Could Your PCP Pick You Out Of A Line Up?

DocBaker

I doubt mine could.  Which makes me think about Little House on the Prairie.  Anyone around in the 1970s remembers idyllic Walnut Grove, where Doc Baker took care of everyone and their pets.  He gave advice, dispensed medicines and sent the tough cases to Mancato (the big city).  People ran into him at the general store and he promised to stop on by the next time he was out their way.  To our modern ears, it sounds very quaint until you realize that this is the model of health care that we aspire to and were supposed to get with the onset of HMOs.  Under that model, we were each supposed to have a PCP who would monitor our health, give us lifestyle advice and send us to a specialist if any red flags showed up.  This would be the ‘gatekeeper’ (insurance term) that would be familiar enough with our health history that his or her decision would be one based on a long view of our individual health status.  Unfortunately, this model was managed to death by efficiency experts until it is neither efficient or effective.  The political choices we have before us continue this trend. Until we as patients demand better, the push will be for PCPs to do more with less.  In a recent poll (Investors Daily)  45 % of primary care physicians will consider quitting medicine if the government takes over the health care system.  That is approximately 360,000 doctors that will consider quitting practice.  Clearly, doctors are as frustrated as their patients.  Health care reform, to make any meaningful changes needs to redefine the role of doctor and patient.  The most efficient role the doctor can play is health coach in a proactive way.  That can’t be done in 5-10 minutes once a year. Or with a quick blood test.  Patients that are empowered by their relationship with their doctor will make the most beneficial (and coincidentally, the most cost-effective) changes to their own health.  In that climate, there will be less of a role for bean counters and government pencil pushers.  Let’s not give up the idea of Doc Baker too quickly. 

Dr. Michalene Elliott is a chiropractor in Rochester, NY who doesn’t want to be managed anymore.

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The Wal-Mart of Electronic Medical Records

medical-prescription-drugs_www-txt2pic-com

Thanks to my friend and faithful blog reader Rick for having his finger on the pulse of all that is truly important in the world of evidence based medicine.   Rick pointed out the New York Times  reporting Wal-Mart is throwing it’s big, floppy hat into the health-IT arena with plans to sell systems for handling electronic healthcare records to small medical practices.

Really?  Wal-Mart? EHR?  Which aisle?  Out of my way.  I gotta see this.  Is that a SOAP note generator over there next to the soap?  HIPAA compliance statements over by the Hippity Hops?  Patient demographics near domestics?

Who decided this was a good idea?

Nevermind that Wal-Mart is, like, the last place physicians go to purchase medical products, business items or software.  It’s not like physicians are there all the time anyhow picking up everything the well-stocked healthcare office requires so you might as well upsell them a tad bit.  Nevermind that Wal-Mart has no experience in electronic medical software or any software for that matter.  There is one even more important point…

This is freaking Wal-Mart!  Hardly known for high quality and durability, this is the place you go to buy cheap crap that will more than likely not outlast the walk from the store to your car and even more likely is made out of cheapass plastic from some far Asian grindshop built with the blood, sweat and tears of some poor, practically enslaved child.  Wal-Mart is, well, the Wal-Mart of companies.

Given the low prices and low standards, then it must be a bargain for this software, right?  Wal-Mart plans to make the electronic medical records available for around $25,000 for the first physician in a practice and about $10,000 for each additional doctor. Continuing maintenance and support will run another $4,000 to $6,500 a year.  Yeah, that sounds about right for my usual checkout tab.  Just pop that onto my Visa, wouldja?  We’ll have to limit it to that amount for now.  Got my eye on a new kidney over at Target’s organ transplant department.

500 Words About the Medical Conscience Rule

compassHave you heard about the governmental approval of a new medical “conscience protection” rule?  It allows health care workers to opt out of administering any form of medical care they feel is objectionable on moral or religious grounds. Hmm…sounds good in theory. People shouldn’t be forced to do things they find objectionable, should they?

A press release on the Department of Health and Human Services Web site says the law will “protect health care providers from discrimination.” DHHS secretary Michael Leavitt said that doctors have a duty only “to provide care that they are comfortable providing.”

But religion is a discussion hotbed and healthcare is a hot button on the front burner of that hotbed and I have a few questions and a somewhat queasy feeling about this rule.

