Some people seized on my words in my last post:
A doctor’s office is always on the brink of chaos – with an incredible amount of information coming in and going out, a large number of phone calls, insurance company headaches, and personnel situations that can throw the best system flat on its face. People forget that there are hundreds of other patients with thousands of test results the office is dealing with. We do what we can to tell patients test results (and with our computerized records, we do a better job than most), and I see that as our responsibility.
Their assumption made by some commenters was that our office must be unique in our problems. We must be disorganized. People who manage other businesses assume that with proper organization skills, a medical office could become fully organized.
Our office is unique, but not in our disorganization but in our obsession with organizing our system. We have been on computerized medical records for 12 years and have been nationally recognized for our efforts in this arena. We are regularly having physicians come through our office to observe our system and how well we run our office. We are increasing our revenue in a time when others are falling – and we are doing so with improved quality and satisfaction.
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So how can I say \”a doctor\’s office is always on the brink of chaos\”? Because it is. There are dynamics in a medical office (at least a PCP\’s office) that are constantly disrupting the best of plans. There are a number of reasons for this, including:
- Interfacing with other disorganized systems – specialists, hospitals, labs, radiologists, and old records are sending information to us in a myriad of forms.
- Unpredictability – Some days are smooth, and go as planned. Other days are sabotaged by a barrage of phone calls, complicated patients, and staff calling in sick.
- Insurance companies – Insurers do nothing to help efficiency, in fact they do what they can to make you not want to deal with them. They make staff wait eternally on the phone and mysteriously don\’t pay for things that were paid for in the past.
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.
But wouldn\’t organization allow you to see more patients? Sometimes it would. Sometimes having a better system will make you more efficient; but the time it takes to build a better system is huge – time that could be spent generating revenue. Many PCP\’s are running with tight margins. 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.
So what is my motivation to make a system that would track labs to make sure all my patients get their results? Doing a good job. I do it because I think it is the right thing to do and because I want to take care of my patients. But the problem is that all of the time spent doing this is unpaid time. 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.
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The system won\’t get better until there is some way of rewarding better work with more pay. Right now the system rewards the doctors who spend the least time with their patients with the most money. We have to live in the tug-of-war between what is best medically and what is best from a business standpoint.
Until this changes, the brink of chaos will be a familiar place.
🙂 you’ve worked really hard at becoming organized and efficient and it shows but it doesn’t really change the fact that when dealing with the “general public” on a daily basis it doesn’t matter what business you are in, whether you are a physician or a taxi driver, or how organized you are…you are always on the brink of chaos and there is always potential for breakdown. to me “public” = “chaos”
🙂 you’ve worked really hard at becoming organized and efficient and it shows but it doesn’t really change the fact that when dealing with the “general public” on a daily basis it doesn’t matter what business you are in, whether you are a physician or a taxi driver, or how organized you are…you are always on the brink of chaos and there is always potential for breakdown. to me “public” = “chaos”
I think its important to note that you have the right mentality. Assuming that you’re on the edge of chaos, even if you’re not, (regardless, I think you are probably are, given the evidence you’ve provided) keeps you on edge enough to perform your best. Complacency is the killer, after all.
People who run their businesses that believe that they are not on the brink of chaos are leaving too much on the table. Either they are wasting time and money (and hence profit) to be stable, or they are so “stable” (and by that I mean inflexible) that when the conditions of the market change, their business takes major hit. These people are living in the fantasy-land of management, IMO.
I think its important to note that you have the right mentality. Assuming that you’re on the edge of chaos, even if you’re not, (regardless, I think you are probably are, given the evidence you’ve provided) keeps you on edge enough to perform your best. Complacency is the killer, after all.
People who run their businesses that believe that they are not on the brink of chaos are leaving too much on the table. Either they are wasting time and money (and hence profit) to be stable, or they are so “stable” (and by that I mean inflexible) that when the conditions of the market change, their business takes major hit. These people are living in the fantasy-land of management, IMO.
“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.”
Ouch.
“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.”
Ouch.
As I see it, unless more doctors are trained, the choke point in PHCP is always the doctor’s time. It makes no difference whether your practice list has 20 or 20_000 patients on it; if you schedule 2x3hour surgeries a day in 10 minute appointments, you can’t see more than 36 patients per doctor (partner or salaried staffer) in a day.
As I see it, unless more doctors are trained, the choke point in PHCP is always the doctor’s time. It makes no difference whether your practice list has 20 or 20_000 patients on it; if you schedule 2x3hour surgeries a day in 10 minute appointments, you can’t see more than 36 patients per doctor (partner or salaried staffer) in a day.
“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”…It’s one thing to gripe as a patient, but it’s another to try to do something about it.”
“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”…It’s one thing to gripe as a patient, but it’s another to try to do something about it.”
I’m very thankful for a PCP who takes time with me at each visit as I have complex issues (persistant recurrent Cushing’s Disease, facing radiation to an invasive brain tumor and scheduled for bilateral adrenalectomy). Even a year ago, I was in better health and could be the hub of all of my medical info. Last month, I had to, reluctantly but with relief, turn it over to her. She won’t make any money seeking in-network coverage for an out-of-network provider for midnight salivary tests, but I’ll make her a cream cheese pound cake and knitted her new baby a blanket.
More importantly, I see her often so she can get PAID anytime I update her on my myraid issues and appointments with specialists. Yes, she is copied on the reports, but she won’t get paid for reading them (that I know of). So I make it a point to schedule a 10 minute visit just so we have billable face time. That’s fair and works for us both.
And now that I am less able and more frail, I don’t feel so bad that she will carry the ball, so to speak, until I get through these next lines of treatment and, hopefully, will need less from her.
In my opinion as a seasoned patient with a difficult disease, the best care a patient can hope for is from a PCP who does not practice solely within the confines of finanicial incentives and feels it is an ethical aaa(or at least moral) duty to act as a real advocate on occasion where the patient’s situation calls for it.
