Yes. That is me in the middle.
Do you like to go fishing? I do on occasion. Although, as I age I at times feel sympathy for the fish. But, I digress.
Many years ago as a student I did a family practice rotation in a great rural location in Pennsylvania. I liked this place so much I worked there immediately upon graduation from Physician Assistant school. My meager experience limited my fishing skills. On several occasions as a child and teenager I recall awakening early. I mean early in the morning and driving from our home in Southeastern Pennsylvania to the Chesapeake Bay. We rented a small skiff and fishing equipment and if fortune found us we wrangled some flounder out of that water. Most of our day, and I must admit favorite part of the trip, consisted of crashing through the waves in the skiff. Our father let my brothers and I steer the boat using the outboard motor. What a blast! Experiencing fatherhood, I realize that my father had true grit allowing us to do this. You see he didn’t like waiting and waiting for fish to bite any more than we did. But he risked his life for our joy.
One day we made a trip to a fish hatchery. The rules, you kept what you caught and paid by the pound. No catch and release. No hook or bait restrictions. No size limits. The trout hit on a hook with no bait. We bankrupted our father in less than one hour. This, by far remains my favorite fishing expedition of all time. Sadly, this hatchery was destroyed by Hurricane Agnes. I do recall several other fishing excursions. They did not involve catching fish. They involved putting a deep sea sinker and some hooks on the line and drowning worms or feeding the fish corn that fell off of my hook. They involved poison ivy , mosquito bites and on one occasion getting our station wagon stuck up to the axels in mud.
My fishing experience changed in Perry County Pennsylvania when I met Jim. Jim worked at a facility near the health center that I worked at. He loved the outdoors and loved to fish. I’m not sure what he is up to now. However, it is trout season in Pennsylvania and I’m sure he caught his limit today. I never met a man before or since who could catch trout like him. He always used live minnows and a treble hooks. He took me under his wing and taught me how to fish. He entered crowded fishing holes with the minnow and hook securely hidden in his fist and boldly asked, “How’s the fishing boys?”. Invariably the resounding response from the mob, “They ain’t biting Jim.” Jim smirked and through his bush of a beard said, “Is that so?”. He lowered his polarized sunglasses and went to work. In less than a minute at least four nice sized rainbow trout wriggled, stranded on the bank of the creek behind him. When asked what kind of bait he was using he would keep that minnow tucked in his hand, smile and say “Worms.” We went to hole after hole and repeated this action. This was a true chilly willy the penguin moment. You see, he caught my limit too.
Your probably asking yourself. “What’s this got to do with Kindergarten.” I’m getting there, I promise.
One of the things that we are taught in Kindergarten is to share. To get along with others. Hopefully with the help of our parents and what they taught us this carries into our adult lives. You see, Jim did not like to share his knowledge of how to catch fish with just anyone. I truly feel privileged he helped me. But I have to admit. I never reached the ability to catch trout like him. True, I improved. I learned catching trout did not simply involve using a minnow or how it was baited. Jim possessed a finesse, a talent, gained by experience and a love of the sport.
Do you like your job? Little wonder if you don’t, 40 percent of primary care physicians at any given time are experiencing symptoms of burnout. Do you like your patients? Do you love your job? Do you love your patients? Do you have experience and knowledge that could be beneficial to the survival of primary care? Why not share it?
I recommend a book that I read in the past and refer to frequently. Love Your Patients! by Dr. Scott Diering. This is a must read for anyone experiencing difficulty with patient satisfaction, professional satisfaction or communicating with patients.
To my Adult Patient:
Today I have diagnosed you with an upper respiratory infection or bronchitis. Almost all upper respiratory infections and bronchitis’ are caused by viral infections. These viral infections cause irritation to your nose, throat, vocal chords and the upper parts of your lungs. You told me about your fever, your chills, your muscle aches, your cough, your sore throat, runny nose and the mucous you are coughing up. I understand that you feel like the cat drug you in. I understand that you can’t miss work. I understand that your family depends on you. I understand that this is not a good time for you to be ill. I even understand that you may be traveling for vacation or business and that tomorrow may be a holiday.
Please read the second sentence above. Look at the word viral. This means that your infection is caused by a virus.
