Tuesday, May 31, 2005

Ordinary Care vs. Extra-ordinary Care

How often does real life intersect with the blogosphere? Outside of Bloggercon, not often, I'd bet.

A few months ago, I dipped my feet back into the world of 15-minutes-per-patient medicine at two locations, my old Kaiser office, and a multiphysician group in Pasadena. I know one of the doctors in the private practice group from when we used to play basketball together. When we ran into each other again, he mentioned that his group was looking to hire a new primary care physician since one of their partners was moving out of state, having had a hard time trying to find affordable housing here in Southern California. I told him I wasn't really interested in giving up my solo practice just yet (it hadn't even been a year!), but that I was interested in moonlighting and helping him out as a part-time doctor.

I was surprised to find out that the doctor who left was none other than the author of Galen's Log. I was hoping for a chance to meet him, just to put a face on a fellow medical blogger, but his office had already been cleared out by the time I showed up to work. Fortunately, it looks like he is finally able to afford a house. Congratulations, Galen! Maybe we'll meet in the real world some day.

One afternoon while I was moonlighting there, I saw a woman who came in for a cold. I asked her for her symptoms, examined her and told her there was no evidence for anything more serious than a viral URI (upper respiratory infection). Advised rest, fluids and OTC cold medications. Took about 5 minutes. This is what I would consider ordinary care.

As I was finishing up, she asked me if I could prescribe something for her back pain. I could've just given her a prescription for some anti-inflammatory pain medicine and gone on to my next patient. But I don't like to do things halfway. So I asked her about her back pain, how long had she had it, was she injured, what has she tried for it, if she had any renal symptoms, etc. I examined her back, doing straight leg raises, range of motion, a brief neurologic exam, checking for costovertebral angle tenderness. Some tender muscles but otherwise nothing abnormal. Call it lumbar muscle strain. I advised she try yoga or Pilates to strengthen her core spinal muscles, some massage and heat. She had already tried Motrin, so I could have suggested she try Naproxen instead, use heat, rest her back and come back if she's not any better. This took another 10 minutes. This is what I would consider better care.

When I asked her what made her back pain worse, she said when she was stressed. It turned out she had been very stressed at her job for the past year due to downsizing. Too much to do and not enough time to do it. Her pain got worse when she was at work and eased up on the weekends. She had trouble sleeping, often woke up in the middle of the night, unable to fall back asleep. She had trouble concentrating. She felt "on edge" a lot. She had been getting irritable and easily angered. She often cried for no apparent reason. She admitted feeling depressed but denied any suicidal thoughts. This was the source of her back pain. If she tried every pain medicine known to man, she would have continued to have back pain. We talked about stress and how it can cause physical symptoms. She wasn't doing much on her own to reduce stress. No time.

I pointed out (like I do for everyone who is stressed out) that when you are stressed, you can do one of two things:
1) get rid of or away from what is stressing you, or
2) change how you respond to stress. I brought up the usual natural forms of stress reduction (eg. meditation, exercise, prayer, yoga, tai chi, listening to music, reading a book, taking a walk). Plus the medicinal forms of modifying one's stress response (eg. St. John's wort, anxiolytics and antidepressant medications). I pointed out how every choice has its potential benefits as well as downsides. Exercise and you can sprain an ankle. Take an antidepressant and you can lose your sex drive. Do nothing and continue to feel miserable.

In the end, she chose a nonhabit-forming SSRI medication, which would help her feel less anxious and stressed. She understood that it would take up to two weeks to have any effect. She thanked me for listening and for the time I spent with her. I advised her to follow up with her regular doctor, whom I wondered if he would spend as much time as I had. This had taken another 15 minutes, for a total of about 30 minutes. I was now 15 minutes behind for my next patient. But this is what I would consider extra-ordinary care. This is the kind of care I strive to deliver every time I see a patient. It is hard to do when you are expected to see a patient every 15 minutes. It is easier to do in my solo practice.

I think most people would agree that this is the kind of whole-person care they would like to have, but don't get very often. For that encounter, I got paid $18.75, based on $75/hr divided by 4. Even though it took 30 minutes, I still had to see 4 patients an hour. In my own solo practice, I find that I am spending an hour talking with a new patient, getting to know them, trying to deliver the best care I can. And then finding out I can only bill their insurance company $100-150, for which the insurance company will cut down to $62-100. So, in the end, I still am making about the same as what I would make if I worked for someone else. Hmm, frustrating.

I know lots of patients who are frustrated by how much they have to pay in healthcare premiums yet how little they get in benefits. And I know firsthand what insurers pay physicians for their hard work, and I don't think it's enough. Where does all the money spent on insurance go anyways? And while it sounds bad for a doctor to gripe about how much money he makes, I know that if my practice cannot survive financially, then my goal of providing extra-ordinary care cannot survive either.