06 September 2013

Are Doctors a Threat to Their Own Occupation?

Yes, according to Dr. Paul D. Simmons and he does not mince words. His final paragraph quite accurately sums up the whole argument, “If my professional organization, the AAFP (American Academy of Family Physicians), wants to know who is eroding the identity, role and practice spectrum of family physicians, they need not look at NPs. They need only look in the mirror.”

According to Dr. Simmons, in recent months, AAFP president Reid Blackwelder has been up in arms about what he sees as the encroachment of nurse practitioners (NPs) and other mid-level providers on the practice of family physicians. Dr. Blackwelder has repeatedly said that NP and physician roles are “not interchangeable.”

I do take delight is his term for specialist – partialist. These partialists are the ones that have slowly pushed the family physicians out of their practices by limiting what they are trained to do. Yes, it is not the NPs that have denied family physicians privileges to practice obstetrics, to do C-sections, to do endoscopy, to practice conscious sedation and to do minor surgeries – in other words, to practice the full scope of family medicine. The culprit according to Dr. Simmons are their colleagues who see us as a threat to their “turf” (and income) who have restricted our credentials and ability to practice.

Dr. Simmons continues, “It is we who have voluntarily given up our scope of practice in many areas, who are surrendering our hospital, obstetrical and surgical practices either in the name of an easier lifestyle or because of pressure to see more patients per day.”

Then he addresses the impending physician shortage by saying that there will not be enough family physicians to fill the gap. NPs he says will serve in that necessary role and do an excellent job. It will happen, it already has happened, and there is no way for the AAFP to prevent it. Good for Dr. Simmons.

This is also the reason I have written about the American Telemedicine Association calling for national licensing which medical associations and state medical boards are in full opposition. Then I also blogged about doctor bashing because this is happening because doctors will not make referrals when they are not current in an area. With the impending shortage of physicians, patients are going to become frustrated. If the frustration becomes large enough, the manure will hit the fan and the doctors opposing NPs, PAs, and pharmacists, plus other doctors who are qualified and could work across state lines may just find themselves hurting for patients. I hope this does not happen, but I would not bet against it. I just say let these doctors shoot themselves in the foot. Maybe the pain in one end will bring some sense to the other end.

05 September 2013

PCPs Are Putting Themselves In a Bad Light

Primary care physicians are taking it on the chin, but in many cases are doing this to themselves. I think doctor bashing is too polite for the things I am reading about what the PCPs are doing. Dr. Michael Cetta cites even more cases where PCPs are damaging their profession. In some areas of the US the shortage is already being felt and people are reacting negatively to what they are doing.

I am even hearing about court actions against some PCPs for not doing what they are not letting others do. Yes, this is getting very upsetting in some areas. These doctors have smashed the pedestal they had placed themselves on, and people are hauling away the pieces. When primary care isn't available like the example covered in this blog, tempers become very short. I have heard from the fellow in this blog again and the doctors are dumping all patients working for the company because they could not wait for about six months for an insurance required physical. If the company was requiring the physical, then they should have waited, but the insurance company would give no extra time. The fellow said this is getting very nasty in the community. Two doctors that had insurance are without insurance because a division of the insurance company that required the physicals, canceled their insurance.

Since this is a company town, this meant that 90% of their patients were gone and the remaining patients said no thank you and are looking elsewhere for a doctor. Then the owner of the building containing the offices of the two doctors served them with an eviction notice because he said they would not be able to pay the rent. One has already moved into another office about an hour away and the second will be joining him. What surprises this person is that the doctors are trying to prevent other doctors from moving into the town they were evicted from.

In some larger communities, Transition Care programs are beginning to take up the slack for PCPs to care for patients fresh out of hospitals. Because of the emphasis by the Centers for Medicare and Medicaid Services (CMS) of penalizing hospitals for too many readmissions, Transition Care programs are sending healthcare providers into the patient's homes. This is stirring up opposition from PCPs who don't want another care provider stepping in, or the PCPs don't understand the value. After all, (tongue-in-cheek) aren't PCPs supposed to have a proprietary right to oversee their patients' health.