A virus is a very small particle that can only reproduce inside another living cell. The viruses that cause your condition actually infect the cells of your nose, throat, vocal chords and lungs and cause irritation. They make the area red, irritated, painful and produce mucous. This mucous can even be yellow or green (purulent). You can cough, wheeze, loose your voice and generally feel miserable. Unfortunately the average upper respiratory infection can lasts 7 to 21 days and the cough and irritation in your lungs can last up to six weeks.
Viruses cannot be treated by antibiotics. Antibiotics only treat bacteria.
I want you to feel better.
I wish I had a pill that could make you all better by tomorrow.
Unfortunately, these viruses must be fought by your body. Over the counter medications and some prescription medications may help with your symptoms. I cannot cure your condition. I explained this to you today. I explained that antibiotics will not help. I explained that antibiotics may cause diarrhea, yeast infections, stomach upset, allergic reactions or even serious bowel infections. I explained that you will feel better in 1-3 weeks and that you may cough for up to 6 weeks.
Please don’t insist that I give you an antibiotic.
Please don’t call me in 2 days and insist that I give you an antibiotic.
If you feel worse, or your fever rises give me a call. If you get short of breath or vomit when you cough let me know. If your throat is so sore or swollen that you are having trouble swallowing let me know. Please don’t get upset if I want to see you again. Please don’t get upset if I don’t just call in a prescription for an antibiotic. I want to do what is best for you. I want you to feel better. I care about you.
Your Primary Care Provider
Are you chasing the carrot? Have you gotten a nibble yet? Pay for performance continues to grow as a policy, with little evidence supporting that it works. Many of my colleagues feel frustrated over the current methodology of pay for performance (P4P) programs. Each insurance company seems to have its own P4P program. Difficulty incorporating EHR systems into compliant reports causes time consuming hand written or hand entered report generation and increased expense for added ancillary staff. Add to this that the rules change frequently and the carrot never gets any closer is leading me to wonder if it is worth the effort.
There have also been several studies that I have read over the past several weeks that show that it is becoming common practice for some physicians to discharge patients from their practice for noncompliance in receiving recommended cancer screening tests or if they have complex medical conditions that make it difficult to get their vital signs or labs to meet guidelines (so called gaming the system). With more than 30 million more Americans expected to have health insurance in the future, how much more gaming of the system will occur. Is this good for patient care?
If after several attempts at compliance with preventive services fail, I grovel, letting my patients know that my reimbursement from their insurance is adversely effected. In effect, if they are not going to do it for themselves or their families, would they do it for me? I have not studied the response to this or how often I have done this but anecdotally it works. This is certainly a shift in my norm of practicing preventive care for the past 20 plus years.
One quality factor that is especially low in some primary care offices is the child and adolescent annual physicals. Some practices now offer incentives this group of patients. “Get your physical and have a chance to win a gift card for downloading music to your MP3 player.” Now were dangling a carrot in front of our patients so we can get a bigger carrot.
It is also apparent that primary care providers are affected much more by P4P programs then other specialties. When our office provides primary care services to a diabetic patient who follows with endocrinology there is no way to remove them from the panel that we are responsible for. If their hemoglobin A1C is not to goal, our fault. If they see a cardiologist who feels that a BP of 140/90 is ok for a diabetic and stops there medicine, our fault. If their cardiologist or endocrinologist is happy with an LDL of 150 and decreases their statin, our fault. So how long will we chase the carrot.
Here is a good video from the AAFP discussing the patient centered medical home.
At the ripe old age of four I recall visiting our family practitioner, a gentle, and kind man advanced in years. I don’t remember if I cried when I got the shots. I don’t remember if I was scared. I don’t remember much past the smell of the disinfectant. What I do remember is the Tootsie Pops. An office visit always produced that reward. Either he or his wife (who also doubled as his nurse, cleaning lady, office manager, secretary and biller) would open the cabinet at the bottom of the exam table and miraculously the bottomless box of Tootsie Pops appeared. Grabbing my favorite color purple, I ravenously removed the wrapper and walked out proudly working on another cavity to help buy my dentist’s new car.
Today we hear much about patient satisfaction. Large companies, practice consultants and speakers thrive on this. We often try to take a problem and make it complex. The consulting firms and those specializing in patient satisfaction position themselves knowing that there are those willing to throw money at the problem to solve it.
Like that simple treat mentioned above, little things can mean a lot. Eye contact, a smile, a warm greeting, kind facial expressions and sometimes just listening is what our patients want and need.
I plan on discussing some simple, inexpensive things we can do to keep patients satisfied with care , with office staff, and with primary care in general.