Thanks for listening,
Kate
I’m very thankful for a PCP who takes time with me at each visit as I have complex issues (persistant recurrent Cushing’s Disease, facing radiation to an invasive brain tumor and scheduled for bilateral adrenalectomy). Even a year ago, I was in better health and could be the hub of all of my medical info. Last month, I had to, reluctantly but with relief, turn it over to her. She won’t make any money seeking in-network coverage for an out-of-network provider for midnight salivary tests, but I’ll make her a cream cheese pound cake and knitted her new baby a blanket.
More importantly, I see her often so she can get PAID anytime I update her on my myraid issues and appointments with specialists. Yes, she is copied on the reports, but she won’t get paid for reading them (that I know of). So I make it a point to schedule a 10 minute visit just so we have billable face time. That’s fair and works for us both.
And now that I am less able and more frail, I don’t feel so bad that she will carry the ball, so to speak, until I get through these next lines of treatment and, hopefully, will need less from her.
In my opinion as a seasoned patient with a difficult disease, the best care a patient can hope for is from a PCP who does not practice solely within the confines of finanicial incentives and feels it is an ethical aaa(or at least moral) duty to act as a real advocate on occasion where the patient’s situation calls for it.
Thanks for listening,
Kate
Great article, I appreciate your candor. I think another problem with having a medical office be tightly organized is that the practice of medicine, especially primary care, is so varied and complex. That is the problem I find with trying to implement an electronic medical record (EMR) — it is much easier for specialists to utilize EMR’s than primary physicians due their relatively narrow focus. EMR’s are also much more complex than a typical business office computer network.
Great point about the financial pressure. Now that medicine is run much more like a “business” than it was back in the 1980’s, we have more economic decisions entering in the medical care of patients. In a market where demand outstrips supply, service will ultimately suffer and prices will increase.
I have only been practicing medicine for about a decade, but I have involved in healthcare since my high school days. I have noticed a steady decline in the education of ancillary medical staff. Doctors’ used to have RN’s in the offices, then LPN’s, now we have medical assistants. Their are fewer people qualified to discuss lab results and refill prescriptions. Intrepreting labs is sometimes not easy. You can’t just look at the numbers and the normals and necessarily know what is going on. Sometimes normal labs are a problem, and sometimes abnormal labs are not.
The only organized physician’s office I have ever witnessed was a solo practitioner who had superior skills in management. Once you get a few physicians together, their differing practice styles make a common plan difficult to implement.
I have considered going solo, but that also has a lot of drawbacks.
Great article, I appreciate your candor. I think another problem with having a medical office be tightly organized is that the practice of medicine, especially primary care, is so varied and complex. That is the problem I find with trying to implement an electronic medical record (EMR) — it is much easier for specialists to utilize EMR’s than primary physicians due their relatively narrow focus. EMR’s are also much more complex than a typical business office computer network.
Great point about the financial pressure. Now that medicine is run much more like a “business” than it was back in the 1980’s, we have more economic decisions entering in the medical care of patients. In a market where demand outstrips supply, service will ultimately suffer and prices will increase.
I have only been practicing medicine for about a decade, but I have involved in healthcare since my high school days. I have noticed a steady decline in the education of ancillary medical staff. Doctors’ used to have RN’s in the offices, then LPN’s, now we have medical assistants. Their are fewer people qualified to discuss lab results and refill prescriptions. Intrepreting labs is sometimes not easy. You can’t just look at the numbers and the normals and necessarily know what is going on. Sometimes normal labs are a problem, and sometimes abnormal labs are not.
The only organized physician’s office I have ever witnessed was a solo practitioner who had superior skills in management. Once you get a few physicians together, their differing practice styles make a common plan difficult to implement.
I have considered going solo, but that also has a lot of drawbacks.
Sure there is an incentive for keeping decent records and being on top of test results. It’s called not having a patient die and ending up on the wrong side of a million dollar judgment. Million bucks can eat up alot of profit margin, even for a specialist.
Eg. see this reported court decision.
http://www.courts.state.va.us/opinions/opnscvwp/1050206.pdf
Sure there is an incentive for keeping decent records and being on top of test results. It’s called not having a patient die and ending up on the wrong side of a million dollar judgment. Million bucks can eat up alot of profit margin, even for a specialist.
Eg. see this reported court decision.
http://www.courts.state.va.us/opinions/opnscvwp/1050206.pdf
We are in a recession. There is no one in this country that isn’t having to do much more with less pay. I am not a doctor, I work for a Fortune 100 company and am faced with a whole lot of responsibility and less and less resources too. It’s everywhere, multi-tasking is the new black. That doesn’t stop me from trying to do it right. Every time. Someday, I am hoping for more reward as well, but being realistic, my motivation is knowing that I personally can do the right thing while making my mortgage.
So for us difficult (to diagnose) patients. What can we do? Do we hand our overworked doctor an expensive gift each time we come in knowing that we are sicker than other patients?
I really do have empathy for your struggles but need your help to get better. How can I do that without being a squeaky wheel? Just like you, I HATE those people and don’t want to be one just because I was lucky enough to get really sick.
I would love to hear from you very busy doctors, the very best way your complex patients can present their cases to you that will allow you to cut through the clutter and hear them and want to help them without wanting to just show them the door because it’s all too much. (I haven’t been kicked out of a doctor’s office but one or two of them looked sorry I came in to see them.) I think I actually said I was sorry for being so ill to one of them! It’s crazy!
Last but not least, kudos to you for embracing change and streamlining your systems! I know it is nothing but painful at first but once you get used to it, it will save you time, stress and papercuts.