The telling fact is disturbing because everyone does not have a PCP and about 50 percent of the Medicare readmission patients will not have been seen by a primary care physician between admissions. Of the $17 billion spent each year on only Medicare patients, 75 percent of those readmissions are considered preventable. Why aren't the PCPs taking care of them? Because they do not have office time to fit them in and some patients do not have access to a PCP.

Dr. Cetta has this example, “To solve this enormous problem, Transition Care programs need to work closely with PCPs. But right now, a large number of patients who could benefit most from Transition Care are weeded out of the programs because of PCP opposition. In one recent pilot program at a hospital in Maryland, roughly a third of all patients who otherwise qualified for Transition Care were weeded out because of their primary care doctor’s opposition.”

Turf wars are not pleasant for the patients and it is time to have patients take up the cry to PCPs saying if you don't have time to see me, then step aside, you will no longer be my doctor. Even caregivers are considering this, as they don't wish to see their people reenter the hospital so soon after discharge.

04 September 2013

Another Reason to Be Careful of Hospitalists

On August 22, I blogged about hospitalists and what this can mean for you. Now another case of why hospitalists may not be the best. This hurts as it affects those of us with diabetes and those with hypertension. Hospitalists see it as their duty to fine tune our management of both. No matter the reason for being hospitalized, I would encourage all people with diabetes and/or hypertension to be careful what they allow the hospitalists to do to you.

The author of this blog relays information from the University of California, San Francisco about elderly patients admitted for an acute problem of pneumonia. They also have hypertension, diabetes, and other conditions that are unrelated to the reason for admission.

The well intentioned hospitalist may see the hospitalization as an opportunity to “tune up” the patient by intensifying the treatment of these conditions. The blog author continues, “This usually does more harm than good. Unless these conditions are out of control, or their treatment is part of the treatment of the acute illness, the patient will be better served by a less is more approach, leaving management to the outpatient doctor.”

An acute illness often causes problems in management of hypertension and diabetes while in the hospital. This is problem one, as control generally returns to normal after the acute illness resolves. But, when a hospitalist intensifies treatment in the hospital, the patient will then go home dangerously over treated.

Problem number two is that is impossible to determine the ideal regimen for blood pressure and glucose management in the hospital. It is just stupid (my words) to titrate medications for these conditions in the hospital. The acute illness may increase hypertension and make glucose management almost impossible until it is resolved. Then the patient is discharged and told this is what he/she must take and because the home regimen, diet, exercise, and other activities, is totally different than the hospital, this can cause all sorts of problems for the patient.

The hospitalist may have made the numbers look great while the patient was in the hospital, but clearly the numbers will be very different when the patient is at home. Hospitalists should think twice before trying to change established outpatient regimens for hypertension and diabetes in the hospital. Changes should only be made in consultation with the patient's normal doctor.

A local person with type 1 had his pump totally messed up by a hospitalist and needed to use multiple daily injections until he could get home and get help from the pump manufacturer. Then he needed to call his endocrinologist to get the settings corrected to what they had been before the hospitalist took charge. Since he knew he would be going back into the hospital two months from now, he has sent a registered letter to the hospital requesting that the hospitalist not be allowed near his room. In addition, the letter stated that under no circumstances was the hospitalist even to touch his insulin pump under threat of a lawsuit.

Since the hospital has refused, he and his doctor are investigating another hospital for the operation and they will go through the same procedure to limit what the hospitalist can do. Because of the location of the operation on his body, his wife will accompany him and take charge of his pump until after the operation is completed. Then he or his wife will reattach the pump to another area and start it. She will also have control of his testing supplies. His endocrinologist will see to it that he can use his own insulin.

Since hospitals are nefarious in allowing blood glucose reading to be maintained at 180 mg/dl to 200 mg/dl, his endocrinologist wants to help him heal faster and maintain his own glucose levels. His endocrinologist says that he should be able to manage having the hospital allow this especially since he has hospital privileges at the new hospital. He will also have a CGM for his use while hospitalized.

03 September 2013

Hospitals – Money Is the Only Driver

Hospital leaders are either enlightened or not. If you look hard enough, you can find many enlightened leaders that have embraced hospital capacity management. These leaders view the emergency department (ED) as the front door to the hospital. These leaders understand that the ED interacts with more patients, family, friends, and providers than any other area of the hospital. This means that the ED is an enormous generator of capacity management, not just affecting the ED, but the entire hospital. Therefore these leaders move resources, implement new processes, such as well-run and staffed observation units, to address the management of the capacity issues directly affecting patients waiting for a hospital bed.

