A Country Doctor Writes:

As I scrolled toward the end of a consultation report from Cityside Pain Management the other day, I gasped internally. The pain clinic listed all kinds of mandated “quality” items, by number, that they have no chance of knowing.

Nor should they.

Since our EMRs don’t talk to each other, they have no way of knowing whether I ever ordered a bone density or pneumonia shot for my patient. And if they went ahead and did something preventative, how would I find out about it? Don’t assume I have a realistic opportunity to look for the occasional pearl in the massive number of outside computer printouts I get as PDFs in my electronic inbox.

No specialist should be jealous of my task of trying to stay on top of all my patients’ health maintenance. I send my patients to a specialist so they can spend 45-60 minutes on the single problem that is the main focus of their practice. Why would I want them to spend a significant portion of their valuable time on something that very plainly is my job?

The answer to my rhetorical question is:

Because CMS, the powerful agency behind Medicare, says so – that’s why. It makes no sense to me, but I’m just a country doctor, what do I know?

It is not unusual to see a patient for a timely “Transition Of Care” visit after a hospital admission and within a minute of entering the exam room know with all the bones in your body that this person needs to go back into the hospital.

The funny thing is that when that happens, if the patient has Medicare, we may indirectly suffer financially from such “avoidable readmissions”. We belong to an ACO, an Accountable Care Organization, which is one of the recent schemes Medicare created to save money. The hospital most of our patients go to, Cityside, is not part of our ACO, but we are at financial risk while we have absolutely no control over the hospital’s charges or readmission rates.

I mean, what else could I have done with Allan Beck?

He had rolled his tractor and broken half a dozen ribs a little while ago. Commendably, he didn’t want to go to the emergency room for nothing, so he had called and argued with the triage nurse about coming here instead. She thought she had him convinced, but half an hour later he showed up at the check-in window.

“Triage to the front desk” was announced and Dr. Kim ended up seeing him briefly and ordering ambulance transport to Cityside.

When I walked into the exam room a week and a half later, the muscular could-have-been-a-movie-star farmer was so pale and frail looking that he seemed to blend in with the faintly blue wall paint.

As the story unfolded between his laconic answers to my questions and my speed reading of the hospital discharge papers, it became evident that the day before discharge, he had substantial atelectases and possibly an evolving infiltrate of his left lung, but that his collapsed lung remained expanded with his chest tube gone.

“Yeah, I’ve been coughing up yellow crud since my first day in the hospital”, he told me.

He had almost no breath sounds in his left lung, his white blood count was up and his reds were the same as when he was discharged, one third down from his baseline. His X-ray showed what I had heard, a massive consolidation of much of his left lung – a nasty pneumonia or even empyema, pure pus.

The ER doc sighed. “OK, send him up.”

The irony is that there is a new scoring system that’s supposed to predict a person’s risk of readmission. Allan’s score was low. Everybody loves to use mathematical models, but when it comes down to it, clinical judgment and anticipating “the worst” would have been more valuable in the very moment that his last hospital X-ray was done.

October is when we do our annual provider evaluations. I’m using the same format this year as last, a personal inventory done by each provider as well as three others – support nurse/medical assistant, clinic manager and referral coordinator/radiologist/care manager. This is complemented by assessments of billing/documentation, quality and productivity data and overall assessments by management.

I guess, in a way, I wrote the provider self assessment as a yardstick for myself. It’s hard sometimes in today’s detail driven healthcare environment to remain focused on what it means to be a doctor.

I’m sharing it here for anyone who is interested. Just to mention, only one of my providers gave himself/herself a “10” on every question, and it wasn’t me…

Health care was supposed to value patients’ privacy and be sensitive to their cultural, religious, philosophical, educational, sexual and socioeconomic background. It was supposed to move the visit agenda and the medical decision making authority from the doctor to the patient. It was supposed to create safe “medical homes” for patients of all backgrounds. It even established certification processes to ensure practices were indeed patient centered.

We are officially recognized as a patient centered medical home, and this is what that looks like:

When you arrive at the front desk for your routine physical, you are handed a form asking you to specify in great detail what your gender identification is.

In the exam room, the medical assistant administers, in rapid fire questioning, a “validated” nine item depression inventory. She then verifies your medications and updates your personal, family and social history. As part of your social history, if you happen to admit to being a smoker, a “smart form” with followup questions pops up with questions from “How many minutes after waking up do you smoke your first cigarette?” to “How ready are you to quit?” Similar questions about alcohol use follow.

If your visit happens to be a Medicare annual wellness visit, you are also bluntly queried about anxiety, sexual difficulties and history of falls as well as anything you want to confess about messing up your medication regimen. And, perhaps most invasive of all, if your body mass index is higher than ideal, your doctor will be required to document a treatment and followup plan to manage your overweight or obesity. If any of these items are omitted, Medicare has the right to demand their money back from your medical provider.

So, after all that, are you still going to be in the mood to discuss your most sensitive issues with your medical provider in the few minutes that remain?

Now, the most amazing thing to me is that people put so much faith in these blunt tools that are promoted as “validated instruments”.

Does a homicide detective ask a suspect “Did you do kill the victim?” and leave it at that? Does a customs and immigrations officer say “Are you a smuggler or a terrorist?” Does a principal ask a prospective teacher “Are you a pedophile?” That sounds about as sophisticated as today’s “validated instruments” in my business.

I still remember when, without using the words “patient centered”, we would sit down and have conversations with patients. We would say things like “can you tell me a little about your habits, your work and your home life?”

And, perhaps most important of all, just a few years ago, the opening phrase in a good medical office visit used to be ”what would you like to accomplish in today’s visit?”

That was before we became certifiably patient centered…

“Räta på ryggen! (Straighten your back!)” everybody seemed to be telling me during my formative years:

My mother said it, and so did my gym teachers all the way through school, not to speak of my drill sergeant during basic training in the Swedish army. Even my own inner voice in many situations, including standing next to my wife, one inch shorter than I but sometimes wearing two or three inch heels.

I never thought much about it, because I never had back pain, except when I tried to stand straight. I went on three-day hikes with a 40 lb. backpack as a Boy Scout and Explorer and during my brief stint in the army without experiencing more of a backache than anyone else.

More than 25 years into my medical career, I suddenly realized what was going on.

My wife and I were taking private ballroom dance lessons in a dusty upstairs studio with mirrored walls. One time, while our octogenarian instructor was rewinding his cassette tape with foxtrot tunes, my wife looked at my image in the mirror and said:

“Your belt looks crooked.”

It did look crooked, but it wasn’t. I shifted my weight around and made my old, familiar movements to straighten my back. It didn’t feel comfortable at all. Still waiting for the music to start, I shifted my weight from one leg to the other while trying to keep my back straight. With my weight on my left leg and my back straight I felt serious pain in my back and my right leg seemed too long to know what to do with. Shifting my weight to my right leg while lifting my left heel so that only my toes touched the parquet floor, something magical happened.

My back stopped hurting and I felt tall and straight. My belt looked horizontal in the mirror and I looked almost taller than my wife.

My simple leg length difference explained years of poor posture and occasional back pain trying to straighten a back that wasn’t crooked in the first place.

There is a medical lesson here, and as a physician in my early fifties I had heard it and probably preached it many times myself:

Don’t assume the pain originates where it is felt, examine the joints and other structures above and below.

In my case, I don’t even need a heel lift, I just stand square on my right foot and on my left tiptoes and I’m tall and straight. When I walk, I’m only on one foot at a time, so there is no problem then. And these days, I don’t stand still very often.

Physician, heal thyself.