Friday, December 26, 2008

Home, business business ideas -Procedures - The Hole in the Medical Home Theory

There’s always a hole in theories if you look closely enough.

Mark Twain

The solution is not an intramural “food fight” over payment.

Allan A. Goroll, MD, “The Future of Primary Care – The Community Responds,“ New England Journal of Medicine, December 18, 2008

Our society tends to place a higher value on technical skills than “cognitive” ones. Being an internist, I think I need to be paid more. And I suspect some of the others need to be paid less. Unfortunately, none of the “proceduralists” have offered to share their wealth with me.

Jane Orient. MD, “What is a Doctor’s Relative Worth,” The Freeman, 2007

I’m beginning to feel a little like Ernie Pyle, a World War II war correspondent. Ernie Pyle reported to folks back home what and how GIs were feeling and doing in European and Pacific theaters.

Medical Wars

As a war correspondent of sorts, I identify with Ernie Pyle. I report what’s happening to frontline clinicians in U.S. medical wars. These wars are subtle and political. They exist between health plans and doctors, hospitals and doctors, and to a lesser extent between specialists and primary care doctors. The battles are rarely public and are mostly unspoken The secretive fights are waged privately over turf – over who does what to whom, and who gets paid, and how much.

Scope of Practice


With primary care doctors, turf wars often boil down to defining the scope of their practices. Most definitions of the scope of primary care practices don’t even mention minor surgical procedures. Nevertheless, I maintain trained and prepared primary care doctors should be free to freeze, cauterize, or curette skin lesions, inject or aspirate joints, tennis elbows or carpal tunnels, and varicose veins; excise or incise skin lesions, and undergo training to do other procedures as outlined in the 2200 page book, Procedures for Primary Care (John Pfenninger and Grant Fowler, 2nd edition. Mosby Books, 2003).

Pfenninger founded the National Procedures Institute in 1989. The Institute and its faculty have trained over 50,000 primary care doctors to do minor procedures. Pfenninger insists primary care doctors doing appropriate procedures for which they are trained improves continuity of care, provides comprehensive care, reduces costs, pleases patients, and enhances practices without compromising patient safety or quality of care.

Seldom Mentioned Procedures

Those who write about primary care procedures seldom mention that primary care doctors in rural areas and in medical homes may also be called upon to perform a variety of diagnostic and therapeutic procedures, some of which must be done as emergencies and in the absence of an available specialist– lumbar punctures, parencenteses, thorancenteses, arterial blood punctures, punch and excision biopsies, suprapubic bladder catherizations, splints and casts, lacerations, central line insertions, endotracheal insertions, and emergency appendectomies and C-sections.

Three Doctors

The other day a primary care physician in New Hampshire told me doing procedures highlighted her day. When she was doing procedures, she felt she was truly being a doctor. She was doing something concrete and often curative, something beyond what physician extenders are qualified to perform. Performing procedures gave her great satisfaction, more so than diagnosing, counseling, and advising patients, all vitally important but in her mind, buy not fulfilling enough for those interested in total doctoring.

A general internist on the Connecticut shore is held in high esteem by patients and conducts a prosperous practice. He has a special interest in lesions and diseases of the skin. Most of his patients are elderly, and like most older patients, they present with various skin lesions. The internist frequently freezes, cauterizes, excises, and biopsies these lesions. These procedures, sometimes of a cosmetic nature but more often are done to rule out malignancy, produce an increased cash flow and leave grateful patients in their wake. Patients don’t have to wait, sometimes for months, to see a specialist.

A primary care doctor in Michigan called and wanted to know why doing procedures wasn’t stressed more as an integral part of the emerging medical home concept. She graduated at the top of her class five years ago and picked family medicine as a specialty because she thought its practitioners could do many things while specialists were limited to doing one thing. She was soon to learn hospital and specialty politics constrain what procedures a primary practitioners can actually do and where they could do them.

A Medical Home Blog’s Shortcomings

The Michigan doctor had read my blog on “Medical Homes: Assumptions and Expectations.” She praised the piece as far as it went. She said what I had said I said well, but I had not said enough. She yearned to do more procedures to hone her skills and to expand her practice horizons.

What could be done to make procedures more routine for primary care doctors? I’m reminded her of a Margaret Thatcher quote, “In politics, if you want anything said, ask a man. If you want anything done, ask a woman.” By getting the word out through me and others, she might get something done.

What I had not said, she said, was that hospitals favored specialists as a greater potential source of future hospital revenues. Consequently, primary physicians were sometimes excluded or bumped from the operating suite schedule She cited the case of a primary care physician in her town who had performed hundreds of colonoscopies in his office partly because he had frequently been denied access to the operating suite.

Possible Reasons Why

Why was this? I asked. She said she thought it might be because hospitals purposefully cultivated specialists. Specialists’ procedures contributed more to the bottom line. Also the “bread and butter” of many young specialists were often minor procedures until specialists got up to speed towards bigger operations. I pointed out that one of the unknown and untold secrets of hospital-done procedures is that the hospitals routinely collect a “facilities fee” just for providing a place for surgeons to do their work. These fees often exceed the surgeon’s fee and contribute significantly to increased health costs. It was best to be cognizant but not paranoid about these economic realities.

“Curious” Omission

She found it “curious” that medical home backers didn’t stress performance of procedures as a fundamental part of coordinated and comprehensive care. The ability to do procedures distinguished primary care doctors from physician extenders. Besides, after all is said and done, there is nothing more coordinated and comprehensive than having a diagnosis made on the spot with lesions removed, diseases treated, and symptoms relieved at one visit. One stop shopping is an important feature of comprehensive care.

Dumbing Down

She perceived (and sometimes resented) primary care was being “dumbed down” by restricting the scope of what primary care doctors could do. In many cases, she added, the distinction between the tasks and skills of primary care doctors and specialists was self-serving. In the process, primary care doctors were being reduced to glorified physicians assistants, perhaps specialists’ assistants was a more apt description, incapable of doing anything more than writing prescriptions, making preliminary diagnoses, giving therapeutic and preventive advice, helping patients navigate the medical maze, managing and coordinating chronic disease, and referring patients to specialists, often for the performance of minor procedures, the primary care doctor could have performed in the first place.

Unfortunately, the result, she said, was a feeling of clinical amd monetary impotence on the part of primary care practitioners, delays in diagnosis, unnecessary expense, anxiety in waiting for minor procedures to be performed, and trivialization and minimization of what the generalist could do.

What Can Be Done?

What can be done? I asked. She said: Get the word out on your blog. Tell the world what we’re capable of doing – competently, safely, conveniently, at low cost for patients. Cut through the politics. Encourage primary care doctors to get their CME credits by attending procedural training courses Plead our case. Help change the primary care paradigm – create a new bottom up framework of thinking.
I said, I‘ll see what can be done.

The Doughnut and the Hole

I’m pessimistic over the near term about incorporating procedures in the medical home because of our byzantine coding system and bureaucratic delays, but I’m cautiously optimistic in the future performing simple procedures in medical homes will render these homes more economically viable, practical, comprehensive, and less fragmented . In medical homes, I see procedures as the doughnut ,the whole of patient care; even though others may see procedures as something that can’t or shouldn’t be done, which is why we have a hole in the medical home concept

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