Square Pegs in Round Holes

Introduction

At a luncheon, I listened to one of my primary care colleagues explain the realities of the 20-minute office visit. She happens to be very knowledgeable in treating developmentally challenged pediatric patients but her problems apply to any patient with developmental, physical or intellectual challenges. Like most physicians who are employed by health systems, she has productivity quotas and goals that are set by people who are outside the realities of medicine, usually administrators/business managers.

Medicine is not a Business, even a Home Business

The reality of being the primary care physician who treats patients with cognitive, physical or some combination of both types of challenges is that these patients have needs that will affect every aspect of their office visit. Many times, their transport to the health care location will involve public transportation or some other means adapted for them. Sometimes just getting to the transportation source requires hours of planning by the patient/caregiver only to find that their transportation left early or did not show up at all.

Imagine if it takes 20 minutes for you to dress your special needs daughter, it’s going to take 20-minutes to get that same child undressed for vital sign measurement and evaluation in the physician’s office. Keep in mind, that many special needs patients have behavioral and cognitive issues that prevent them from understanding the vital nature of complete and comprehensive health care assessment. For them, they are out of their secure and familiar environment; in a place where there may be excess and unfamiliar stimulation that will affect their behavior for the rest of the day.

The other reality for the intellectually or physically disabled is that they may have very complex health problems that they may not be able to address or their caregivers may not be able to relate to the physician. Couple this with unfamiliarity of the physician in terms of the diverse needs of this population, just because that physician may not have more than one or two challenged patient sin their practice and the business of medicine has created a situation where problems may not be properly addressed. My solution in terms of wound care for these often fragile patients has been to go to their facility/home but my primary care colleagues do not have the luxury of leaving their clinic to do home visits with any regularity.

Why we entered medicine in the first place

Most of us were trained to solve patient problems by identification of those problems and application of extensive medical knowledge. With the emphasis on getting patients in and out of clinic as rapidly as possible, many problems are never addressed or solved. Imagine if you are not cognitively or physically challenged but are the appointment following or concurrent with the patient who has these issues. Not only will your visit be abbreviated or affected, much of the office staff will be spending time and resources on the patient who needs more help. As a result or dealing with possible frustrations on the part of the needy patient, the physician may not be able to focus on your needs or the needs of other patients in the office because they have been frustrated as they are attempting to give the best care possible to their impaired patients.

At this time, we are better in terms of identifying those with physical and intellectual challenges as opposed to addressing their medical needs. We know that great rewards come with treating these populations especially when we are able to prevent or slow any discovered disease processes. Providing the highest level of care is always paramount in the mind of the primary care physician. To this end, my primary care colleague said the the primary care visit should be longer, because it’s often more comprehensive and the specialist visit should be shorter, because it’s more focused. Regardless  of specialist or primary care, the office visit should reflect the needs of the patient and should not be limited by a “one size fits all” approach to office visit length. Rather than decrease the costs of health care by shunting more bodies through the door, the “numbers” approach likely ends of utilizing more health care dollars because of missed opportunities to address the comprehensive needs of patients.

Those Patients

On another occasion, I listened to a colleague speak about not wanting to treat any patient who would not fit in the chairs of her waiting room. This was her way of stating that she would not treat obese patients. “They bring down my productivity,” she said emphatically. I can’t afford to lose money on treating these types of patients so I made sure that they don’t fit in the chairs in the waiting room if they weigh more than 200 lbs. Imagine if you are a patient who is morbidly obese, more than 100 lbs overweight, who enters a physicians office and can’t find a chair that will accommodate you so that you can attend your office visit.

Imagine the embarrassment if you have to ask for a properly sized chair so that you can sit and even fill out the paperwork to prepare for that visit. Imagine how welcome you would feel if you receive less than respectful and comprehensive care.  The morbidly obese, the developmentally challenged and the mentally challenged individuals in society all have medical issues that need to be addressed. By its nature, morbid obesity is a chronic metabolic problem yet my colleague who makes sure the chairs in her waiting room discriminate against morbidly obese individuals, would treat them differently from the Type I diabetic or the patient with chronic obstructive lung disease. Is is ethically sound to discriminate against a population of patients who are simply seeking, and paying for your services by not accommodating them in your office?

Taking Back Medicine

Imaging a situation where patients get the care that they need without exception. In this situation, the physician determines the patient’s needs and has the time to address those needs. Rather than being pushed by time constraints, the physician (and office staff) would have plenty of time and resources to treat patients with special needs. In truth, patients do not come to physician offices to socialize but come because they need care. It is up to the physician to take back the delivery of that care and set the parameters in which that care is rendered. When a patient receives less than optimal care because of the time constraints placed on the physician, the physician bears the brunt of the criticism. “Those money-grubbing doctors didn’t take time to talk to me”.

As physicians, we need to set the standards of patient care, much the same as we set the standards of practice of medicine. One of those standards needs to be ensuring that the limited resources of primary care physicians are addressed. A good primary care physician can be the resource that decreases health care costs if giving the tools to address all problems in a comprehensive manner that reflects the individual needs of the patients. As specialists, we are often given an advantage at the expense of our primary care colleagues and their vital work. This leads to burn-out and frustration on their part but also leads to increases in health care costs because patient needs are not addressed.

These problems are not solved by increasing the number of mid-level practitioners who often lack the medical knowledge/training to lead the comprehensive care team. While mid-levels can assist with comprehensive patient care, they are not the solution to effective or efficient delivery of comprehensive care. It is the primary care physician who should and does leads the best comprehensive care team and who can provide the most cost-effective care if given the tools and resources for their work. The greatest and most needed resource right now is time to deliver care. The public enjoys greater satisfaction and those of us who are in specialties, are able to obtain the best information to perform our services when the primary care physician can expedite a sound referral. In short, we as physicians need to take back the management of health care and deliver the best health care on our terms as the patient needs not according to a general plan that is even frustrating for relatively healthy people let alone those who have multiple chronic problems.