primary care

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What If Your Doctor Really Listened Instead Of Just Telling You What To Do?

(Alex Proimos/Flickr)

(Alex Proimos/Flickr)

On many a Friday, Dr. Joji Suzuki goes trawling through the medical wards of Brigham and Women’s Hospital with trainees in tow, looking for smokers.

One recent Friday, he finds Thrasher West, a patient who’d had trouble breathing but now is about to go home, where a tempting half-a-pack of cigarettes awaits her.

Dragging in the smoke, blowing it out — smoking feels good to her, West tells Suzuki. But then, she thinks, “Damn. Why’d I do that? Because it’s not good for me –” (Here, her deep cough adds emphasis.) “It’s bad for my health…Aw, I’ll give it up when I finish the pack.”

Suzuki, the hospital’s director of addiction psychiatry, does not lecture her about the risks of smoking. He does not suggest nicotine patches or pills or any other aids for quitting. He just mostly listens, and thoughtfully echoes what she says, and draws her out — when, for example, she mentions that she once quit for five years.

Dr. Joji Suzuki (Courtesy)

Dr. Joji Suzuki (Courtesy)

“Something happened, and you made a decision to stop,” he probes.

Her sons begged her, West recalls. One said, “Mommy, please stop smoking, please stop smoking.”

“Pleading with you…” Suzuki reflects.

“He had tears in his eyes. And he’s my baby, that’s my baby boy.” She reassured her son that she would be around for a long time, she remembers, and he answered, “You keep smoking, no, you won’t!”

Suzuki interprets: “They love their mama so much, they don’t want to lose her.”

The conversation, lasting just a few minutes, may sound like a simple chat. But Suzuki is expertly following principles that have been hammered out over decades and studied in copious research. He listens — actively, empathetically — more than he talks. His comments and questions remind West of her reasons to quit, and bolster her confidence that she can do it. They tap into her values and goals — her love for her family, her desire to live.

By the end, West says she wants badly to stop smoking, and she urgently asks Suzuki to write her a prescription for nicotine patches.

She has just experienced the subtle power of a method that’s increasingly popular in medicine: It’s called motivational interviewing, often referred to just by its initials, MI.

“The big shift in the practice of MI for most practitioners is that you go from telling patients why they should change or how they could change to drawing out from the patient their own ideas about why change would be beneficial to them and about how they might be able to do it,” says Dr. Allan Zuckoff of The University of Pittsburgh, a national leader in the field and author of a new self-guided book, “Finding Your Way to Change: How the Power of Motivational Interviewing Can Reveal What You Want and Help You Get There.”

Click to enlarge. (Courtesy Chang Jun Kim, of the Motivational Interviewing Network of Trainers)

Click to enlarge. (Courtesy Chang Jun Kim, of the Motivational Interviewing Network of Trainers)

Motivational interviewing goes back decades in the field of addiction counseling, Zuckoff says, but in medicine, it’s been really taking off in the last few years.

Hundreds of studies have been published on using it in health care, from diabetes control to reducing the risk of heart disease. It’s being tried for patients with incontinence, psoriasis, hepatitis C, Parkinson’s — virtually any disease in which the patient’s behavior — taking medication, choosing food — affects the outcome. And of course, it can be used for the lifestyle issues that are the biggest driver of American chronic illness: overeating, smoking and drinking and drugs, lack of exercise.

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Why The Primary Care Problem (Lower Status, Pay) Matters

By Jeff Levin-Scherz, M.D., M.B.A.
Guest Contributor

Medscape just published its annual physician compensation survey. The survey includes almost 20,000 physicians and is given online, so it’s probably not entirely representative.

Also, the survey results are self-reported, and physicians generally under-report their income. But the comparative reported income among specialties is informative. This survey is among the largest available, and does not require an expensive paid subscription.

(Courtesy of Medscape)

(Courtesy of Medscape)

The results are no surprise. But they’re worth noting: Specialists make 45 percent more than primary care physicians, and orthopedists make 224 percent more than pediatricians.

The majority of respondent physicians were employed, and men consistently make more than women in the same specialty. Women have the largest representation in specialties with the lowest incomes.

Physician income was a bit lower in the Northeast but higher in the Northwest. Massachusetts’ physicians report that their income is 46th in the nation.

Internists are the least satisfied in their job (47 percent), and the least likely to choose their specialty if they could choose again (25 percent), but high in the rankings of specialties where the respondent would choose medicine again (71 percent).

(Courtesy of Medscape)

(Courtesy of Medscape)

Family physicians were only slightly more likely to choose the same specialty again as internists (31 percent), yet they were the most likely to say they would choose to go into medicine again (74 percent).

