20 September 2013

New Physicians Want 35 Hour Work Week?

This blog is derived from this blog written by Leslie Kernisan. She makes many points that I can agree with and I list them first followed by points I have.

Points of agreement: (Read the blog for Dr. Kernisan's explanations.)

#1. If the 35-hour work week will mean more thorough and better care, then make this happen.
#2. If the newly minted PCPs would truly take care of the Medicare beneficiaries, this could be a great purpose.

The following are a listing of Dr. Kernisan's tasks she performs regularly:

#3. Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion.
#4. Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family.
#5. Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. (See this JAMA article to understand how well intentioned practice guidelines could cause serious problems for elderly patients.)
#6. Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family.
#7. Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful.
#8. Helping patients and families prioritize and identify a few key health issues to work on at any given moment.
#9. Helping patients and families evaluate the likely benefits and burdens of possible medical approaches.
#10. Helping patients and families cope with the uncertainties of the future.
#11. Weighing in on family conflicts.

Now I have left out one factor that I feel doctors should not become involved in and I am admitted tired to hearing them.

A point of disagreement and points not covered which need to be considered

#1. Addressing end of life planning. I have seen doctors, hospitals, and family side-step this so often that I place no value in these discussions. My own family has shown their own opposition about my wishes for end of life. With rationing on the horizon, doctors and hospitals are turning a deaf ear. I realize that medical supplies and other factors are not infinite, but still rationing is the buzz-word at the CMS and in the Congressional arena. Read this blog - http://bobsdiabetes.blogspot.com/2011/08/cms-threatening-more-euthanasia.html And this blog - http://bobsdiabetes.blogspot.com/2013/05/medicare-enforcing-healthcare-rationing.html

#2. The physician shortage will be here and is in many areas of the country. It will take more than a decade to correct for this as it is, even if the 35 hour-work-week becomes a reality.

#3. Let us stop squabbling about who may be able to help during the shortage. Many doctors are urging their state medical boards to prevent NPs, PAs, and Pharmacists from practicing unsupervised. Most medical professional organizations are also filling the printed pages, the internet, and air with their opposition to these professions. Even if allowed to practice, there will still be a shortage as many of them have gone the specialist route in search of better wages. I feel fortunate that I have at present two NPs that I see on a regular basis. Even though my state allows them to practice independently, they still work under the supervision of MDs. My blog - http://bobsdiabetes.blogspot.com/2012/11/are-doctors-lobbying-themselves-out.html

#4. Many state medical boards have even limited PCPs and Family Physicians and what they can practice, at the request of specialists and their whining. Licensing boards are also limiting what some para-professionals can and can not do. Because some doctors have seen the need for education in the diseases of cancer, diabetes, MS, and others, they have taken patients knowledgeable in these diseases and spent time and occasionally money to train them as peer mentors or peer-to-peer workers to assist them in educating their fellow patients. A few state medical boards are now trying to even stop this from happening. This blog - http://diabetestopics.blogspot.com/2013/09/are-doctors-threat-to-their-own.html

#5. PCPs are even trying to prevent organizations hired by the hospitals to enter patient's homes after a hospitalization and assist patients in need. Many of these patients seldom see a PCP, don't have one, or cannot get an appointment to see one soon enough after being discharged from the hospital to prevent rehospitalization. This blog - http://diabetestopics.blogspot.com/2013/09/pcps-are-putting-themselves-in-bad-light.html

#6. With the tsunami of new patients coming January 1, 2014, many doctors and specialists are cleaning house of undesirable patients that might prevent them from receiving the incentives from CMS that they feel they are entitled to receive. This blog - http://bobsdiabetes.blogspot.com/2013/09/changing-doctors-now-may-not-be-best.html

#7. With the CMS program for assisting obese patients now underway, most hospitals have established the weight-loss clinics into the bariatric clinic to charge a fee to do an evaluation. This evaluation is to determine if the bariatric clinic can convince these patients to go the bariatric surgery route, thus gaining the surgeons and hospital more money. If not, these patients are deemed unfit to accomplish weight loss and not accepted into the program. This blog - http://bobsdiabetes.blogspot.com/2013/05/medicares-obesity-program-has-problems.html

#8. Even the doctors now have DSM5 for medication for every conceivable mental health issue and are to forget counseling from a positive perspective to enable their patients to take charge of a mental health problem and overcome it. Medications are now the only answer. This blog - http://diabetestopics.blogspot.com/2013/09/the-dehumanizing-of-patients.html

#9. I have no idea if this is just my corner of the world, or is more widespread, but when a patient questions a procedure, operation, or medication, we are told we more than likely have cancer and need to see the oncologist. Four doctors have thrown this in my face in the last five months even after I have been given a clean bill of health by a VA oncologist after two different days of tests and procedures. Then when I tell them this, they just say that the VA is not the most reliable. Only one doctor has thanked me for going through the tests and eliminating the concern about my elevated white cell count. No blog – yet.

#10. More doctors will need to enter the realm of contract medicine to fulfill patients' needs, as doctors are more and more becoming employees of hospitals. Because hospitals are driven by the bottom line, little will change under the ACA and patients will continue to be treated only when they have a disease, illness, or injury requiring a doctor's care or that of a specialist. Heaven help the patient with hypertension or diabetes if the hospitalist decides to “tune-up” these patients when they are hospitalized for an unrelated disease or illness. This blog - http://diabetestopics.blogspot.com/2013/09/another-reason-to-be-careful-of.html

#11. More and more doctors believe and rely on faulty studies. They become very defensive when a patient becomes a “micro-expert” and knows the difference. This is especially true for some diseases and illnesses. This blog - http://bobsdiabetes.blogspot.com/2013/06/ada-relies-on-faulty-studies-not-good.html

#12. Some patients are even excited about the prospect of being able to see a doctor less often and become able to write their own prescriptions. There would be some restrictions some patients will not be able to meet. This blog - http://diabetestopics.blogspot.com/2013/07/some-patients-may-not-need-doctors-as.html

#13. Dr. Kernisan has covered “patient engagement” in her blog - http://thehealthcareblog.com/blog/2013/09/12/patient-engagement-on-metrics-and-meaning/ I am concerned about a problem I encounter all too frequently, the doctor version of patient engagement. The doctor asks the questions using his/her technical language and the patient is often unable to answer because they do not understand the question. I lose out because I do ask what a term means in lay language and the doctor often fumbles my question and out the door goes patient engagement. One part of patient engagement remains out in the cold because most doctors will avoid allowing patients to access their medical records. Hopefully, meaningful use will be denied for these doctors. Even one of the physician clinics had signs up in every exam room about access to EHRs and to ask the receptionist for a form and password. When asked, the receptionist says that it is not available yet. My translation – to let the inspector see this to pass meaningful use.

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