Two Good Doctor Posts

By John Ballard

Amid the madness stirred up by the health care debate I often come across evidence that many medical professionals really are in their chosen fields to be caring, healing practicioners. Two recent posts from The Health Care Blog illustrate the point.

Margalit Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS (Electronic Health Record/ Practice Management Software) and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.  In plain language, she helps providers keep up with technology.

She recently encounted a doctor in a rural setting whose lifestyle would fit comfortably into Mayberry, hometown of The Andy Griffith Show.

Last week I went to see a doctor about an EHR [Electronic Health Record]. Dr. Greene (not his real name) is a typical solo primary care physician in a typical small town in the typical middle of nowhere. Four hours from the closest airport and miles and miles of winding roads, cow pastures and corn fields away from medical centers of excellence. Dr. Greene is in his late fifties and has been practicing medicine for over thirty years in the same location. He works six days per week and missed �two and a half� days of work since he hung his shingle up and never missed a Rotary Club luncheon. Dr. Greene is planning on practicing for ten more years and now, he wants to go electronic.

Dr. Greene�s practice is located in a small and spotless one-story building with large windows and an open floor plan. We sat down at a white laminate round table in the kitchen during his lunch break. His wife of many years is his office manager and the only other employee is a nurse who doubles as front office receptionist. His shortest appointment is for 30 minutes and new patients, who are scheduled for 1 hour, come at the end of the day just in case it takes longer than planned. His notes, written on special gold colored paper in nicely rounded cursive font, are concise and neatly organized by visit date. Like most doctors who use paper charts, he doesn�t code his visits. He checks diagnoses and procedures on a sparse super-bill devoid of any numbers. His wife and office manager takes it from there and all his claims go out electronically every day.

Dr. Greene collects 99.6% of his charges and he never used a collection agency and he never will. Wait a minute�. This is impossible. Insurers deny payments all the time and they certainly don�t pay what you bill out. Not to mention that patients are not very quick to pay either. How can you collect 99.6% of charges? How about allowables and adjustments and write offs and all other administrative nightmares that are part and parcel of a medical practice? Dr. Greene walked out of the kitchen and returned with a piece of paper he picked up at the front desk: his fee schedule.

Dr. Greene�s fee schedule was neatly typed on a letter sized pink sheet of paper and carefully encased in a clear plastic protecting sleeve. The fee schedule contained about fifteen procedure codes, mostly E&M codes for various office visits. He doesn�t do any procedures in the office and if he does an �EKG or some other simple thing�, he doesn�t charge separately for it. The fee schedule had two columns for each code; the Medicare allowed fee and the actual fee he charges all his patients. I had to look several times at the column headings to understand � Dr. Greene charges less than Medicare is willing to pay him. For the most common visits, he charges a lot less than Medicare will pay. He bills these lower charges out to Medicare, to all private insurers and to his cash patients. Why????

Dr. Greene was laughing and Mrs. Green was smiling at my total lack of understanding. I guess city folks are not so bright after all. For Dr. Greene this is a matter of principle. It is an entire philosophy. This is about fairness and honesty. His patients are his neighbors and he knows all too well that most cannot afford to pay the Medicare deductibles. He charges what people can pay and he makes it simple, straightforward and fair. His fee schedule is displayed at the front desk. In return, his patients pay their bills promptly. Fairness in small communities is usually reciprocated. Medicare and commercial payers, probably assuming he is mad, are quickly paying his claims just like a quarterback quickly snaps the ball to avoid a challenge. That�s how you get 99.6% of your charges collected with very little overhead. And, no, he is not at all interested in changing things. He is making a very nice living, thank you.

Dr. Greene wants an EHR. Why? Because he wants to receive lab results electronically from the little hospital down the street, and because he wants to use templates. Templates??? You mean you want to click on boxes instead of writing those beautiful golden notes? He thinks a dozen or so customized templates would make him more efficient and allow him more time with his patients and perhaps he can go home a bit earlier too. He wants to send prescriptions to pharmacies and not have to write down the medication list each time. No, he doesn�t want to create documentation for higher billing codes. And he doesn�t want to be left behind.