We are in a recession. There is no one in this country that isn’t having to do much more with less pay. I am not a doctor, I work for a Fortune 100 company and am faced with a whole lot of responsibility and less and less resources too. It’s everywhere, multi-tasking is the new black. That doesn’t stop me from trying to do it right. Every time. Someday, I am hoping for more reward as well, but being realistic, my motivation is knowing that I personally can do the right thing while making my mortgage.
So for us difficult (to diagnose) patients. What can we do? Do we hand our overworked doctor an expensive gift each time we come in knowing that we are sicker than other patients?
I really do have empathy for your struggles but need your help to get better. How can I do that without being a squeaky wheel? Just like you, I HATE those people and don’t want to be one just because I was lucky enough to get really sick.
I would love to hear from you very busy doctors, the very best way your complex patients can present their cases to you that will allow you to cut through the clutter and hear them and want to help them without wanting to just show them the door because it’s all too much. (I haven’t been kicked out of a doctor’s office but one or two of them looked sorry I came in to see them.) I think I actually said I was sorry for being so ill to one of them! It’s crazy!
Last but not least, kudos to you for embracing change and streamlining your systems! I know it is nothing but painful at first but once you get used to it, it will save you time, stress and papercuts.
In the classroom I always refer to it as “controlled chaos” =)
In the classroom I always refer to it as “controlled chaos” =)
Fighting Chaos…
Some people seized on my words in my last post. The assumption made by some commenters was that our office must be unique in our problems. We must be disorganized. People who manage other businesses assume that with proper organization skills, a medica…
Hippocratic Oath—Modern Version
“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick”
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
This is just parts of the oath that has come to the attention of me and my friends. It truly saddens me that this “oath” is not upheld by numerous doctors!! I however, did have the luck of finding a PCP that went far beyond the extra mile for me as his patient than any other doctor I have ever been to see. I went to see him for a routine appointment and my lipid profile came back high even while being on medication. So I started walking 2 miles a day 4x’s a week and 3 weeks later, I had gained 12 lbs. So I made another appointment to see him. As soon as he saw me, he asked what was going on with me and I told him that was why I was there. (He still makes comments about how puffy my face was at the time.) So he did some bloodwork, but it took longer than normal for me to her back from him because he noticed my cortisol was high and was doing RESEARCH to try to find out why. He called me in to do another test specifically on cortisol because he thought I may have Cushing’s Disease. When it came back high, he told me that he did not have a clue what he was dealing with and sent me to an endocrinologist. This dr. did 1 UFC and told me to come back in 6 mos. I tried to see a Cushing’s specialist 100 miles from where I live, but he refused to work with any other doctor locally. My PCP was very happy to work with anyone so that he may gain knowledge about this disease to help me and any other patients that might have the same problem. He is now working with my Cushing’s specialist I found on the west coast. As a matter of fact, the last time I saw my PCP he told me he took a Cushing’s class because of me and that he would have skipped right past it because before he didn’t even know what it was, so it wouldn’t have interested him.
Now, this is an extraodinary doctor as far as I am concerned. I said he went the extra mile for me, which compared to most, he did. But in all reality this is his job just as it is for any doctor or so the oath that you swore by states that you should. Knowledge is key!! I have an endocrinologist here where I live that asked ME what an IPSS was. But we as patients are supposed to just sit back and hope that you have lived up to your oath and will take the extra steps to search for information or seek help outside of your own to make sure we are cared for properly. The oath doesn’t say you only do this if you get extra pay for it. This should be the first thing you realized before getting into practice, that you were in it for helping others no matter what the amount of time needed and not just for $$$.
I am very grateful to all the doctors that still live by the oath they took. Who care for their patients as they should, spend time with them and show true concern that they are willing to spend however long it takes to make sure their patient gets well just as my PCP has done for me.
Hippocratic Oath—Modern Version
“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick”
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
This is just parts of the oath that has come to the attention of me and my friends. It truly saddens me that this “oath” is not upheld by numerous doctors!! I however, did have the luck of finding a PCP that went far beyond the extra mile for me as his patient than any other doctor I have ever been to see. I went to see him for a routine appointment and my lipid profile came back high even while being on medication. So I started walking 2 miles a day 4x’s a week and 3 weeks later, I had gained 12 lbs. So I made another appointment to see him. As soon as he saw me, he asked what was going on with me and I told him that was why I was there. (He still makes comments about how puffy my face was at the time.) So he did some bloodwork, but it took longer than normal for me to her back from him because he noticed my cortisol was high and was doing RESEARCH to try to find out why. He called me in to do another test specifically on cortisol because he thought I may have Cushing’s Disease. When it came back high, he told me that he did not have a clue what he was dealing with and sent me to an endocrinologist. This dr. did 1 UFC and told me to come back in 6 mos. I tried to see a Cushing’s specialist 100 miles from where I live, but he refused to work with any other doctor locally. My PCP was very happy to work with anyone so that he may gain knowledge about this disease to help me and any other patients that might have the same problem. He is now working with my Cushing’s specialist I found on the west coast. As a matter of fact, the last time I saw my PCP he told me he took a Cushing’s class because of me and that he would have skipped right past it because before he didn’t even know what it was, so it wouldn’t have interested him.
Now, this is an extraodinary doctor as far as I am concerned. I said he went the extra mile for me, which compared to most, he did. But in all reality this is his job just as it is for any doctor or so the oath that you swore by states that you should. Knowledge is key!! I have an endocrinologist here where I live that asked ME what an IPSS was. But we as patients are supposed to just sit back and hope that you have lived up to your oath and will take the extra steps to search for information or seek help outside of your own to make sure we are cared for properly. The oath doesn’t say you only do this if you get extra pay for it. This should be the first thing you realized before getting into practice, that you were in it for helping others no matter what the amount of time needed and not just for $$$.
I am very grateful to all the doctors that still live by the oath they took. Who care for their patients as they should, spend time with them and show true concern that they are willing to spend however long it takes to make sure their patient gets well just as my PCP has done for me.