The goal of this rule, supposedly, is to make sure doctors who are firmly against abortions aren’t forced to perform them. However, the new rule also permits emergency room workers to withhold information from rape victims about access to emergency contraception. It also allows doctors in federally-funded clinics to refuse to tell a pregnant woman that her fetus has a severe abnormality.

The U.S. Conference of Catholic Bishops praised the new rules, saying medical workers “should not be required to take the very human life they are dedicated to protecting.” The rule is scheduled to take effect the day before President Bush leaves office.  Coincidence?  Sure, like cops with white powdered sugar on a dark colored uniform.

But a large number of medical groups oppose the rule.  Wacko fringe groups?  Not quite.   The American Medical Association, the American Nurses Association, the American Academy of Family Physicians, the American Academy of Pediatrics, and 27 state medical associations. Democratic House Representatives Diana DeGette (Colorado) and Louise Slaughter (New York ) plan to introduce a Congressional resolution rejecting the Bush administration’s last-minute rules.

Perhaps they have questions like me.  Perhaps they, too, are the teensiest bit afraid of Dr. Government.  Perhaps they are wondering:

Does the law mean a doctor can refuse to treat someone who is gay? Or refuse to prescribe medications for someone who is gay and has HIV because they feel that homosexuality is wrong?

Can care be refused to someone who overdosed using illegal drugs because the doctor doesn’t approve of drug use or of illegal activities?

How about refusal of treatment of an unwed mother because they disapprove of premarital sex or having children out of wedlock?

Wait a second! What if the doctor is anti-gun? Does the law permit withholding treatment to someone who was injured by a gun?  What if it was the patient’s own gun that went off when he was cleaning it?

Should medical professionals be permitted to refuse to treat a member of any particular group who they deem as immoral?

Of course not. This is a dicey, ill-conceived last minute plan to slip in a policy that makes sense to some people on isolated religious grounds but the risks if its implementation are too great and far reaching.

 

Dr. Brett Kinsler is a chiropractor practicing in Rochester, NY who does not support the conscience rule….and no, wiseguy, this does not count as part of the 500 words.

Medical Licensure Should Be National – Sorry Nebraska

I hate when I miss the policy studies from the Cato Institute. Did you miss it too? The one about medical licensing? See, in the United States, the authority to regulate medical professionals lies with the states. To practice within a state, doctors must obtain a license from that state’s government. State statutes dictate standards for licensing and disciplining medical professionals. They also list tasks clinicians are allowed to perform. This goes for chiropractors as well. I would dare say that the scope of practice for chiropractors from one state to the next can be dramatically different. A fact that caused one of my MD friends to exclaim that the human body doesn’t change when it crosses state lines.

The Cato Institute argues that state licensure not only fails to protect consumers from incompetent physicians, but, by raising barriers to entry, makes health care more expensive and less accessible. Institutional oversight and a sophisticated network of private accrediting and certification organizations, all motivated by the need to protect reputations and avoid legal liability, offer whatever consumer protections exist today.

Consumers would benefit if states to eliminate professional licensing in medicine and leave education, credentialing, and scope-of-practice decisions entirely to the private sector and the courts.

Good call, Cato! This is not a desire to reduce state’s rights but rather to standardize a system that would benefit all by being more nationally homogeneous. Let medicine police itself….and remind me to send a box of chocolates to the Cato Institute, I think they could use break.

 

Dr. Brett Kinsler is a chiropractor in Rochester, NY but his skills are the same when he crosses state lines.  His office website is www.rochesterchiro.com

Adventures in Empathy: “Nope, I Don’t Feel Your Pain”

Patient: This is terrible.  I am overwhelmed.  I don’t know if I have one year to live, two years or what.

Doctor: Okay.  Do you have glaucoma?

I remember working as a tech at St. Whatever Memorial Hospital a bunch of years ago where I often felt the callousness and lack of empathy shown toward patients by jaded staff members was epidemic.  Patients were referred to by their diagnosis and bed numbers, not by their names. Mrs. Johnson became the “lung cancer in room 4” and Mr. Preston was the “congestive heart failure in room 6.”  Now, there is actually some documentation of this attitude among medical physicians toward cancer patients.

