Saturday, November 29, 2008

Simple Office Procedures in the Office as an Innovation

To perform minor surgical procedures in the office may seem quaint rather than innovative, for doing so for family doctors of yesteryear was routine.

But innovations need not be complicated or new. They can be as simple as returning to old family doctor tradition of performing simple procedures in the office.
Many primary care physicians across America now perform simple procedures in their offices. They do for multiple reasons: procedures pay more for time spent than cognitive visits, they are often simple easy to do, office procedures save patients time and money, procedures can be thought of as one-stop comprehensive care.
Rather than say anything more, I reproduce here a sample passage from my book Innovation-Driven Health Care (Jones and Bartlett, 2007).

Dr. John Pfenninger is a family practitioner who passionately believes his compatriots in their offices can do more procedures and do them well with more conveniences for patients and less cost to the health system. Here is his story.

“The story of the National Procedures Institute (NPI) is quite simple. I was born and raised on a farm. So I was used to, and enjoyed, working with my hands. Surgical specialties interested me, but the time needed to finish the residency program and the lifestyle afterward were not very enticing. Subsequently, I chose family practice, so that I could ‘could do everything like the old country doctors.’”

Family Practice Residencies Deficient in Teaching Office Surgical Skills

“It didn’t take long to see that family practice residency programs really were quite deficient in teaching office surgical skills. Initially, physicians that were in private practice as ‘GPs’ became residency directors. They tended to do many more of the surgical procedures. They delivered babies, performed appendectomy, set fractures, and so forth. As time went on, however, experienced faculty became few and far between. Salaried physicians had a tendency to do less and less with their hands. Hospital credentialing processes and liability concerns from insurer’s further limited interest in procedures.”

Learning to Do the Simple Things

“Still, there were many of us who wanted to learn how to treat hemorrhoids, inject veins, do vasectomies, put in IUDs, do dermatological surgery, perform the procedures needed of emergency and hospital care, and more. However, there was no formalized training available to learn these procedures! Although state and national academies offered a small smattering of selections once or twice a year, there just wasn’t enough quality education being offered in the procedural skills area.”

Doing Office Procedures Makes Sense

“Doing office procedures makes so much sense. Many things can be performed in the office as opposed to the hospital. Surgeons are trained to do everything in the operating room but this markedly increases cost. Sebaceous cysts, lipomas, hemorrhoids, and many other conditions can be treated in the office setting. Patients appreciate this, as do the insurers, because costs are kept to a minimum.”

Other Advantages

“Other advantages of doing procedures include a reduction in delay of diagnosis. In other words, if a skin lesion looks atypical and the clinicians are comfortable doing a biopsy, it is biopsied on the spot. The alternative is referring the patient away. This may take another r6 to 8 weeks before another evaluation. In the case of melanoma, that puts the patient at increased risk.”

“Physicians who do procedures have a tendency to know more about the disease process. Describing what a rose smells like or what an orange tastes like is difficult. How does one explain the color red to a blind person? Similarly, it is difficult to explain various disease processes.”

“However, if the clinician becomes involved with seeing, feeling, and exploring the innuendoes of a disease process, the diagnostic acumen becomes more accurate. Doing procedures an also break up the monotony of the day-to-day practice.”

“In addition, reimbursements are still are grater for surgeries and procedures, virus nonsurgical areas. Numerous studies are available showing that those who perform procedures have a significantly higher net income. For most family physicians, they choose the specialty not to be case managers and paper pushers, but rather to provide comprehensive care. Doing procedures makes this more likely.”
NPI Born in 1989

“Thus, in 1989, the National Procedures Institute (NPI) was born with the purpose of teaching surgical and procedural skills for primary care clinicians. It has grown from teaching two courses the first year to over hundred in 2006. Over 15,000 clinicians have trained with the National Procedures Institute. After 17 years of teaching procedures skills, NPI remains the leader in educational opportunities in the field of teaching primary care physicians to perform appropriate procedures in their offices.”

“Along with the text Pfenninger and Fowler’s Procedures for Primary Care, NPI seminars have changed the way physicians deliver medical care in the United States, NPI can accessed at”

2 comments: said...

Here, I do not really imagine it is likely to have effect.

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