I understand that being a physician is an occupation. And just like any other occupation, certain financial requirements need to be met. But I, being a patient who has suffered from a very complex & rare disease, have come to learn that many physicians are adopting the philosophy you mentioned…”spend the least time with their patients with the most money.” They are faced with a dilemna. Do I treat patients to the best of my ability or do I watch my profit margins with disregard to “optimal patient care?” Unfortunately, the latter is often the chosen path.
So, I would like to know….whatever happened to the Hippocratic Oath? I understand that many physicians do not feel that this document written in the 4th century BC is applicable to the new age of medicine, and I do agree with that. However, Louis Lasagna, the Academic Dean of the School of Medicine at Tufts University wrote a new modern version of the Hippocratic oath in 1964. Although this was written 44 years ago, it continues to convey the goals and complexity of the profession and provides the appropriate moral compass and inspiration for new grads & seasoned physicians alike. And in fact, it is used in many medical schools today.
Again, I understand that being a physician is essentially running a business and I am certainly happy to hear that you have chosen to do a “good job” because it’s the “right thing” to do to “take care of your patients.” But with more & more physicians choosing to disregard optimal patient care in exchange for the almighty dollar…it leaves us patients with nowhere to turn and a society who suffers. Here we are in the 21st century, but I feel that progressive medicine is a misnomer.
Modern Hippocratic Oath– Louis Lasagna, 1964
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
I understand that being a physician is an occupation. And just like any other occupation, certain financial requirements need to be met. But I, being a patient who has suffered from a very complex & rare disease, have come to learn that many physicians are adopting the philosophy you mentioned…”spend the least time with their patients with the most money.” They are faced with a dilemna. Do I treat patients to the best of my ability or do I watch my profit margins with disregard to “optimal patient care?” Unfortunately, the latter is often the chosen path.
So, I would like to know….whatever happened to the Hippocratic Oath? I understand that many physicians do not feel that this document written in the 4th century BC is applicable to the new age of medicine, and I do agree with that. However, Louis Lasagna, the Academic Dean of the School of Medicine at Tufts University wrote a new modern version of the Hippocratic oath in 1964. Although this was written 44 years ago, it continues to convey the goals and complexity of the profession and provides the appropriate moral compass and inspiration for new grads & seasoned physicians alike. And in fact, it is used in many medical schools today.
Again, I understand that being a physician is essentially running a business and I am certainly happy to hear that you have chosen to do a “good job” because it’s the “right thing” to do to “take care of your patients.” But with more & more physicians choosing to disregard optimal patient care in exchange for the almighty dollar…it leaves us patients with nowhere to turn and a society who suffers. Here we are in the 21st century, but I feel that progressive medicine is a misnomer.
Modern Hippocratic Oath– Louis Lasagna, 1964
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
Quote: The system won’t get better until there is some way of rewarding better work with more pay. Right now the system rewards the doctors who spend the least time with their patients with the most money. We have to live in the tug-of-war between what is best medically and what is best from a business standpoint.
Until this changes, the brink of chaos will be a familiar place.
Quote.
Sounds like a professional problem to me.
Patient: “Doctor, it hurts when I do this.”
Doctor: “Stop doing it.”
Physician, heal thyself.
PS: No one wants their doctors to be more successful than the patient who is suffering.
Quote: The system won’t get better until there is some way of rewarding better work with more pay. Right now the system rewards the doctors who spend the least time with their patients with the most money. We have to live in the tug-of-war between what is best medically and what is best from a business standpoint.
Until this changes, the brink of chaos will be a familiar place.
Quote.
Sounds like a professional problem to me.
Patient: “Doctor, it hurts when I do this.”
Doctor: “Stop doing it.”
Physician, heal thyself.
PS: No one wants their doctors to be more successful than the patient who is suffering.
In most businesses, we reward quality. In medicine, we penalize it. Doctors who take the time are paid LESS than those who don’t. Doctors who focus on quality are paid LESS.
My objection is a system that financially motivates poor care. I am not all about the money, but I resent having to make that choice every day – whether I do everything I can for people or get paid well. It should not be either/or. People wonder why poor care is being done and poor customer service is happening?
It is what we are paying people to do. That is just plain stupid.
I deeply desire to follow the hypocratic oath as closely as possible, but why is the payment system telling me I should break that oath?
Do you guys get that?? I am not whining that I am not paid enough – I actually am paid just fine. I am saying that the system is a mess because we are financially motivating the mess. Until we start financially motivating good medicine and quality service, we won’t ever get it.
In most businesses, we reward quality. In medicine, we penalize it. Doctors who take the time are paid LESS than those who don’t. Doctors who focus on quality are paid LESS.
My objection is a system that financially motivates poor care. I am not all about the money, but I resent having to make that choice every day – whether I do everything I can for people or get paid well. It should not be either/or. People wonder why poor care is being done and poor customer service is happening?
It is what we are paying people to do. That is just plain stupid.
I deeply desire to follow the hypocratic oath as closely as possible, but why is the payment system telling me I should break that oath?
Do you guys get that?? I am not whining that I am not paid enough – I actually am paid just fine. I am saying that the system is a mess because we are financially motivating the mess. Until we start financially motivating good medicine and quality service, we won’t ever get it.
So what can we do as patients to help get this done? I would love to help anyway I can to improve things.
So what can we do as patients to help get this done? I would love to help anyway I can to improve things.