Dr. Greene, unlike some of his colleagues in town, has no plans of running away and retiring early in the face of new challenges. He will get an EHR and he will exchange clinical information and he will advance with the times. He will be exploring quality improvements and medical homes and even accountable care organizations. Dr. Greene knows that EHRs slow you down and are well positioned for improvement, but he also knows that his grown children, who are themselves physicians, will expect an electronic office if and when they return to their hometown to continue the tradition. There was a faraway dreamy look in his eyes now. Lunch hour was over and there was one patient in the waiting room.

For all the pundits and the health economics experts, and for the political activists on either side, who are actively trying to dismantle our health care cottage industry and reconstitute its remains into large corporations of efficiently employed physicians, this is what you are attempting to dismantle - Dr. Greene, and the thousands of others like him who practice medicine four to five hours away from a major airport beyond miles and miles of cow pastures and fields of corn.

Regular readers here may recall past posts about the medical home and ACO concepts. Make no mistake about it: despite a chorus of complaining by misinformed lay people, plenty of doctors are getting on the new technology  bandwagon. I know that years ago my firstborn was nearly lost in the first trimester of my wife's pregnancy simply because a pharmacist misread a prescription and issued her four times the amount ordered by the OB doctor. E-prescribing will significantly minimize mistakes like that.

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Dr. Herbert Mathewson's account of his experiece as a patient reveals one of the pitfalls of technology, the unfortunate loss of what laymen call, literally, the human touch.

It appears that except for physical therapists, masseuses, and priests no one lays on the hands anymore. Certainly contemporarily trained physicians do not.

Recently I went to my local ER because a 2-day old pain in my back �due to a strained muscle� from a gym work-out was now, at 11:00 PM, causing me to be quite short of breath and unable to lie down. The ER reception desk was empty and, as the sign instructed, we picked up the phone and announced our presence. An ER nurse came out, signed me in, registering me as a new patient, escorted me back to a cubicle, recorded my vital signs, took a short history, listened to my chest (�A few crackles there in your back�), started an IV, ordered an EKG and a chest x-ray, and drew a whole bunch of bloods, one tube of which revealed that I was probably having pulmonary emboli (clots to my lungs). The CT scan confirmed the diagnosis of �multiple bilateral pulmonary emboli�.

Then I saw my first doctor. While standing at the bottom of the bed juggling a clipboard that was barely controlling various colored sheets of paper, she took a short history, listened to my chest (�A few crackles there in your right posterior chest�), told me that the CT scan was positive, and that the admitting hospitalist would come to see me soon. The nurse explained that the ER doc was busy with a very sick patient being transferred into town.

The admitting hospitalist was a true gentleman. He even sounded like a gentleman with his clipped British accent and Eastern Indian last name. He took a longer history, listened to my heart and lungs (�A few crackles on the right side there�) and outlined what was to happen next; a stay in hospital for three days at least, immediate anticoagulation, and tomorrow an ultrasound of the legs and an echocardiogram looking for a source of the clots. He explained things very clearly, was reassuring, and answered my questions succinctly and thoroughly. I felt that I was in good hands, �but I was a little uneasy that no one had done a complete, or even a semi-complete, physical exam.

What has happened to all that we were taught in second year Physical Diagnosis?

No one stretched my calf looking for a positive Homan�s sign. No left lateral decubitus positioning to listen for that subtle, easy to miss heart murmur. No confirmation that my extraocular movements were normal. No listening intently for a carotid artery bruit. Forget looking for splinter hemorrhages on my retinas or even under my fingernails. My abdomen could have been hiding an enlarged liver or spleen, but no one would have discovered it that night. Come to think of it, I do remember the admitting hospitalist briefly pushing two fingers against my shins and commenting, �trace edema�.

