Friday, January 09, 2009

Hospitalists,nocturnalists,admitologists,anyone rember personal physicians

A recent perceptive,poignant, essay has attracted the attention of two of my favorite medical bloggers. Dr. RW and DB have both blogged about this entry by Dr. Cherie Glazner.

At least the patient described in the narrative saw a physician. While jogging last week I was listening to a local call-the-doc talk show. The first caller's narrative was that he was recently seen by a cardiologist (actually he was not seen by a cardiologist but by his PA). He was told that his aortic aneurysm has grown from 3.5 to 4.5cm in diameter over the last year and if it grew to 5.0 cm he would need to have surgery. The caller did not indicate displeasure at not being able to discuss this with his doctor but was calling for more information about what would need to be done if the growth continued.

The second caller was also asking for information. He had a heart scan as part of a "wellness" evaluation and had a score of 600. He "saw" a cardiologist at a local heart center (actually had appointments at the doctor's office, he never saw him).An isotope stress test was done and he was told by the nurse that he had "no significant blockages" and he
should return in a year or so for followup.

Yesterday, I saw my dentist and following the hygienist poking about and cleaning, he poked about a bit and we briefly discussed a bridge issue. He then talked at some length about how he really didn't like the situation with his allergist with whom he had appointments but never was seen by anyone other than his NP. He pointed out that he always "sees" his patients.

My urologist is a dinosaur.I saw him last month.Yes,I actually saw him and talked to him and he actually examined me. When in practice i frequently referred him patients. Back then he would schedule both the patient and his wife for the last visit of the day so there would be time to describe exactly what the treatment options and complications for prostate cancer would be. He said he still does that. His economic situation was such that he and his 3 partners merged with 3 other practices and partnered in some way I did not understand with a therapeutic radiologist in the hope that their practice would still be viable.

My brother-in-law has coronary angiography following an episode of chest pain and an EKG that "showed some problem." After the cath, he was seen by someone in a white coat that he had not seen before . The white coated,scrub suited man explained the procedure very briefly ( there were " no significant blockages"),gave him several prescriptions and told him to call the office for a followup visit in 6 weeks. My sister said that somehow he didn't seem like a doctor.I told her he wasn't, he was a PA ( I looked him up on the state board's web site).He was later seen by the PA for the office visit.

I was having lunch yesterday with another retired doc.We talked about things like the above and he said "it is amazing, isn't it? It is really all about economics.When we began practice (35 plus years ago) we could afford to be generalists and take time to talk to patients and not delegate to NP and PAs (where they even around then?) but now we couldn't." He said "you just don't get paid enough to do what we used to do.The image in your head of the type physician you think you were trained to be cannot realistically exist under the current economic situation."

3 comments:

Esther said...

What would you say to someone (me) interested in going back to school to become a doctor (probably a surgeon) then? As a patient I know I prefer to be seen by the doctor and not the PA, but that route would be less schooling and loans I assume.

Steve said...

Is it really about economics? If a single doctor opened a small office with one assistant, and charged a reasonable fee without accepting the responsibility for making insurance claims, wouldn't he/she be able to be comfortable financially? My chiropractor seems to do quite well charging me $60 cash for each visit. It seems to me that too many doctors want to build an "office empire" with a large staff and all the accompanying headaches and expenses.

Anonymous said...

I think it's becoming clear to physicians that direct/conceirge practice models may end up being the only way to practice "proper medicine" at the generalist level.

If trends continue, it should become clear to patients also. Then, hopefully, we'd have a growing movement of doctor supply matching patient demand.