Ian Furst of Wait Time & Delayed Care responded to my last post by pointing out the role PCP's play in poor communication. He is right. I don't want to sound like a whiner, just pointing the finger at others without noticing those faults I and other PCP's have. So this post will turn the finger around (no, not that finger) and point out ways PCP's drop the ball in the healthcare process. The main reason for us not doing all we should, as is usually the case, is laziness. If I don't get paid to do something and do not benefit in some tangible way, I often don't do it. One could argue that PCP's are simply too busy to give time to other tasks, but then there is no room to complain about specialists doing the same thing. I like complaining about specialists too much for me to give that up (it's a fun hobby), so I am obligated to be sure I am not falling down on my job. If the system is to improve, all of us must do our part to make that happen.

So here is a list of ways to be a good primary care physician (that we often botch up):

  1. Let your consultants know why you are consulting them. The more information they can have, the better. This is not just to make them happy, but if you are truly managing the patient as a whole, you must have a question you cannot answer if you are making a consult. A note here: we are in the process of trying to give our consultants e-mail access to our documentation, but there is not quite as much interest as I would expect.
  2. Don't consult until you have done the reasonable things that precede consultation. For instance, I know that my orthopedists will generally give people an NSAID and send them to physical therapy for many conditions. It is very reasonable for me to do so prior to sending them for that consult. Don't waste the time of the consultant if you can do it yourself.
  3. Call the ER if you are sending patients there. I have found it most helpful to explain to my ER colleagues why I am sending a patient to them. This lets them be more focused in the question I have and makes them much more likely to call me up when they are finished.
  4. Don't order tests if you don't know what you would do with the results. I try to order tests only when I am trying to make a decision, and not simply to find things out. For instance, when I have a person with sciatica, I won't order an MRI scan unless there is a possibility a person would go for surgery. If they are not yet surgical candidates, what is the purpose of an MRI scan? Just give them steroids and send them to PT. A large portion will get better. This is true for pretty much any test you order.
  5. Patients aren't noncompliant to be mean to you. It is easy to get angry and offended when a person comes in after you have given clear instructions and has not done any of these things. Why are they here at all? Why waste my time with someone who won't do what I say? The fact is, these people come in and pay you for a reason. They really aren't wasting your time when you are being paid, are they? There are almost always reasons for noncompliance, and there are reasons why people come back to you. To offend you and waste your time are not on this list.
  6. When you sign an insurance contract, don't be surprised when the insurance company follows that contract. If it says that they have a drug formulary, then expect them not to make an exception of you. You always have the right to back out of contracts. Drug formularies, by the way, were put there because physicians would always prescribe the "latest and greatest" medications when older ones would do just fine. I remember when the formularies first came to our market, how I suddenly stopped writing for brand-name NSAID's and wrote generic Naproxen. Looking back, I was easy prey for the smooth talk of the drug reps. It was our lack of self-control that played a big part in making formularies a mainstream practice.
  7. Always remember the cost of what you do. Even with copays, medication costs add up quickly, as do procedures. Being conservative with use of medications and test ordering is much appreciated by most patients.
  8. Run your practice like a business. Don't get caught answering financial questions by your patients. Your job is to offer medical care, but they should be paying for that care. This means that your business office must always have your support when they expect payment. The reason many docs are not making money is that their compassion for their patients spills over into the financial realm.
  9. Look away from others' cars in the doctor's parking lot. Really, that is where envy hits the hardest. The "why should they...why don't I" questions lead to a lot of unnecessary grumbling. You can be perfectly happy with a used Camry (or a Yugo?).
  10. Prepare for change. We are getting to be a scarce commodity and yet one that reform will hinge on. This means that having good data collection, good disease management systems, and efficient practices will stand you in good stead for the future. Those on the front of the wave of change will benefit the most. The laggards will always lose. Even though change may be for the worse, the only way for things to be better is for them to change. Things suck now, so why complain about change?

Nothing earth-shattering here, but things that are hard to stick to for all of us. We can get this persecution complex among physicians that does not help our cause. If we can do our job as best as we can, then perhaps we can have a hand in effecting change for the better. I have to tell myself this every day.

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