I agree, insurance companies are definitely governing the reimbursement rates. But the thing is….so many doctors are sacrificing patient care in order to make more money. But you see, there are many doctors out there that are providing exceptional patient care and still manage to make excellent money. None of my physicians are hurting. My endocrinologist has a beautiful home, beautiful office, nice cars…. He is bound by the same insurance rules & restrictions that you speak of, yet he spends time with his patients and will do whatever he has to do to make sure that his patients receive optimal care. And he makes a fine living. My surgeon, a man who graciously answers e-mails & reads MRI’s sent to him from total strangers….doing so on his own time, asking nothing of you monetarily. He is thriving in his practice. I have had multiple e-mail communications with him since then (again some very lengthy) and he doesn’t ask for a dime for all that he does. The big hand of insurance bears down on him too, but it doesn’t stop him from spending time with his patients and answering every little question you could think of (and then some!) It boils down to passion and desire to be the very best physician you can be. If money instead of passion about their profession is what drives them, then substandard care is what their patients will get. With all due respect, giving excellent care within the confines of insurance can be done, the passion just has to be there. I know…I’m married to one.
THE INTERPRETER’S GUIDE TO DOCTOR SPEAK
WHAT YOUR DOCTOR SAYS: ………………………….. WHAT YOUR DOCTOR REALLY MEANS:
I’d like to run a few more tests……………………………………I want the sunroof option for my new sports car.
I’d like you to see a specialist…………………………………….. I have absolutely no idea what’ wrong with you.
Bend Over……………………………………………………………Bend Over (Hey, some things are bad enough
without some deeper meaning!)
Please make a follow-up appointment……………………………I’d also like the CD player with the five disc changer
The nurse will take over from here………………………………..I’m late for my tee-off time.
I have good news & I have bad news……………………………..I have bad news.
You’ll feel some slight discomfort…………………………………..This is gonna hurt like hell!
Hmm….that’s interesting……………………………………………..What the heck is that thing?
Any history of medical problems in your family?………………..Maybe I can blame this on genetics in case
I screw up.
This is a highly treatable disorder………………………………….How much insurance you got?
I agree, insurance companies are definitely governing the reimbursement rates. But the thing is….so many doctors are sacrificing patient care in order to make more money. But you see, there are many doctors out there that are providing exceptional patient care and still manage to make excellent money. None of my physicians are hurting. My endocrinologist has a beautiful home, beautiful office, nice cars…. He is bound by the same insurance rules & restrictions that you speak of, yet he spends time with his patients and will do whatever he has to do to make sure that his patients receive optimal care. And he makes a fine living. My surgeon, a man who graciously answers e-mails & reads MRI’s sent to him from total strangers….doing so on his own time, asking nothing of you monetarily. He is thriving in his practice. I have had multiple e-mail communications with him since then (again some very lengthy) and he doesn’t ask for a dime for all that he does. The big hand of insurance bears down on him too, but it doesn’t stop him from spending time with his patients and answering every little question you could think of (and then some!) It boils down to passion and desire to be the very best physician you can be. If money instead of passion about their profession is what drives them, then substandard care is what their patients will get. With all due respect, giving excellent care within the confines of insurance can be done, the passion just has to be there. I know…I’m married to one.
THE INTERPRETER’S GUIDE TO DOCTOR SPEAK
WHAT YOUR DOCTOR SAYS: ………………………….. WHAT YOUR DOCTOR REALLY MEANS:
I’d like to run a few more tests……………………………………I want the sunroof option for my new sports car.
I’d like you to see a specialist…………………………………….. I have absolutely no idea what’ wrong with you.
Bend Over……………………………………………………………Bend Over (Hey, some things are bad enough
without some deeper meaning!)
Please make a follow-up appointment……………………………I’d also like the CD player with the five disc changer
The nurse will take over from here………………………………..I’m late for my tee-off time.
I have good news & I have bad news……………………………..I have bad news.
You’ll feel some slight discomfort…………………………………..This is gonna hurt like hell!
Hmm….that’s interesting……………………………………………..What the heck is that thing?
Any history of medical problems in your family?………………..Maybe I can blame this on genetics in case
I screw up.
This is a highly treatable disorder………………………………….How much insurance you got?
i do — i personally think that patients should have some control over medical reimbursement rates. That way if a doctor decides to blow me off, well, the rate gets cut 15%; if I give kudos, the rate goes up 15%. I also think that insurance companies should increase the rate of reimbursement for doctors who have low patient turnover. Every time I switch doctors, guess what happens — a whole new round of tests for a baseline, a 2x normal cost visit and a loss of the continuity that helps a good doc get it right when it comes to a dx. I think the costs of patient turnover are very very high and insurance companies ought to consider it on rates — if someone has 25% of their patients who are in network and stay in network switch to another PCP, well, frankly, that is a pretty cost-ineffective doctor. If the doctor has only 5% switch, that is much more efficient. People get annoyed for too many tests and leave, people get annoyed for two few — most people want efficient and effective medical care and if they are happy, well, the insurance company ought to take that as a sign that this is a good doc. that would surely reward a doc who takes a bit more time to do a better job.
i do — i personally think that patients should have some control over medical reimbursement rates. That way if a doctor decides to blow me off, well, the rate gets cut 15%; if I give kudos, the rate goes up 15%. I also think that insurance companies should increase the rate of reimbursement for doctors who have low patient turnover. Every time I switch doctors, guess what happens — a whole new round of tests for a baseline, a 2x normal cost visit and a loss of the continuity that helps a good doc get it right when it comes to a dx. I think the costs of patient turnover are very very high and insurance companies ought to consider it on rates — if someone has 25% of their patients who are in network and stay in network switch to another PCP, well, frankly, that is a pretty cost-ineffective doctor. If the doctor has only 5% switch, that is much more efficient. People get annoyed for too many tests and leave, people get annoyed for two few — most people want efficient and effective medical care and if they are happy, well, the insurance company ought to take that as a sign that this is a good doc. that would surely reward a doc who takes a bit more time to do a better job.
