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Going Gets Tough

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Going Gets Tough

My goal is not to have fodder for good blog posts.  My goal is not to impress people with my great ideas.  My goal is not to get pats on my back or praise from my colleagues.  It's not bad to have any of those things, but the goal I have is much bigger, and is long-term.  I want to be part of the proof that we can do better than to give people the sickness-centered, treatment-heavy, over-priced, and chaotic care most Americans are getting! 

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Our Broken System - #3: Dropping the Baton

My patient was angry, confused, and frustrated.

He had transferred his care to me because I take care of his kids and he badly needed help with a terrible pain in his leg that wasn't getting any better.  He went to another doctor - an orthopedist - who predictably focused on the joint as being the cause.  After x-rays and MRI scans of the joint, my patient was told that there was "nothing wrong."  The pain continued to get worse, and he had just now broken out in a rash.  His calls to the specialist were met with suspicion, and flat out rejection.  Now he didn't know where else to turn.

When he finally came to me his pain was excruciating.  He sat across the room, writhing as he tried to find some position that would not be as painful..  His skin was now very sensitive to touch and the rash was very strange in appearance.  His joint exam was entirely normal.  This was clearly not a joint problem; it was a neurological problem.  I knew him from visits with his kids, and never felt he was one to exaggerate or invent symptoms, so I trusted what he was telling me.  Besides, there was that strange rash.  Nothing was working for the pain, and he wasn't taking any narcotic pain medications "because they didn't work."  I asked my partner to come look at the rash, and he agreed with me that this was very likely to be reflex sympathetic dystrophy (RSD), a pain condition caused by trauma to a sympathetic nerve.  It's weird, it doesn't respond to pain medications at all, and it hurts like hell.

He needed pain management to get a nerve block, as no drug I could prescribe would do more than blunt his terrible pain.  But there was a catch: he was a Medicaid patient.  Medicaid patients have two big disadvantages: first, they are very limited in the physicians they can see, as reimbursement is bad; and second,  the reputation of Medicaid patients (partly deserved, partly not) is that they abuse the system and seek drugs.  In our city, the only pain management doctors who treat Medicaid patients are at our local academic facility, Smarty Pants University of Health Science.   This is not good news.  Not only are they difficult to reach, but they tend to view all patients suspiciously. My experience was pretty bad with how my patients get treated there, but I had no choice.

I felt this patient needed to be seen very soon.  To try to reduce the automatic suspicion, I called the pain clinic and spoke directly to the physician.  I explained the history of symptoms, their severity, the ineffectiveness of narcotics, and about the appearance of the rash.  I also reassured him that my patient seemed to have real pain, I don't think he's seeking drugs, and that I suspected RSD.  I was met with an unenthusiastic response and a reluctant assurance that he would try to get my patient in "as soon as possible."  Clearly he didn't believe what I was saying.

A few days ago, my patient came back.  "They don't believe me," he told me, almost in tears.  "They suggested that maybe this was, you know, in my head," he added as he pointed to his head.

"What about the rash?" I asked, incredulous.

"They didn't think much of it.  They told me that they could treat me when you figure out what's going on," he said, getting angry.  I had ordered an MRI scan to assess his lumbar nerve roots to see if maybe this was causing the pain and referred him to a dermatologist to get that angle on things.  His pain was getting no better with the Neurontin I prescribed, and the rash had spread in a pattern that made me question the diagnosis (although not the reality of his pain).

We both sat quietly for a long time, unsure what to say at this.  I sighed.  "I guess I'm going to have to figure it out then," I said, shaking my head.

"And I guess I have to hurt for a while longer," he said.


This story,  in which I've changed significant facts but kept the core, illustrates another broken part of our system: consults. Consulting physician, both academic and private, often result in anger and disappointment on the part of my patients, and very little help in addressing my questions and concerns.

