Saturday, October 31, 2015

I am witnessing a duality in creating my "ideal medical practice".  Corporate medicine uses structure to design a healthy community.....reimbursement, budget, staff, department. building, campus.  I am using anecdotal success to design......learned information applied in real time to my salaried position.  (sounds like a watered down version of my practice but in the eyes of professional regulation, I am a family medicine doctor just like any other).

My experience with hospitals is when large hospital joins larger hospital system.....reputation brings volume (more doctors ask for privileges to practice, local business align with hospital, patients set allegiance with hospital name) and volume brings profit.
My experience with healing is all patients possess the appropriate way to improve suffering but it must be teased out of the tangled mess acquired over decades (spiritual, physical and nutritional baggage).

So can the medical model work to end suffering.  No, it can control suffering... and in a few cases successfully reverse (like what you see with visits to Mayo Clinic....people sign up, get evaluated by intake doc, speciality doc, testing doc, summarizing a few days to be send back to place of origin with homework for the local healers.  In my opinion its nothing fancy, just the impeccable timing and focused communication among several aligned physicians with a captured audience.  A well functioning local hospital can have the same success when large departments are cohesive, testing is not redundant and patient is willing to go from department to department in a single well designed plan.

The problem I experience with hospitals in the last 20 yrs is -there's poor communication between departments, between doctors, between testing facilities.  It brings excessive testing, excessive prescription use, prolonged suffering and sick days at work....this all culminates in less energy by the patient to make the visits, and be engaged in being their own advocate for finding the endpoint.  (we have all experienced this in calling the phone company to dispute a bill, getting an automated phone menu, repeating the voice commands then being switched to punch dial for a department, finally speak with a live representative describing the problems, being placed on hold to only repeat your autobiography to a fresh person who promptly forwards you to a manager extension that goes to voice mail.....kinda get the wind taken out of your sails by then right?!?! ) So imagine someone labeled with irritable bowel syndrome, fibromyalgia, non differentiated connective tissue disorder, chronic pain, obesity, metabolic syndrome........

The fix was supposed to be the primary care doctor role.  In the 90's we were given the title of "gatekeepers" to arbitrate if and when a specialist was to be seen.  Patients were very unhappy with being told, you can't go to him (not in network) or I do not believe you need that test yet (direct to consumer advertising pushes the most expensive test or pill with little to no benefit over standard).  Insurance companies acquiesced to the masses and gave more options for patients and doctors.  I remember in residency, to take care of all the insurance forms and call backs, an entire department had to be created to handle the paper chase man-hours....and this is from a speciality that receives the smallest reimbursement of all departments.  I have worked for 6 hospital systems in 2 different states and I am always told by corporate that primary care offices "do not make money".  So if you tally the budget and payments received, most primary care offices are in the red.  But....hospitals can sustain primary care practices for the trickle down profit of blood tests, surgical procedures, imaging tests, rehab......when all these things per reimbursed properly, the hospital can justify keeping primary care doctors around.

Q-can the average primary care doctor be an advocate for the suffering patient with a tangled mess of acquired decades of baggage?
A-yes.  If....the doc is well versed with using different tools to untangle.  (Maslow's Hammer 1966, if all you have is a hammer, everything looks like a nail)  Imperative is the ability of the doc to negotiate the truncated patient visit with the exact set of questions.  If we all doctors had 60 minutes to do a quid pro quo,  I believe even the untrained person could design a decent direction for patients to proceed to better health.  We don't have 60 minutes, we have 10 (maybe 15 if you argue to the corporation that issues your have a dedicated panel of patients that are satisfied!!!)  What Can I do in 10-15minutes?  Listen ...but interrupt if you give too much information ...all this so I can extract just enough story-line to justify writing a prescription to turn suffering temporarily down a bit.  Disease management as my guru Andrew Weil calls it.   So requirements to successfully be an advocate for creating a local Mayo Clinic experience is 1-visit time and 2-integrative medicine training.  Neither of which we are afforded as a primary care doctor coming out of residency training.

In attempting to create an Integrative Patient Care Practice (a local Mayo Clinic type center), one would have to lay out a structure to "corporate" for allocating budget.  It would have to be strategically placed in the hospital campus to anchor the new department as a destination medical specialty.  It would have to hire talented ancillary care to help with lifestyle change.  That's a lot of planning and proposal based on  anecdotal evidence from a doc that "doesn't see as many patients as an average family medicine practitioner", "practices medicine but also does that cooky acupuncture (needles or something like that)" and "teaches yoga, eats organic veggies like a hippy".  Sarcastically this is what I experienced as I went to corporate in the past, presented my vision of a Lifestyle Center and was immediately met with questions like what is the budget, is this viable for the economy of the area, who will we have to hire (even had one head walk out of the meeting early)  Difficult questions to answer for a concept that doesn't exist.  I don't blame them, this is the language they don't speak.

So for my patients who follow my blog, have no fear, I know what has been working for 20yrs and I have refined my personal life be healthier husband/father/son and it has afforded me a better spyglass to see into patients "tangled mess".  All the cool experiences I have lived through helps me avoid Maslow's golden hammer law, just in the last 10 months of my return to working for a hospital, I have seen countless patients coming in with weight loss 20-40lbs.  This as the result of educating new patients last spring about how to lower cholesterol medicine dose, wean off 1 of many blood pressure pills, or exercise with walking.  The beauty of inspiring a "way out" is you fill the sails with wind by empowering change with knowledge.  Ultimately my heart says to do whats right for my patients but my paycheck says I have to do what's right as a salaried Family Medicine provider. (I Got This!!!)