Thursday, August 14, 2008

Ouch........that hurts, Dr. Rob....

I've been following some medical blogs lately, which you already know if you read this blog, and Dr. Rob's has been featured prominently here. His latest series on the doctor/patient relationship has been an interesting give-and-take from both sides of the issues. The New York Times even picked up on it.

Just as it was getting interesting, I chose to go visit my parents. I was torn, trust me, but my parents always come first. And since they have dial-up due to the rural area in which they live, accessing anything of importance is moot. No, even the wireless broadband cards won't work there consistently unless one stands at a certain angle elevating laptop to such a degree know what I mean. I have to sit in a certain chair turned a certain way just to use my cell phone.

I came back to another post by Dr. Rob with a response to the comments on the NYT's article. Frankly, it made me sad. In fact, when I tried to comment about it on Dr. Rob's blog, I typed and wiped umpteen responses. In the end, all I could say was "Ouch".

Why? Because it made me despair more for those attempting diagnosis and treatment for Cushing's. For anything, really, but this is the cause I have taken on because I have been there. Am there, and will be there.

Ask Lisa....she knows:
At some point during my long and ongoing illness it occurred to me that it might be a fault of my own for not getting answers for my ailment.
And now she's dealing with umpteen specialists who all say something different. And no one the same. Who is going to mediate all this? Her PCP? No way....

This brings me back to what Dr. Rob just wrote:

But the real reason things are hard to improve in most offices is that there is no financial incentive to do so. With a primary care physician shortage, there are no shortages of patients. Customer service won’t determine how busy physicians are. It is unusual for a PCP in our area to have any problem filling their practice.
Ok, so, PCP's can still get plenty of patients without improving anything. Ouch.

Reengineering the office will cause a drop in revenue that they cannot afford. This is one of the reasons computerized record adoption has taken so long; medical offices can’t afford the drop in income needed to adapt to a new system.

There is not only no financial motivation to do a good job, there is a disincentive to do so. You earn less when you do right by your patients because you spend more of your time doing things you aren’t paid to do. Either that, or you spend less time with your family.

I'm feeling less like a person and more like a number. Object. THING. Commodity. OUCH!

To give Dr. Rob credit, he does say he tries to do a good job because "it is the right thing to do and because I want to take care of my patients". I'm sure there are other doctors out there like that. I want to believe that, anyway. I really, really do. (Hunting my rose-colored glasses....hmmm...they need some cleaning....)

Does it all boil down to a PCP shortage? Who is at fault? Is it the PCP's? The specialists? Us? It's one thing to gripe as a patient, but it's another to try to do something about it. Sadly, as a Cushing's patient realizing this dilemma, one tends to not feel much like doing anything when the most needs done.

So what is the problem? You can get all sorts of answers to that, and I found umpteen dozen when reading pertinent blogs. I'd like to point out two which are well-written and to-the-point.

Kevin Pho on comments with his article, Shortage of primary care threatens health care system.

The key is how doctors are paid. Known as "fee for service," most physicians are paid whenever they perform a medical service. The more a physician does, regardless of quality or outcome, the better he's reimbursed. Moreover, the amount a physician receives is heavily skewed toward medical or surgical procedures. A specialist who performs a procedure in a 30-minute visit can be paid three times more than a primary care physician using that same 30 minutes to discuss a patient's hypertension, diabetes or heart disease. Combine this fact with annual government threats to indiscriminately cut reimbursements despite rising office and malpractice costs, physicians are faced with no choice but to increase quantity to maintain financial viability.
Roy M. Poses, MD, writes for Health Care Renewal, and in his article "On Disparities Between Reimbursement of Primary Care and Proceduralist Physicians" he neatly outlines the problems and what PCPs, specialists, researchers and patients can do to improve health care. The main points in his synopsis include the pay-gap between PCPs and specialists and the role of Medicare's Resource-Based Relative Value Scale (RBRVS) system of reimbursement.

Dr. Poses goes on to quote an article in the Annals of Internal Medicine and comment on it:
"primary care practice is not viable without a substantial increase in resources available to primary care physicians." Yet primary care is an extremely important, albeit neglected part of the health care system. Most patients value "having a primary care physician who knew their medical problems." Furthermore, "patients with a regular generalist physician have lower overall costs than those without a generalist physician."
The best part of this whole article, though, is the outline of what each group involved can do:


  1. If you are a primary care or cognitive physician, realize why your financial position is becoming untenable and stop feeling guilty about protesting an unfair system.
  2. If you are a procedural specialist, realize that you are in the same boat as the primary care and cognitive physicians. If our part of the boat sinks, yours will not long stay afloat.
  3. If you are a health care researcher, think about addressing this elephant in the living room which many of you have so long ignored.
  4. All others, tell your political representatives that fair physician reimbursement and a viable primary care system are both worth having.
While Number 3 is somewhat pertinent and I'm trying to do that here, Number 4 definitely applies to me. And to you.

I can do that. Can you? Actions do speak louder than words, even when the word is an "ouch".



  1. I frequently hear primary care physicians comment that they cannot afford to implement EMR. I do not believe this is true. An excellent analysis showing a $150,000 return on EMR investment over a 5-year period can be found at

  2. Thank you for that link. Can't wait to peruse it.




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