People struggling with lung cancer reach out for some compassion from their doctors – these are called “empathic opportunities.”  What the researchers in one study discovered was that doctors generally ignored these moments. Questions about morbidity (being sick), and mortality (dying) were addressed less than 10% of the time. Listening to transcripts and recordings of 20 conversations between men with lung cancer and their doctors, Researchers at the University of Rochester School of Medicine identified moments when a doctor might respond with a few words to address patient concerns ranging from fear of illness and death, to mistrust about care and the health care system, to confusion about treatment. When doctors did not respond to initial opportunities to be empathetic, patients would try repeatedly, throughout the rest of the visit, to elicit that support in some way.  Physicians missed nearly every opportunity to respond with compassion.

Lack of time, failure to recognize empathic opportunities because they are attending to other tasks such as making a diagnosis, a sense of failure when there is limited potential for a cure, or a physicians own vulnerability to illness and dying were all listed as possibilities for the physician’s actions.

Sadly, the authors state that physicians often start medical school with empathy for their patients, and only later learn to detach.  Sure, being empathic all the time could be exhausting — remember that empath on Star Trek: TNG?  She was always tired and rather annoying from sensing everyone’s feelings.  But studies actually suggest that rather than draining a physician’s emotions, providing empathy is actually a way to prevent burnout and lessen stress. Furthermore, expressing empathy can be taught and these statements can be brief and powerful, not prolong the encounter or necessarily changing a physician’s style.

Some physicians argue that they don’t lack empathy, they just have difficulty expressing it.  Well, patients don’t require extensive counseling or endless dialogue from non-mental healthcare providers.  A few, well-placed phrases of interest and concern go a long way.  Substitute a “That must be really hard for you” for some of the usual statistical references.  Slipping in a “tell me a bit of what you’re going through” in place of a discussion of blood lab values might also help.

Do you sense lack of empathy in your own physician or are you a doctor who finds yourself cutting off emotional conversations with patients? How would you advise others that feel a lack of empathy from their own doctors?

Source: Morse et al. Missed Opportunities for Interval Empathy in Lung Cancer Communication. Archives of Internal Medicine, 2008; 168 (17): 1853 DOI: 10.1001/archinte.168.17.1853

Rochesterchiro – The Skeptical Chiropractor – is written by Dr. Brett Kinsler.

Dr. Kinsler and Dr. Elliott Recognized by the NCQA

Treatment for uncomplicated low back pain varies widely. While most physicians follow the recommended approach of pain management and gradual return to physical activity, some prematurely prescribe costly imaging, epidural steroid injections-or refer their patients to surgery.

NCQA, the National Committee for Quality Assurance, has a Back Pain Recognition Program (BPRP).  This program seeks to recognize medical and chiropractic physicians who deliver superior care to millions of Americans who suffer from low back pain. The BPRP program consists of 13 clinical measures and three structural standards that address the broad spectrum of low back pain and focus on underuse, misuse and overuse of treatment modalities.

NCQA BPRP Seal

NCQA BPRP Seal

NCQA developed BPRP requirements from widely accepted medical evidence, with significant input from physician specialists and health plan and employer representatives.

Our office has been recognized as part of this program and Dr. Elliott and I are among only a dozen physicians at this time in New York State to achieve this honor.

http://recognition.ncqa.org/PSearchResults.aspx?state=NY&rp=4

We feel the NCQA BPRP program is a step in the right direction toward evidence based chiropractic treatment and are thankful for the opportunity to earn this recognition.

Dr. Brett Kinsler and Dr. Michalene Elliott are NCQA recognized chiropractors in Rochester, NY.  Their website is www.RochesterChiro.com

X-rays: Is seeing the only way to know?

There are so many myths about chiropractors I have a hard time finding a starting point.  Let’s address one of the more harmful myths in today’s column: x-rays.  I recently heard the proposition that “a thorough chiropractor is one who takes x-rays on every patient before he touches them.”  I actually hear some variation of this quite a bit from new patients.

It is simply not true.  The chiropractor who x-rays every patient is no more helpful than the medical doctor who gives every patient an antibiotic.

