Medicine Magic Lamp

My real estate agent voice was trembling on the other side of the line. I was expected to walk through the house with the buyer and show him few things. I called her because I forgot my keys to the house. Luckily she was in the neighborhood. She said that she would be on her way. I couldn’t fathom the reason behind her shaking voice until she uttered: “Did you know that ‘the doctor’ shot himself?!” My first reaction was that of disbelief and shock. It took me a moment to realize what she is really saying.  “He was my daughter’s doctor and she heard from some of her friends. I hope it is not true”, she added. Five days later, and I am still pondering what happened.

I did not know ‘the doctor’ on a personal level but I have seen him in the physicians’ lounge every once in a while. He struck me as a confident nice man. A man that can be successful in whatever he put his mind into. In fact, he had the look of a politician. Our interactions were limited to greetings but sometimes these can be enough to form an opinion about somebody. His piercing blue eyes gave one the feeling of warmth and trust. I learned after his death that he was a fourth generation physician and that his great grandfather established the local clinic in the early 1900’s.

I knew that his practice has been recently in trouble. He made it clear to the community that it will be closing its door this month. He had a strong competition from the other multispecialty clinic in the community over the past few years. His practice ended mainly dependent on a single large health system that did not have his specialty presence in town. However, when that large health system decided to consolidate all their patients and bring their own physicians to town, the doctor practice almost collapsed.

The doctor, God bless his soul, was and is not the only one who is dealing with these issues. Issues that stems out of the efforts to redesign the current health care system. Physicians are constantly under pressure to join patient-centered medical homes, accountable care organizations, coordinated care organizations and others. Otherwise, they risk payment cuts from various insurance agencies and Medicare. Small group practices have to swallow the cost of electronic health records programs, and other various new regulations or risk more cuts.

It appears that all the recent health care reforms and regulations are geared toward consolidating medical practices into bigger systems that has the resources to deal with them. Implementing an electronic health record (EHR) for example come with a price tag of $233,297 for the first year for an average five physician practice according to a recent study. This cost includes hardware and software expenditures and lost productivity during implementation of EHR. Sure there will be improved productivity down the road but there is also the annual cost of maintaining EHR, which is estimated at $17,000 per physician.

This is a big burden that small practices cannot handle easily. But government not only want to implement EHR, it wants physician and health care systems to demonstrate “meaningful use” of EHR. Therefore, EHR system they use has to be a certified to satisfy the rules of meaningful use. On top of that, physicians have to prove it so that they can get some incentives. Meanwhile, they have to take care of patients, deal with the competition and politics de jour.

Government is rubbing medicine magic lamps and the genies are coming out. However, these genies may not grant physicians all their wishes. They have to choose to either ride on the shoulders of these genies or risk being crushed under their giant feet. The ideal solution will be for the physicians to transform into genies and lead the way but they are too busy taking care of patients and the genies are already out. The doctor was busy taking care of his patients and did not have the chance to transform. Rest in peace doctor!

A chief complaint

In the email that I got from the person at our billing department it was explained to me that I couldn’t bill the patient for a follow up visit if he/she has no complaints. She further elucidated that when they have no complaints, I should write the diagnosis as a chief complaint. I follow patients with chronic kidney disease and many of them come to me to monitor their kidney function, blood pressure and to manage risk factors for progression of their disease. Many of them do not complain of anything specific until very late in the course of their disease.

In Medical school and Residency, we learned that a “History and Physical” has a seven essential elements: chief complaint, history of present illness, past medical history, social and family history, physical examination, review of laboratory and imaging findings, and an assessment and plan. The chief complaint, we were told, is better described using the same words used by the patient. A follow up note, on the other hand, has four elements: subjective, objective, assessment and plan. I do not recall ever being told to include the patient diagnosis in the chief complaint so that I can bill him. In fact, we never received any education about billing patients!

Yesterday, I received a copy of one of my colleagues note. It started with the chief complaint: “I am here for a postoperative global assessment!” While, I was pretty sure that the patient did not say that, I knew exactly what it meant. It is the only way my colleague can get paid for his services. This is our modern day Medicine. Physicians have to document their “services” in a way that appease bureaucrats in insurance companies and Medicare and not conform to their trainings.

Instead of compassionate care and sound clinical judgment, we are now witnessing the gradual transformation of Medicine into lines of services that are gradually falling into the abyss of hardhearted automation. This automation has to comply with regulations, paperwork requirements and guidelines. All while maintaining a great score on the patient satisfaction surveys to sustain the physician salary without performance cuts.

The state of current Medicine has a chief complaint and it is not about how to bill better. Medicine is sick .The history of its present illness is that physicians have left the field to others to tell them what to do and how to do it best. At this time, it appears to be a hopeless case. Its prognosis is poor! I guess the chief complaint and the diagnosis are the same: Medicine has a terminal illness.