Dr. Rob, here is an article you may have run across in the past. It illustrates your point quite well. It is one of my favorites and I recommend everyone who posted here to read it…
On the folly of rewarding A, while hoping for B
Dr. Rob, here is an article you may have run across in the past. It illustrates your point quite well. It is one of my favorites and I recommend everyone who posted here to read it…
On the folly of rewarding A, while hoping for B
I’m a licensed barber. Does this mean I get to give you a buzz cut because I can do those faster, and make more money in an hour, or am I suppose to take the time needed to give you the kind of haircut you want, and expect, even when you wait until the very end to to say, “Take it just a little bit shorter all over!”?
You see, being a barber is a public service, but so is being a physician. A patient is a customer, paying for your service, just like you are the patron, paying for a haircut. Sure you don’t get all of the money, but neither does a barber. We have fees, supplies, chair rent, taxes, etc., just like you. If my profits are eaten up because you require twice the time that a normal haircut would, it doesn’t mean I have a right to give you a rotten haircut. Consider this, you probably wouldn’t even pay for it, and if you did, you would never come back! Should doctors expect more from their patients for shabby service?
I pay around $300 a month just to have insurance coverage for my husband and I. On top of that, I also have my co-pays, and my portion of the bill, that insurance doesn’t cover. I have max out of pockets and deductibles, which also run into the thousands! Doctors don’t see all of that money, but I’m sure paying for it! I expect my doctor to spend as much time with me as needed! I’m not out to take up extra time from my doctor, but when I have a valid problem, I expect to be taken care of appropriately. No short cuts!
I’m a licensed barber. Does this mean I get to give you a buzz cut because I can do those faster, and make more money in an hour, or am I suppose to take the time needed to give you the kind of haircut you want, and expect, even when you wait until the very end to to say, “Take it just a little bit shorter all over!”?
You see, being a barber is a public service, but so is being a physician. A patient is a customer, paying for your service, just like you are the patron, paying for a haircut. Sure you don’t get all of the money, but neither does a barber. We have fees, supplies, chair rent, taxes, etc., just like you. If my profits are eaten up because you require twice the time that a normal haircut would, it doesn’t mean I have a right to give you a rotten haircut. Consider this, you probably wouldn’t even pay for it, and if you did, you would never come back! Should doctors expect more from their patients for shabby service?
I pay around $300 a month just to have insurance coverage for my husband and I. On top of that, I also have my co-pays, and my portion of the bill, that insurance doesn’t cover. I have max out of pockets and deductibles, which also run into the thousands! Doctors don’t see all of that money, but I’m sure paying for it! I expect my doctor to spend as much time with me as needed! I’m not out to take up extra time from my doctor, but when I have a valid problem, I expect to be taken care of appropriately. No short cuts!
I have only been following this in bits and pieces as time allows, so please forgive me if I’ve missed anything important.I am male, 41 years old and in remission from Cushing’s disease ( why does this strike such a chord with Cushie’s?- Because to everyone else- including most docs- we are just overweight lazy people who need to exercise more and eat less) coming upon my 1 year anniverary from pituitary surgery.
My pcp was straight up with me when I showed him my striae and we discussed all of the issues that I had been dealing with for the past few years. He had never seen a case of naturally occurring CD, only in textbooks at med school. He agreed that with my symptoms and history that I might have the disease, and sent me onward to a local endocrinologist. That doc was very excited as we went through the office visit, he took about 15 minutes to determine that “yes it looks like CD”, and he sent me home with a script for one 24hr. UFC. Which came back as normal -within normal limits- his office girl said. I wanted to speak with the doc to know the score from him. “Well you do not have CD, it came back normal.” YUK. ” When I pushed him for more testing( cuz I know it takes more testing) he said come back in 6 months, we’ll test again.”
So to make a long story just a bit shorter and to get to the point, It took 2 more years and 4 endocrinologists who all wanted me to test one time every 3 months before I took it upon myself to find a CD specialist. Wow, think of all the money I could have saved for the insurance co., my own pocket and time suffering if only I had made the decision to do that from the beginning. Duh. Imagine all the poor souls who suffer because their local doc is all they have access to.
And I don’t meant that local docs are bad, just that if you are a doctor, your patients deserve the best you can give them. No you are not gods, and you cannot fix everyone. But darn it, at least be interested!
I want a doctor who really cares more about me than his bottom line. Is that wrong? I do not believe it is. A doctor’s office is a business, understood and I would not want it any other way. Just ask anyone dealing with socialised healthcare. No thanks, I’ll pay for my own. But the doctor himself too often is also the business manager, accounts payable and HR for his practice. No business will provide the best product for its’ customers if all that management is seeing is the bottom line.
I’ll leave with a copy of the email I received fro a great surgeon who truly cares for his patients. He read my (2) pituitary MRI scans( which were read as normal by the radiologists/doctors who took them).
BTW, he read them on his own time and wanted no compensation.
outrage
Dear Phil, I’m sorry I had to request your address again, it has slipped somewhere into the vast reaches of my computer and I knew I needed to get back to you on your MRI.
I have had a chance to go over things there, and here is what I think.
The latest scan (on the disc, from 09/06) is the one with best quality, and it shows an abnormal pituitary gland. The stalk is tilted to the left, a bit more than is really allowed in normal variation. This would imply a mass of some sort on the right (i.e., opposite) side of the gland.
On the dynamic images, there is a subtle suggestion of just that. The only kicker is that the abnormality isn’t confined entirely to the right side of the gland, as there seem to be small patches of low signal, or “hypointensity,” present on both right and left side.
In a circumstance such as this, we would consider operating on the pituitary if the hormonal numbers pointed to Cushing’s. It’s hard to give a specific tumor diagnosis here, but I’d bet that an exploration of the gland would reveal such.
MRIs in Cushing’s can be very hard to sort out, some show nicely specific areas of tumor, others show patchy changes such as I see in yours (usually suggestive of tumor but not allowing the surgeon to pin it down to a specific part of the gland prior to surgery) and some show no change at all (yet can still have a tumor hiding within).