Pediatrician income is among the lowest of all specialties, yet they are twice as likely to say that they would choose the same specialty. Internists and family physicians would go into medicine again, but they would go into sub-specialties, and not do general primary care. The high cost of health care in the U.S. is in part due not to a shortage of primary care physicians, but also due to a surplus of specialists.

Why does all this matter?

The American College of Physicians reported on the impending “collapse” of primary care in 2006. There have been efforts to change this situation since, including “patient centered medical homes,” and short-term enhanced Medicaid primary care fee schedules built into the Affordable Care Act.

The continued relatively lower pay of primary care physicians and the lack of job satisfaction of general internists and family physicians means that our historic way of delivering primary care is about to change. Much future primary care is likely to be delivered by nurse practitioners or physician assistants, and some office-based primary care will be supplanted by telehealth or by apps with underlying algorithms.

The Medscape survey suggests that we will continue to face serious challenges to continue to deliver the highly personalized primary care which many of us value, and the highly coordinated care needed by the frail elderly and those with serious chronic illnesses.

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Your Doctor, Always Available, For A Monthly Fee

For 10 years, Jeff Gold showed up to a job he wanted to love: being a family doctor.

“I was busy as a bee,” says Gold, 39, with up to 2,500 patients, seeing 20 or so a day.

Dr. Jeff Gold runs a direct primary care office in Marblehead. (Martha Bebinger/WBUR)

Dr. Jeff Gold runs a direct primary care office in Marblehead. (Martha Bebinger/WBUR)

Rushing from one patient to the next, calling insurers who wouldn’t approve prescriptions, filling out paperwork that didn’t seem relevant to his patients, Gold kept asking himself, is this what I signed up for?

“I thought I was gonna help everybody and spend time with everybody and it’s impossible to do,” Gold says.

So Gold quit, wrote a business plan to be a doctor who does not take insurance, hired one staff member (a nurse), and borrowed almost $400,000 to outfit a two-exam-room office next to a candy shop and café in Marblehead.

Gold may be the first physician in Massachusetts practicing under a model called direct primary care. For a flat monthly fee, Gold offers patients one-hour same-day appointments, no wait. The doctor is available 24/7 in person, at the office, at the patient’s home, via text, email or Skype. Continue reading

Got A Headache? Study Finds Flaws In Treatment, ‘Alarming’ Rise In Imaging Tests

(19melissa68/Flickr)

(19melissa68/Flickr)

Sometimes less really is more. A case in point: the treatment of routine headaches.

Doctors are increasingly ordering pricey, advanced imaging tests and referring patients to specialists, which, it turns out, offers little help to headache sufferers, a new study concludes.

Researchers from Boston’s Beth Israel Deaconess Medical Center suggest that patients might be better served (and the health care system might save money) by instead focusing more on lifestyle changes for people seeking headache relief.

For the study, published online in the Journal of General Internal Medicine, researchers used a nationally representative database to analyze practice patterns among physicians treating headache patients.

I asked the lead author, John N. Mafi, MD, a fellow in the Division of General Medicine and Primary Care at BIDMC, to sum up the bottom line results. Here (slightly edited) is his emailed response:

“…We found alarming rises in use of advanced imaging (CT/MRI), referrals to other physicians (presumably specialists), and a decline in first-line recommended life-style modification counseling, meant to prevent headaches. We also saw no change in use of discouraged medications, with opioids and barbiturates ordered in about 18% of visits throughout the study period.

These findings represent alarming trends in the management of headache, and to me, they reflect a larger trend in the U.S. healthcare system where over-hurried doctors are ordering more tests, more medications, more referrals to specialists and less time talking and connecting with their patients.

To me this suggests that the visit-based model of healthcare is broken, Continue reading

You’ve Heard Of The ‘Slow Food’ Movement? Now Meet ‘Slow Medicine’

(Photo: Facebook, at left: Dr. Pieter Cohen)

(Photo: Facebook, at left: Dr. Pieter Cohen)

Slow Medicine (ˈslō me-də-sən). The practice of medicine in which one is careful in interviewing (and examining) patients, careful to balance benefit and harms of diagnostic and therapeutic interventions, slow to intervene when symptoms are undifferentiated, committed to observation as an important diagnostic and therapeutic strategy and skeptical of newly introduced diagnostic tests and therapies. Although Slow Medicine might incidentally reduce costs of medical care, cost does not drive decision making but rather the drive is an effort to provide the best and safest medical care possible.

“Slow Medicine” may be about to catch on fast.

It began as thousands of emails over the years between Cambridge Health Alliance primary care doctor Pieter Cohen and Dr. Michael Hochman of Altamed Health in Los Angeles, debating and interpreting the latest medical literature. First just back-and-forths with each other, then shared more broadly with colleagues.

The focus might be their take on colon cancer screening, or spinal manipulation for sciatica, or how to treat mild high blood pressure. Their writings were opinionated but always data-driven, and clear on how that data could or should be translated into real-world medical action.