Dr. Robbin Dick is a little over the top, but he has a right in many cases and does spell out some of the shortcomings found in many hospitals. It has a lot to do with who has what position in the hospital pecking order. Some hospitals only operate this way and the higher up the ladder a particular doctor, the more control he/she wields and some wield this control for every advantage to them. Others care and share duties and see that procedures are within the needs of the hospital.

Often it is the surgeons and cardiologists that are high on the hospital ladder and they demand that their needs and lifestyle are fostered at the expense of everyone else.

I was surprised by Dr. Dick's statement in his blog, but in discussing this with now three different hospital administrators, he is right with one exception. The exception hospital is run by Nuns to this day, and they do not hesitate to fire any doctor that thinks he/she has a lock on the hospital ladder and start demanding certain things happen for their benefit. When I talked to the head of the hospital recently, she apologized for not responding to me earlier, but employee matters were taking more time than they should. I know this person and asked her point blank if she was referring to the two surgeons no longer on the hospital staff. She laughed and told me I had been reading the local paper, which was true. Many hospitals have retained religious ownership, but are run by other people trained for this. This is a rare hospital.

This hospital will admit that the ED is the driving force and they do make way for the patients arriving this way, but at the same time, she admitted that they space out surgeries when possible to make room for those arriving through the ED. She also stated that when surgeons feel that they have special hours, that is when their wheels fall off and out the door they go. In the last ten years she did say that have had 10 different surgeons. She maintains that they are all told that they have no special privileges and when they feel they do, to pack up and leave. They have four surgeons all working different hours on a rotating basis. Plus, she said they have eliminated four other surgeons and cooperate with another hospital in transferring specific patients to them.

This administrator admits that it would be great if they could be providing patient centered care, but this does not pay the bills. She does say that maybe this will happen in the future, but the current healthcare law will not permit this although some are claiming it is possible. She says if they do this, they will lose money unless they can divide the hospital and have a high profit side and a very low loss side.

The other point she made to me was something Dr. Dick rails against. She said that when doctors become too big for their britches, this means that the hospital will lose money. She admits that doctor centered care was a money loser and this she would not permit.

02 September 2013

September Calendar of Monthly Events

September shows up as a very active month for celebrations. I have limited the selections, as some have no interest for me. Although it is listed, I will not write about whole grains month because as people with diabetes, we don't need the extra carbohydrates and most people could eat better if they did not include many of the whole grains. The Academy of Nutrition andDietetics is naturally heavily promoting them. What can you expect from a subsidiary of big food?

The three that I am promoting include the National Cholesterol Education Month, the
National Yoga Awareness Month, and the Healthy Aging Month. You may find other events that interest you here.

This link to the Centers for Disease Control and Prevention has a decent discussion about cholesterol, but nothing about the test that I discussed in this blog. While the test is not for everyone and not cheap, it will help determine if you do not need certain statins. If you require statins, try to have the doctor start with a lower dosage and then move up if your situation requires it.

I found an interesting Risk Assessment Tool for Estimating Your 10-year Risk of Having a Heart Attack that I used. I will not relay my results, but they were not what I hoped. This is another great reason to always obtain your lab results when you find calculators like this. Both links and this are worth exploring and reading about cholesterol. And for someone that thought he knew a fair bit about cholesterol, even I learned a few things. I may do a blog about cholesterol when I finish my reading, but no promises.

The National Yoga Awareness Month (a national observance designated by the Department of Health & Human Services) is interesting if you are supple enough for yoga, which I am not. I will still write about this as it is interesting and as a form of exercise, can be very beneficial. David Mendosa has some interesting blogs about yoga and by typing yoga into the search box on his site. You will find quite a few blogs.

I have known several people that do yoga very frequently and I was aware of a yoga club that existed for several years, but I have not heard or seen anything about it in the last few years.

The other event of interest is Healthy Aging Month. Healthy Aging Month is an annual observance month designed to focus national attention on the positive aspects of growing older. It is to promote taking personal responsibility for one's health, whether it is physically, socially, mentally, or financially.

This link has many tips for the elderly to help them with aging and is short, but worth reading.