking a good history also slows doctors down and allows them to avoid cognitive errors (as described beautifully in the book How Doctors Think), think more clearly, and avoid jumping to premature conclusions.  Even the time honored skill of thinking through a differential diagnosis and thinking hard to make a long list of possibilities is a checklist and safeguard to consider other alternative problems that wouldn't appear when stressed.   Being a doctor requires thinking and less knee jerk responses. 

So what did the two patients have?

The first patient didn't have the flu.  She had a kidney infection known as pyelonephritis.  In taking the review of systems when asked about her urination pattern, she realized that it had changed during her illness.  Also, in asking questions, she had no other signs of having a upper respiratory illness, no cough, no runny nose, no head congestion.  Instead of simply writing a work note for a presumed virus and moving on to the next patient, this patient received antibiotics.  Untreated, pyelonephritis can be serious and require IV antibiotics or hospitalization.


The second patient didn't have stomach flu.  In fact, patients also make similar mental shortcuts by telling us what they think is going on - "stomach flu" rather than telling us specific systems.  When people refer to stomach flu, like food poisoning, often there is nausea and vomiting which then is followed by diarrhea.  He didn't have diarrhea just persistent abdominal pain.

He had gastritis, irritation of the stomach lining, due to alcohol abuse. Asking about his social history, he admitted to binging on a 12 pack of beers that day, a behavior, not uncommon for him.  Not only was he treated for this, he was also recommended to quit drinking.

So even experienced doctors can take a page from medical students.  It's the taking the history that matters.  Everything else we do, the physical exam, lab work, and imaging tests are tools and not the truth.

Want to know, one other time a patient lies?

When you see an otherwise healthy young man in the office who simply wants an annual check-up just to be safe.  These types of patients are as common as seeing the Loch Ness monster.

The real reason he's there?  His spouse, girlfriend, or significant other for a symptom he's been complaining about but didn't want to see a doctor.

If I don't get to that truth, guess who I'll be seeing next week?  The same patient again but with his spouse, girlfriend, or significant other.


Or he's asking about Viagra.