After a day shadowing a physician in a program sponsored by our local medical society, a banker summed up his impression with, �A physician�s job is a day-long quest for credible data�. I agree, and it is clear to me that the physicians caring for me that night were doing just that as efficiently as possible. Why bother checking for Homan�s sign when an ultrasound tech the next morning will tell you if there is a clot in the leg, its location and how big it is? The echocardiogram will give so much more information about my heart dynamics than an application of a stethoscope for a minute or two. With a dramatic CT scan showing all the clots and some pleural fluid, and with me having significant pain every time I took a breath, why spend a lot of time percussing my chest, feeling for vocal fremitus, or switching back and forth from bell to diaphragm on the stethoscope?

As technology has advanced, objective test results have replaced many physical findings as the foundation of a correct diagnosis. The job of the physician has become in large part that of deciding which test will give the best information. That is not bad, but I remember that our Physical Diagnosis professor won more �Best Teacher� awards than any other faculty member, � or any imaging machine. He not only provided us with our first glance into the real magic of clinical medicine, but he imprinted us with the appreciation that �laying on of the hands� was a vital part of a respectful relation with the patient.

I received excellent, efficient care. I was diagnosed quickly and treated appropriately, courteously, and was fully informed. But, in remembering Eliot Hochstein, MD I have to say that as a patient I sure do miss some parts of the �good old days�.

One part of the �good old days� hasn�t changed. At about 1:30 AM after all the tests that night were done and I was being prepared to be moved upstairs to a bed, I was still really uncomfortable because I had not yet received any pain medication. I asked for some, and got my first dose at 2:00 AM.

These are not simply "feel good" anecdotes for casual reading. Together with their mostly intelligent comments threads they show how medical professionals are responding to trends in medicine. No everyone is talking sunshine and roses. Some are negative to the point of being ugly. But the larger point is that if health care is to get better outcomes and stop runaway costs this conversation is totally essential.

As a layman I am encouraged to see honest discussions among those where the rubber hits the road, mostly unmolested (for the most part) by sniping from the insurance industry. This represents a shift in the public debate. Two years ago insurance people were in the comments thread like flies at a picnic. Now the mood is changing, hopefully for the better. The reader with time to do so is encouraged to drill into the links and read the comments threads at both of these posts.

Thanks to a link in the comments this story from the NY Times is also worth a visit.

[...]
Art and medicine may seem disparate worlds, but Dr. Verghese insists that for him they are one. Doctors and writers are both collectors of stories, and he says his two careers have the same joy and the same prerequisite: �infinite curiosity about other people.� He cannot help secretly diagnosing ailments in strangers, or wondering about the lives his patients lead outside the hospital.

�People are endlessly mysterious,� he said in an interview in his office at the medical school, where volumes of poetry share the bookshelves with medical texts, family photos and a collection of reflex hammers.

[...]
He worked in Tennessee during the early days of the AIDS epidemic, before there were any effective treatments. Before AIDS, he said: �I must have been a conceited ass, full of knowledge. AIDS humbled a whole generation.�

He came to know many of his patients and their families. He visited their homes, attended their deaths and their funerals. One patient, near death, awoke when Dr. Verghese arrived, and opened his shirt to be examined one last time.

�It was like an offering,� Dr. Verghese said, with tears in his eyes. �To preside over the bed of a dying man in his last few hours. I listen, I thump, I don�t even know what I�m listening for. But doing it says: �I will never leave you. I will not let you die in pain or alone.� There�s not a test you can offer that does that.�

His long hours and intense involvement with his patients led to his first book, �My Own Country,� but also drained him and contributed to the failure of his first marriage. Still, it was not a mistake to get so close, he insists.

�I�ve never bought this idea of taking a therapeutic distance,� he said. �If I see a student or house staff cry, I take great faith in that. That�s a great person, they�re going to be a great doctor.