family practice issues and general life events

I went to a meeting this week.  And in the three days since, I have been debating whether I should write about it at all, or I should just let it go, but it has really bothered me.  Not the presenter or the people putting on the meeting, but some of the attendees of the meeting.  Now this meeting was with the local physicians who are utilizing a care measures program with the Oklahoma Medicaid and try to improve patient outcomes and to decrease costs.  Nice thought, does it work, well the program claims to be saving $40 million on the physician side of direct costs since its inception in 2008.  Don’t ask me where the numbers come from, but some of it includes savings that have been realized by less utilization of the Emergency Room.  In all honesty, I like the program because it helps to remind me of the things I need to do, and should do for my diabetic and hypertensive patients.  (There are more patient diagnosis, but we have not added them yet)  Plus, they pay me an incentive for meeting goals that are established, and they are not super strict.

Anyway that is not where the concern came from.  The concern came from the resident table when one misunderstood the comment of one of the programs nurses, and took it to mean that it is the physician’s fault if they don’t understand their directions.  And it was his fault, if they didn’t understand directions from the educator, the hospital, the nurse, and the physician.  Well if they don’t understand the physician, I would like to point out, that it is the physician’s fault, but regardless, he became so angry and everyone started to jump on the band wagon.  And then everyone started yelling about how if they smoke or drink their checks should be taken away.  This is where the difficulty truly begins.

I am not arguing whether I agree or disagree with the Medicaid and welfare programs, however, benefits cannot be tied to smoking or alcohol usage, as they are both LEGAL.  Is there an entitlement feeling in some of this population- yes.  Should we work to change that?  Yes, but as healthcare providers, we should also realize that cutting off all of their benefits will not decrease costs, it will increase them.  How?  Well because ER utilization will increase, because they cannot afford to see their physician.  And with EMTALA when the get to the ER they will all be evaluated, and probably treated because the paperwork to not treat is a lot more arduous than that to treat, and the physician would have already evaluated them anyway.

Or you can look at those without insurance or other care that try to make ends meet, when they end up in the ER they are sicker and more costly than they would have been had they shown up when symptoms started.

My problem is that the anger directed toward the Medicaid population for being noncompliant, I wonder if these same physicians are as angry at their insurance population who are noncompliant?  If their answer is no, maybe the problem with educating is the physician.  Maybe it is the better than thou attitude that is causing the problem.  If as a resident, you are already angry, and you have yet to get out of residency yet, you are in the wrong field.  Primary care, especially family practice requires compassion and the ability to empathize with your patients.  Over the last 7 years in private practice, I have seen patients that I thought were merely not listening one day actually understand what they couldn’t grasp for 3 years.  And I have been able to get patients to lose 50 pounds over the last 7 months, because of educating them repeatedly.

It has required me to understand why they don’t always get their medication filled maybe they ran out of punches and instead of letting them pay cash for the meds on the $4 plan, Wal-Mart put that medication on their card and tried to charge them cash for the more expensive med (True story), or they didn’t follow their diet because when their check came in on the 3rd, they stocked up on food that would not spoil, which generally mean more sugar and less healthy.

I left the meeting scared for the future.  If in your training you are already that cynical, where does that leave the healthcare situation in this country?  Medicine is not 9 to 5, and while many could ask me how I can talk, since I have my schedule structured so that I don’t take call (my husband takes mine), I at the very least try to find ways to better serve my patients.

There is a need for the practice to find out why the patient is noncompliant, and that doesn’t just apply to the medicaid population, but to those with insurance.  And if we believe that people with insurance are doing a better job at taking care of themselves, than you need to only look at the rate of obesity and diabetes in this country to know that is not true.

We need to find a way to help them meet the challenges of their day to day.  To find out what resources that will allow for them to have better health.  We have to help them become better partners in their health.  And we have to be able to listen.  The 15 minute office visit doesn’t allow for this, and based on the comment from another resident who said, “Well it is really only 8.” well I can see where an even more concerning problem for the future is.  Those that are focused on the clock cannot be meeting the needs of their patient.  I understand people don’t like to wait, but they are even less happy to do so, when you rush them in and out like cattle, cutting them off at 8 minutes in.  Is there even time to delve into their diabetes, their depression, or routine maintenance by 8 minutes?

Some visits will be simple, ear infections, strep, but for complete care you have to understand where the patient lives, what their culture is, the challenges they face.  Am I perfect at this?  No, but I don’t dwell on the clock, I don’t say at 7 minutes in, Well that is all the time we have, here is your prescription.  We need to actively listen to our patients, and if we don’t want to do that, well than we should go do something else.

Medicine can be taught, but compassion and empathy cannot be.  And if you don’t possess either, than primary care is not where you belong.  If you went into medicine for the money, well you are an idiot, there are easier careers that require less training and risk for the money, and in primary care, while you will be living better than most of the population, you will not be living like a rock star.

Everyday there is some report about a shortage being faced in medicine- nurses, primary care physicians, specialists, etc. But if we just fill those positions with bodies instead of compassionate, skilled individuals are we actually better off?

Medicine is challenging.  You have to be willing to fight for your patient, regardless of their income, and they have to believe that you will care whether they get better.  Sometimes it will be the happiest day of their life- when they have a baby, or sometimes it is the day when you diagnose their cancer, or tell them that they aren’t going to get better.  It is the willingness to have the hard conversations with the patient, the fight to make them more accountable for their own health.

What family medicine is not, is a blame game.  You cannot take care of a patient, if you cannot take the time to make sure that they understand your directions.  Sometimes it is frustrating, and sometimes patients will make you crazy, but it is a trust you undertook when you took that oath.


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