Have the numbers that Dr. Cushing’s Specialist has been gathering supported the Cushing’s diagnosis as yet? In any case, I don’t really agree that the MRI is normal, for the reasons given above….Hope this helps you,
Best regards, a True Doctor
I have only been following this in bits and pieces as time allows, so please forgive me if I’ve missed anything important.I am male, 41 years old and in remission from Cushing’s disease ( why does this strike such a chord with Cushie’s?- Because to everyone else- including most docs- we are just overweight lazy people who need to exercise more and eat less) coming upon my 1 year anniverary from pituitary surgery.
My pcp was straight up with me when I showed him my striae and we discussed all of the issues that I had been dealing with for the past few years. He had never seen a case of naturally occurring CD, only in textbooks at med school. He agreed that with my symptoms and history that I might have the disease, and sent me onward to a local endocrinologist. That doc was very excited as we went through the office visit, he took about 15 minutes to determine that “yes it looks like CD”, and he sent me home with a script for one 24hr. UFC. Which came back as normal -within normal limits- his office girl said. I wanted to speak with the doc to know the score from him. “Well you do not have CD, it came back normal.” YUK. ” When I pushed him for more testing( cuz I know it takes more testing) he said come back in 6 months, we’ll test again.”
So to make a long story just a bit shorter and to get to the point, It took 2 more years and 4 endocrinologists who all wanted me to test one time every 3 months before I took it upon myself to find a CD specialist. Wow, think of all the money I could have saved for the insurance co., my own pocket and time suffering if only I had made the decision to do that from the beginning. Duh. Imagine all the poor souls who suffer because their local doc is all they have access to.
And I don’t meant that local docs are bad, just that if you are a doctor, your patients deserve the best you can give them. No you are not gods, and you cannot fix everyone. But darn it, at least be interested!
I want a doctor who really cares more about me than his bottom line. Is that wrong? I do not believe it is. A doctor’s office is a business, understood and I would not want it any other way. Just ask anyone dealing with socialised healthcare. No thanks, I’ll pay for my own. But the doctor himself too often is also the business manager, accounts payable and HR for his practice. No business will provide the best product for its’ customers if all that management is seeing is the bottom line.
I’ll leave with a copy of the email I received fro a great surgeon who truly cares for his patients. He read my (2) pituitary MRI scans( which were read as normal by the radiologists/doctors who took them).
BTW, he read them on his own time and wanted no compensation.
outrage
Dear Phil, I’m sorry I had to request your address again, it has slipped somewhere into the vast reaches of my computer and I knew I needed to get back to you on your MRI.
I have had a chance to go over things there, and here is what I think.
The latest scan (on the disc, from 09/06) is the one with best quality, and it shows an abnormal pituitary gland. The stalk is tilted to the left, a bit more than is really allowed in normal variation. This would imply a mass of some sort on the right (i.e., opposite) side of the gland.
On the dynamic images, there is a subtle suggestion of just that. The only kicker is that the abnormality isn’t confined entirely to the right side of the gland, as there seem to be small patches of low signal, or “hypointensity,” present on both right and left side.
In a circumstance such as this, we would consider operating on the pituitary if the hormonal numbers pointed to Cushing’s. It’s hard to give a specific tumor diagnosis here, but I’d bet that an exploration of the gland would reveal such.
MRIs in Cushing’s can be very hard to sort out, some show nicely specific areas of tumor, others show patchy changes such as I see in yours (usually suggestive of tumor but not allowing the surgeon to pin it down to a specific part of the gland prior to surgery) and some show no change at all (yet can still have a tumor hiding within).
Have the numbers that Dr. Cushing’s Specialist has been gathering supported the Cushing’s diagnosis as yet? In any case, I don’t really agree that the MRI is normal, for the reasons given above….Hope this helps you,
Best regards, a True Doctor
sorry, the word “outrage” was from the password required to post. Don’t know how it got into the post.
And the pit. surgeon removed two tumors from my pituitary gland. That after two reports written by radiologists and one prominent neurosurgeon who saw the scans as normal.
sorry, the word “outrage” was from the password required to post. Don’t know how it got into the post.
And the pit. surgeon removed two tumors from my pituitary gland. That after two reports written by radiologists and one prominent neurosurgeon who saw the scans as normal.
Rob-
I do understand. I have never forgotten the talk I heard from a hospital CIO saying that in order to be profitable, a physician should only spend 10 minutes per patient with the goal moving towards 8 minutes per patient. That was a few years ago so I am guessing that you are now pressured to spend 5 minutes per patient. You diagnosticians, not fortune tellers. That is a very small amount of time. I have always assumed that was an average? So you see a whole lot of flu shots in one day and then a couple of more complicated cases? It would average out?
What about specialist? Are they also held to this model? If they are, it’s no wonder so many folks with rare diseases are so frustrated.
I have another friend in the industry that said a patient should only bring in 3 issues at a time to the doctor appt. That is all the doctor can handle. Which also makes sense since you only have 10 minutes or less.
Knowing that we can’t change this system…What can your patients do? How can we help? We are willing to do whatever you need so that you can help us get our health and quality of life back.
Rob-
I do understand. I have never forgotten the talk I heard from a hospital CIO saying that in order to be profitable, a physician should only spend 10 minutes per patient with the goal moving towards 8 minutes per patient. That was a few years ago so I am guessing that you are now pressured to spend 5 minutes per patient. You diagnosticians, not fortune tellers. That is a very small amount of time. I have always assumed that was an average? So you see a whole lot of flu shots in one day and then a couple of more complicated cases? It would average out?
What about specialist? Are they also held to this model? If they are, it’s no wonder so many folks with rare diseases are so frustrated.
I have another friend in the industry that said a patient should only bring in 3 issues at a time to the doctor appt. That is all the doctor can handle. Which also makes sense since you only have 10 minutes or less.
