Ideal Medical Practices

Is anyone listening?

The Feb 15,2009 American Family Physician noted the following:
"a growing numberof physicians cannot afford to  offer recommended childhood vaccines, according to a study in the December 2008 issue of Pediatrics.  5% of  pediatricians and 21% of  family physicians surveyed reported that they had considered not offering vaccines to privately insured patients because of rising costs and declining reimbursement rates."  The AFP then noted  "65% would not give a vaccine if the reimbursement amount was less than the purchase price"

So let's consider the implications:
1 . Is anyone noticing that the burden of immunizing children has  become a personal finance issue for physicans instead of their parents or society?
 2 .What does it mean for the future if 45% -almost half- of physicans are actually willing to give a vaccine for free or when it costs them money?

Can this healthcare system -can this MADNESS possibly be sustainable?

In Maine the State began a new policy in Jan 2009.  Formerly the state  purchased vaccines in bulk and in return for paper work, supplied them to doctors for free.  We were allowed to charge oh $10.00 or so for giving the  vaccine to cover our paper work, time, the syringes, needles etc.  Maine has no more money, though.  As of Jan 1 the state supply is small and may only be given to kids who have medicaid or no insurance.
That's right-if you have insurance - and isn't heath insurance supposed to be the good thing that everyone is after?-  if you have insurance your doctor has to buy the vaccine out of their own pocket and weeks or months later, after filing complicated paperwork,  accept reimbursement at a  lesser amount than it costs so that their patients can be protected.  The doctor pays for health care. What a concept!
 

Oh but it is worse than that.  Few manufacturers of vaccines will sell a doc a dose or two as we needed them. We are only allowed to spend  hundreds of dollars purchasing 10 doses at a time. Ten doses which may not be needed before  they expire, and the hundreds of dollars are completely wasted. The public is angry at docs and sure we are rich. Primary care docs are angry and worn to the bone at  a non-system that hurts patients and is killing us.
Is anyone listenng??

Jean Antonucci

Farmington ME

Where the patients are

So I am at  a conference for a few days.And for a few days I hear stories of "what we did".Interesting and occasionally inspiring stories, but nothing to take home. All the right words are said. But nothing I  can use as a tool.
Then today I went to a session that was team taught by six people who live  all over the globe.
 They know where the patients  are.
They said  you know, the job of science  is not to open doors to wisdom. Its' job is  to set limits on infinite error.
 Think about that and statin use.And about lowering  blood pressures to limits where one of the speakers said  "I should have known known better. She fell"
Science and education and remembering why you went into medicine,they said, those things give  us ways  to  build a future different than the one towards which we seem to be heading
They know where the patients are- how often, they asked me,  do you and your patient agree on  what the nature of the trouble is?
The 64,000 question !
I ask, I engage, I have  patients set the agenda .I say what do you want  to do? What  do you think is wrong?  But the power of words lies in  the patterns with which we use them. How often do my patients  think that the  nature of the problem is what I think it is? I do not know. How can I  not know that?

We betray science if we misuse it.Doctors  have the gift of knowledge.And knowledge is power- we are supposed to use it to convey benefits to others. Our fundamental role is to teach is it not? We examine touch look and listen then we teach, because otherwise we will not see where  the patients are

So a Turkish proverb is a response to some one recently who told me  " nope we have gone too far and  put too much into this pilot, this project, we cannot turn now"  The Turkish proverb:no matter how far you have gone down the wrong road,turn back.
 That's where the patients are- back where we used to be and where we need to go.

Jean Antonucci MD

Sometimes

Sometimes i really like my job.  I just spend so much time trying to get a minute to DO it.

The latest is podiatry calling me.  "We saw your patient Mary."
"Her insurance requires that we know the last day she saw you.  Can you look that up for us?"

What??
I realize I will never be without work and out on the street.

But I sent a patient to a dermatologist recently because I was pretty sure what he had but he was getting better so slowly and his wife was terribly frightened.  I never heard what they said, so I called. "Oh, we sent that report," they said, and named an address they mailed it to - where  I worked locums a few months in 1996.
"But I sent you a letter..."
"Oh that goes to the doctor."

What??

I like it that my education can be used to help someone who does not know what I know. 

I admitted a 3 yr old this past week.  The mom told me that the nurse asked her if I had explained things.  Mom got pouty.
"Yes! She tells me everything! Not like the last doctor."
But when I needed to send the three year old home in the midst of heavy snow, I needed to give them a dose of amoxicillin.
Only I am allowed to hand it to the Mom.  But only the nurse was allowed to mix it.  But she didn't know how, so I told her.
I wasted an hour waiting for a dose of amoxicillin to come up 2 floors, for the nurse to  mix it so  I could hand it to Mom.

What??

So many rules, so well intended, that conflict with each other, waste time and money and hurt people.
So much frustration from everyone.
I mean, I like what I do but I can't do it.  I am too busy doing forms and calling podiatry back and explaining to people I wrote to that my address is on the the top of the letter, and wondering why a pathologist told me a specimen was normal when he printed it out as atypical, and re-doing prescriptions routinely that pharmacists lose and having specialists call me for additional information for people they will see tomorrow but when the patient shows up claiming they have no information at all- when they called the day before.

I put out fires more than I do my wor.

I like my job.
But I wish I could DO it.

Jean Antonucci MD