It was good stuff, by doctors and for doctors but much of it also suitable for the lay public. (CommonHealth quoted from a “Slow Medicine” message in this post on lung cancer screening for smokers.) The list of willing “Slow Medicine” email-recipients swelled; it added a Facebook page; and now, as of this weekend, it has gone national: On NPR’s Shots blog, in a post by Dr. John Henning Schumann, host of Public Radio Tulsa’s “Medical Matters,” titled “If Slow Is Good For Food, Why Not Medicine?”

It begins:

Maybe you’ve heard about the slow food movement. Maybe you’re a devotee.
The idea is that cooking, nutrition and eating should be intentional, mindful and substantive. Avoid fast food and highly processed grub. For the slow food set, the process is as important as the product.
Now I’m seeing a medical version of slow food. The concept is bubbling up in response to industrialized, hypertechnological and often unnecessary medical care that drives up costs and leaves both doctors and patients frazzled.

And about Drs. Cohen and Hochman’s brand of Slow Medicine: Continue reading

Lesson Of The $446 Ear Rinse: Medical Bills That Make You Say ‘What?!’

(Photo: Robin Lubbock/WBUR)

(Photo: Robin Lubbock/WBUR)

THIS COMMUNICATION IS FROM A DEBT COLLECTOR. THIS IS AN ATTEMPT TO COLLECT A DEBT.  ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.

Get your attention, all those upper-case, bold-face letters? They certainly got mine, when they came in the mail recently. It was a virginity-losing moment: My first debt-collection letter in more than a half century of financial clean living.

And of course, it was a medical bill that did it — just as it’s medical care that causes more American personal bankruptcies than any other bills.

My health bills for preventive care had all seemed reasonable until now — or at least, they were bountifully paid by insurance. Mammograms, children’s check-ups, all were fully covered. But I’d shifted recently to an insurance plan with a $500 personal deductible, and I’d made a naive mistake: When my doctor kindly offered to clean my waxy ears during my annual check-up last April, I said, “Okay…”

Well, really, how was I to suspect that three or four minutes of whooshing ear-rinse could add up to $446 out of my pocket? (Correction: $446 upon first billing, but knocked down to $338.03 after several long and tortured phone calls, and a medical re-coding. It still struck me as insane, but I paid it to get the collection agency off my back.)

Doctor, if we’re going to cross the line from preventive to billable, I’d like you to let me know.

It’s an ever-more-common American rite of passage: That shocking moment when you unfold the bill, look at the total that is unpaid by your health insurance, and expostulate, “Are you (expletive) kidding me?!?”

Readers, do you have an eye-popping bill and back-story you’d like to share? We’re hoping to make this a series — “Medical Bills That Make You Go ‘What??!'” You can send in your story — and, if you’d like, scans of your bills that will protect your privacy — by clicking on the “Get In Touch” button at the bottom of this page. Goodness knows, you have few other outlets for your frustration.

In my own case, I’m asking you to brave the numbing tedium of any billing tale because there’s a clear object lesson here: Yes, preventive care, including check-ups, must be fully covered by insurance plans under Obamacare. But that doesn’t mean that everything that’s done during a check-up has to be covered.

And therein lies the rub. The line between “preventive” and “diagnostic” or “procedural” can creep up on you, as WBUR’s Martha Bebinger has reported: When Is Preventive Care Free And When Do You Pay? Her report included this valuable lesson: As one Massachusetts woman was horrified to discover, it’s possible to go in for a free — because it’s preventive — colonoscopy, but then, while you’re still on the table, if the doctor finds polyps and removes them, that transforms it into a non-preventive — and thus potentially billable to you — “surgical procedure.”

I’d read that story but clearly I didn’t take its lesson enough to heart. I also take full blame for my longtime practice of getting routine primary care at an expensive top Boston hospital: You can see in the upper right corner of the image above that the initial charge to my insurer for my check-up — which involved no lab tests and nothing higher-tech than a blood pressure cuff — was nearly $1,192.

Still, in hopes that my own financial pain might help others, I asked Blue Cross/Blue Shield of Massachusetts, the biggest health insurer in the state and the one that happens to cover me, for useful pointers. I spoke with Debra Wilson, a senior manager in the Member Service Division. Our conversation, lightly edited:

DW: I think it’s great that you’re highlighting this for people. Folks go in and have preventative visits, and things will invariably come up. The patient is there and having their physical, but they’re also addressing problems. These problems could be longstanding. So it’s important that when something does come up and present itself, that the patient ask questions.

It’s very important that all of us are educated in our health care decisions, and part of that is that we not be afraid to ask, ‘What does that entail and what might the cost be?’