A thorough chiropractor is one who takes a complete medical history, carefully examines the patient and formulates a logical diagnosis and treatment plan.  As part of the work-up, the patient may require diagnostic imaging such as x-rays or an MRI.  Patients in certain profiles, with specific medical problems or history of certain types of trauma absolutely require x-rays.  X-rays are used to rule out some types of medical problems, congenital conditions and deformities.

Routine x-rays of all new patients is not a thorough practice — it is criminal, a waste of money, time and needless exposure to radiation. 

You certainly may need x-rays…but if you come across a chiropractor whose practice is to x-ray all patients, you are probably in the wrong office.

 

Dr. Brett Kinsler is a chiropractor in Rochester, NY who does not routinely x-ray his patients – even if they ask really, really nicely….only if they need it.

Art Imitates Pain

 

Every day I must ask patients how they rate their pain.  It seems stupid and patients are frequently stumped.

ME: Where is your pain on a scale from zero to ten with ten being the worst pain you’ve ever experienced and zero being no pain.

THEM: It hurts.

ME: I know, but can you put it on that scale?

THEM: It freakin’ hurts a lot.

ME: So like an 8?

THEM: Whatever.  Can you fix it?

A patient recently told me about the PAIN exhibit www.painexhibit.com  The PAIN Exhibit is an educational, visual arts exhibit from artists with chronic pain with their art expressing some facet of the pain experience. The mission of the PAIN Exhibit is to educate healthcare providers and the public about chronic pain through art; and to give voice to the many who suffer in abject silence.

Some of the pieces on the website are awe-inspiring.  Some truly disturbing.  Most are poignent.  Many are worth seeing.

Perhaps instead of pressing patients for a pain rating, we should hand some of them a box of crayons.

Dr. Brett Kinsler is a chiropractor in Rochester, NY

Doctor-Patient Relationship

As in all branches of healthcare, the doctor-patient relationship is paramount to the practice of chiropractic, but is an extremely complex interpersonal exchange.  The relationship must be strong and be based on good communication, openness and trust in order to facilitate a proper diagnosis and treatment.  The patient must trust his chiropractor and have confidence in his training, competence and continuity.  The chiropractor should be adept at making patients feel at ease and developing rapport.  A sense of humor is important for making a patient feel comfortable and reducing tension.

 

The doctor-patient relationship is the cornerstone of medical ethics and goes well beyond the legal covenant of patient privilege.  The doctor of chiropractic has numerous duties to the patient in their partnership, including:

 

  • Beneficence – assisting the patient in improving his or her health and conditions
  • Non-malfeasance – first, do no harm
  • Respect for patient autonomy, choice and individuality
  • Respect for patient dignity, privacy and right to confidentiality
  • The doctor’s role is to guide the patient in making treatment decisions in the patient’s best interest.

 

The chiropractor should be available to patients in an emergency situation, willing to return phone calls to answer reasonable questions and prompt in reporting test results to patients.

 

Patients can assist in the doctor-patient relationship by:

 

  • Being prepared with their questions and concerns in advance of a visit
  • Respecting the doctor’s time and professional boundaries
  • Ensuring their chiropractor has an up-to-date listing of their medications, surgeries, allergies and health conditions
  • Ensuring third-party payer arrangements and financial obligations are met
  • Having realistic expectations in their goals
  • Be willing to be an active participant in his or her treatment plan

 A good Patient Provider Interaction Resource can be found here.

Health 2.0


Consumers are now getting more of their health information from the internet than they are from face-to-face encounters with their healthcare providers.  This is part of a movement called Health 2.0.  Silly name but the concept is real.  Things have already gotten to the point where for a few patients each day, I will specifically tell them to either look something up on the internet or to stay off the internet based on their diagnosis.  Some diagnoses will lead them down a worrisome wild goose chase that I will then need to correct the learned misinformation on a future visit.  

Consumers need to remember that the internet as a source for health information is only as valid as the source providing that information.  And the fact that something has been agreed to in a general consensus, like a wiki, still doesn’t make it absolutely true.  You may recall that at some point in history, the general consensus was that the world was flat.  Still didn’t make it true.

Be careful who you believe in the electronic healthcare arena.

 

Dr. Brett Kinsler practices chiropractic healthcare in Rochester, NY.  His office’s website is www.rochesterchiro.com

 

 

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