From the patient's perspective, the passing of the medical baton carries the following assumptions:

  1. Care from the specialist will be based on what I've already done
  2. I communicate with the specialist
  3. I trust the specialist to whom I am referring them.
  4. The specialist trusts and respects me.
  5. The specialist communicates with me.

Sadly, none of these assumptions are true in many cases, and all of the assumptions are rarely true.  Why?

  1. Specialists rarely know and often don't care what I've already done on the patient.  Some of this is because they don't have access to the labs I've ordered, the tests I've run, or my thought process up to this time.  We try to send information ahead of time, but somehow that rarely gets in the hands of the person actually seeing the patient, and so many of them don't bother looking.  We've tried to send information through secure messaging (email), but were met with almost universal refusal.  Ironically, the one physician who does engage me electronically works at Smarty Pants U.
  2. Some of the problem is on my part as well.  I don't send a note to the specialist saying why they are being sent.  Yes, they do get an ICD-9 diagnosis, and usually some supporting documents, but they almost never know what specific question I want answered.  Some of this is because I am busy and don't have the time to do extra, and some is because the specialists  are busy and don't like to be bothered with extra.  Regardless, the baton is nearly always poorly passed.
  3. I often can't send patients to the specialists I prefer.  There are some specialists I know and respect, and I try to use them as often as possible.  But often I am sending patients to someone I have never met and know only by the notes they (sometimes) send back.  The story in this post underlines the fact that Medicaid patients are much more likely to get my "less-preferred" specialists.
  4. I am not always trusted.  This is especially bad in the academic setting; they assume that a community doctor is too dull-witted to work at Smarty Pants U, so take everything I do and tell them with skepticism. But this is also true with some community specialists, who think a PCP is to dull-witted to be a specialist.
  5. Specialists are increasingly bad at communicating with me about the patient (and business, I might add) I sent to them.  A significant proportion of my consultants don't send their notes in a timely manner, if at all.  When I do get their note, they are usually filled with useless information, telling me the patient's entire history (which I, of course, already know), exam, habits, shoe size, and whether they have an inny or outy belly-button, all before they get to the part I want: the assessment and plan.  I often have to go through 4-5 pages before I get to useful information.  Additionally, I rarely have access to results from labs and tests done by that specialists.

The failure of the successful transfer often results in what my patient got: frustration and problems not addressed.  This bad transfer happens for many reasons, including: the arrogance and/or laziness of doctors, the disorganization of medical offices, the inaccesability of tests and labs, the ridiculous documentation requirements which hide useful information, and the volume-driven foundation of the system, which discourages taking extra time to communicate or find the appropriate information.

So my patient has to live with his pain while I try to figure out how to treat a condition I am not supposed to be treating.  In this case it is only pain; in some cases it is worse.  I every case, it costs the system a lot of money and makes the likelihood of a good outcome much lower.



Our Broken System - Example #2: Fat Cats

We have a cat.  He's fat.  His name is Zander, but we call him "Cat," "Kitty," "Loaf of Bread" (because that's what he looks like when he lies down and his fat spreads), lard butt, and "Fatso Catso."  In the picture above he is sitting on a puzzle because...well, because he's a cat.

There are two main reasons he is fat:

  1. He always wants to eat.
  2. We feed him too much.

Lest you think that we are bad cat servants (which is what you call people who own cats...I mean, people who live in the cat's house), let me paint a picture.  It's 6 AM and I go downstairs.  The cat immediately meows continuously until I feed him.  Then I go upstairs and do my normal morning routine.  While I am up in the shower, my wife comes downstairs and is met by meowing and an empty bowl.  We've learned that the cat's desperation for food is not indicative of his eating history, but my wife's natural reaction is to assume I did not feed the cat, and so give him a second bowl.  He will do this every morning, sometimes tricking us into feeding him 3 times.

The same routine happens in the afternoon (we feed him at 6 PM).  Around 3 o'clock, the cat begins his campaign of meow assaults on whomever he can bother.  If you walk to the door of the garage, he rushes to it, knowing that behind that door is his food.  Naturally, the only reason we would walk to the door is to feed him, right?