Knowing that we can’t change this system…What can your patients do? How can we help? We are willing to do whatever you need so that you can help us get our health and quality of life back.
I have a rather unique perspective on this whole situation as I have had the opportunity to observe this issue from both sides….as a healthcare provider and a patient. I am a licensed physical therapist and have dealt with insurance, Medicare, medical necessity letters, depositions, documenting to the nth degree, paperwork , paperwork, paperwork, etc… Working in the healthcare arena is completely different than it was 20 years ago. And with the onset of HIPPA, it changed everything regarding the way a medical practice is run (i.e.: requiring a compliance officer, piles of documentation, etc…)
Insurance & Medicare reimbursement has slammed all healthcare providers. With the onset of the Balanced Budget Act, reimbursement for all Medicare patients was drastically reduced. And then, as you know, most insurance companies followed suit. Functioning within the Prospective Payment System as enforced by the HealthCare Finance Committee, we therapists were faced with learning a whole new way of approaching patient care. In physical therapy, patient care was based on their estimated Resource Utilization Group Score (RUGS) meaning it’s solely based on diagnosis. The time allowed to treat was based on this score. Therefore, each patient had a different individualized program and we had very rigid requirements regarding the amount of time we spent with the patient based on these scores. For example, treating a patient with a Stage IV decubiti, we received higher reimbursement than a Stage II. A patient who required only gait training, would be allowed less reimbursement than someone who just had a total hip replacement. And with this RUGS system in place, I observed that the complicated patients were getting the care that they needed.
So how could this apply to a physician? The Healthcare Financing Committee is a powerful governing body and I don’t see any reason why they cannot utilize and enforce RUGS scores with physicians as well. In my honest opinion, I think all physicians should lobby to have the system changed. It would not be that difficult as it is already in place for therapies. Under PPS, a PT’s evaluation is service based, and then all treatments thereafter are time-based according to the patient’s RUGS score. Of course as a physician, during the discovery phase, you may not have a definitive dx; therefore the HCFC would have to develop a RUGS scoring system for the testing process in addition to the treatment. So, your initial evaluation of a patient is service based and therefore, you would get a flat fee. Once you submit the dx you want to test for, the patient’s RUGS score is determined on that dx and you are allowed a certain amount of time/reimbursement based on this. For example, a patient you suspect has diabetes vs. a patient you suspect has Cushing’s….the RUGS score will be much higher for the patient with possible Cushing’s as it is much more involved & requires multiple tests & treatments.
Yes, I too am a Cushing’s patient and I am thankful to doctors, like yourself, who continue to provide optimal care within the limitations of insurances & Medicare. But like you said, there are too many doctors who have given up the fight or just don’t care anymore and as a direct result, complicated patients are getting thrown to the wayside. (I myself, have had that happen, delaying my dx & treatment.) If the system changed, then I believe many doctors would change their way of practice. As they say “The squeaky wheel gets the grease”. For the sake of medicine as a whole and patients nationwide, I hope physicians start squeaking!!
I have a rather unique perspective on this whole situation as I have had the opportunity to observe this issue from both sides….as a healthcare provider and a patient. I am a licensed physical therapist and have dealt with insurance, Medicare, medical necessity letters, depositions, documenting to the nth degree, paperwork , paperwork, paperwork, etc… Working in the healthcare arena is completely different than it was 20 years ago. And with the onset of HIPPA, it changed everything regarding the way a medical practice is run (i.e.: requiring a compliance officer, piles of documentation, etc…)
Insurance & Medicare reimbursement has slammed all healthcare providers. With the onset of the Balanced Budget Act, reimbursement for all Medicare patients was drastically reduced. And then, as you know, most insurance companies followed suit. Functioning within the Prospective Payment System as enforced by the HealthCare Finance Committee, we therapists were faced with learning a whole new way of approaching patient care. In physical therapy, patient care was based on their estimated Resource Utilization Group Score (RUGS) meaning it’s solely based on diagnosis. The time allowed to treat was based on this score. Therefore, each patient had a different individualized program and we had very rigid requirements regarding the amount of time we spent with the patient based on these scores. For example, treating a patient with a Stage IV decubiti, we received higher reimbursement than a Stage II. A patient who required only gait training, would be allowed less reimbursement than someone who just had a total hip replacement. And with this RUGS system in place, I observed that the complicated patients were getting the care that they needed.
So how could this apply to a physician? The Healthcare Financing Committee is a powerful governing body and I don’t see any reason why they cannot utilize and enforce RUGS scores with physicians as well. In my honest opinion, I think all physicians should lobby to have the system changed. It would not be that difficult as it is already in place for therapies. Under PPS, a PT’s evaluation is service based, and then all treatments thereafter are time-based according to the patient’s RUGS score. Of course as a physician, during the discovery phase, you may not have a definitive dx; therefore the HCFC would have to develop a RUGS scoring system for the testing process in addition to the treatment. So, your initial evaluation of a patient is service based and therefore, you would get a flat fee. Once you submit the dx you want to test for, the patient’s RUGS score is determined on that dx and you are allowed a certain amount of time/reimbursement based on this. For example, a patient you suspect has diabetes vs. a patient you suspect has Cushing’s….the RUGS score will be much higher for the patient with possible Cushing’s as it is much more involved & requires multiple tests & treatments.
Yes, I too am a Cushing’s patient and I am thankful to doctors, like yourself, who continue to provide optimal care within the limitations of insurances & Medicare. But like you said, there are too many doctors who have given up the fight or just don’t care anymore and as a direct result, complicated patients are getting thrown to the wayside. (I myself, have had that happen, delaying my dx & treatment.) If the system changed, then I believe many doctors would change their way of practice. As they say “The squeaky wheel gets the grease”. For the sake of medicine as a whole and patients nationwide, I hope physicians start squeaking!!
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