You get the picture.  He is deceptive and is difficult (if not impossible) to satiate.  We've gotten better at regulating his weight, but only at the cost of the persistent meowing which serenades 50% of our waking hours.

What does this have to do with our broken system?  Just change the food to money, and then think of all of the people who profit off of health care.

The second broken thing in our system is the fat cat.  A fat cat is a person, group of people, or company that gorges off of the money in our system.  Not everyone making money in health care are fat cats, most are simply getting money they earned from providing goods or services.  But there are a number of fat cats in health care who are being given all the food they meow for.  Here are a few examples:

Drug companies:  Why are drugs so expensive?  Because they can be.  If government and private insurers were not paying for most of the drug costs, who could afford $200/month for Lipitor?  People wouldn't buy most medications if they had to pay full price; the full price is impossibly high.  Even many generics are over $100 per month.   Despite this fact, the prices continue to be high and drugs continue to sell.  Why?  Because someone else picks up the tab.

It's as if the auto industry charged $500K for a new car.  Since nobody can afford this, the government mandates car insurance to cover most of the cost.  This brings the cost down to $20-50K for car buyers.  Or if Bananas cost $100 per bunch, but food insurance brought the cost down to $4.   If you sold cars or bananas, would you resist this model?  Would you trade a $500K payment from the government for a $20K check from the consumer?  No more than my cat would turn down the third bowl of cat food.

Hospitals:  Stents 'R Us hospital in our town just built a large cardiology wing costing 600 Gazillion dollars.  They did this using money from a procedure that has not been shown to prolong life or save lives.  Sure, stents make a lot of sense logically (opening a blockage is a good thing, one would think), but it is, as of now, an unproven thing.  But the marble lobby and the spiral staircase bear witness to the fact that they are not only paid for, they are paid for quite handsomely.  Eat up, kitty.

Ancillary Services:  Why does a CT scan in India cost a fraction of the cost in the US?  Are scanners more expensive in the country in which they are made?  Are the companies that sell the CT scanners warmhearted toward the people of India?  No, CT scans are expensive in the US because they can be.  Again, it's the fact that the third-party payors shield consumers from the exorbitant amounts charged that makes it reasonable to price CT scans out of the realm of affordability.  So what do the payors do about these high costs?  They pass them on to the taxpayers or raise the rates of the insurance policies.  It doesn't hurt them to pay so much, so they just keep feeding the kitty.

Doctors:  Yes, we doctors are not immune to eating the cat food.  Some docs pile up the number of appointments, giving less time for care so they can make more money.  We primary care docs are stuck with a decision between money and quality of care.  It's a terrible decision to have to make, and many decide that money is the most important thing.  Other PCP's just order a lot of tests from their own labs or x-ray facilities.  We did this for a while, and the seductiveness of the dollar sign was too much for us, and we got rid of our x-ray equipment.

Then there are the highly-paid specialists.  A banker friend of mine recently told me about a specialist who was complaining about how horrible reimbursement is, and how bad medicine is now.  Then he found out that this doctor earns over $750,000 per year.  Why do docs see so many patients that they can't offer good care, and why do other docs feel entitled to incredibly large salaries?  Because they can.  Someone keeps filling the bowl.

I think that the biggest cause of this gluttony is the third-party payor system which hides the cost from the consumer and gets us all used to the idea of paying for all that cat food.  How many people are getting rich off of medicine?  How many professions wouldn't exist without this all-you-can-eat buffet of cat chow?  How many companies are rewarding investors with huge profits because their devices or drugs are paid far above their cost of manufacture?

All of this money is thrown at care, and what does it get us?  Does it get us better care?  Does it get us longer lives?  Does it get us happier patients, or satisfied doctors?

No, it just gets us a bunch of lard-butt kitties meowing for more to eat.


Zander appreciated the comfortable spot we made in the back of his minivan.