Ask questions beforehand so you’re fully aware of what’s going to be involved, not only with the procedure but the cost. It can generate a liability to the patient, and no one likes an unplanned bill. We’ve also asked our network management team, the folks in the field working with physicians’ offices, if they could also educate the patient at the time — usually after the fact, but let them know, if they were in for a visit and also had a procedure or additional service, that they could receive a balance bill.

We don’t want to discourage these conversations with physicians because it’s probably something they do need to have addressed, and it’s being done all in one trip, so it’s efficient. We just want everyone to be aware of what could happen in terms of cost liability, that that could change depending on services rendered.

The tricky part for the patient is that it can be hard to know whether something is considered preventative or diagnostic or a procedure. For example, at that same checkup of mine, my doctor found that my blood pressure was a bit elevated, so we discussed ways to lower it. Conceivably, that could be billed as not preventive but diagnostic, or an education procedure?

That’s discretionary, based on that particular provider’s office and their billing practices. Certainly, that could be within the preventative visit, but again, I think it’s important not to be afraid to ask those questions.

Would it be reasonable to go into a preventive appointment and say, ‘Doctor, if we’re going to cross the line from preventive to billable, I’d like you to let me know’? Would that be weird? Continue reading

Study: Primary Care May Be Path To More Effective Suicide Prevention

The unanswerable question, “What If?” often dominates the talk when it comes to illness. What if the tumor had been caught earlier; what if the child’s ache taken more seriously? When it comes to suicide, the agonizing “What Ifs?” can run rampant.

Recently, following three suicide deaths by high school students in Newton, Mass. there has been much talk about what, if anything, might have been done to prevent these acts.

A new national study offers no easy answers — indeed, many people who die by suicide do so without any prior mental health diagnosis, researchers report. But this new research does suggest there may be opportunities — through primary care doctors, and other specialists, for instance — to more accurately identify people at risk for suicide, and perhaps intervene before it’s too late.

The new federally-funded study — based on a longitudinal review of more than 5,800 people who died by suicide from 2000 to 2010 — found that nearly all of these individuals (83 percent) saw a doctor or received some kind of health care in the year prior to their death, but half of those individuals did not have a mental health diagnosis. Moreover, researchers report: “Only 24% had a mental health diagnosis in the 4-week period prior to death.”

Also, strikingly, one in every five people who died by suicide “made a health care visit in the week before their death,” says the paper’s lead author Brian K. Ahmedani, Ph.D., assistant scientist in the Center for Health Policy and Health Services Research at Henry Ford Health System in Detroit, who speaks about the work in an accompanying video.

The study, published online in the Journal of General Internal Medicine, concludes that: “Greater efforts should be made to assess mental health and suicide risk. Most visits occur in primary care or medical specialty settings, and suicide prevention in these clinics would likely reach the largest number of individuals.”

Of course, that’s easier said than done. Anyone familiar with a typical primary care visit knows it can be, well, a bit rushed — not quite the perfect venue for dwelling on complicated emotional issues that may be difficult to articulate. Unless specific psychiatric symptoms are raised, they are often not part of routine care, says Massachusetts General Hospital psychiatrist Steven C. Schlozman, Continue reading

Helping Primary Care Treat Minds As Well As Bodies

A doctor's office waiting room. (veggiesosage/flickr)

A doctor’s office waiting room. (veggiesosage/flickr)

Sometimes, medical doctors view their patients only from the neck down.

But that is unwise: Over 70% of primary care visits today are related to psychosocial issues – things like anxiety or depression manifesting themselves as chronic pain, stomach aches or heart palpitations.

And, according to Dr. Russell Phillips, director of the Center for Primary Care at Harvard Medical Center, these underlying problems create all sorts of complications. “Mental health conditions complicate the treatment of everything else,” he said. “If someone has diabetes and depression, symptoms of their depression may make it harder for them to manage their diabetes.”

Of course, the problem is exacerbated by patients not even being aware that they have any underlying conditions. Doctors have to try to solve problems that “patients can’t even name,” said Phillips. He gave a quick assessment of the system today: overworked primary care physicians struggle to treat conditions in limited time and often with limited resources.

Phillips envisions a system for addressing all of these issues that would begin with mental health: Continue reading

Hard-To-Get Primary Care: Mass. Waits Still Long, ‘No New Patients’ Common

(Source: Massachusetts Medical Society)

(Source: Massachusetts Medical Society)

In what’s become an annual ritual, the Massachusetts Medical Society has just released its check-up on just how hard it is to get in to see a primary care doctor in this state. Bottom line: Mostly pretty hard, at least for a non-emergency first appointment. You’re likely to have to wait a month or two. At more than half of practices, you’ll be told, “Sorry, we’re not taking new patients.”

One bright spot: If you have public insurance — Medicaid or Medicare — most Mass. doctors will still see you.

From the press release:

Massachusetts Medical Society President Ronald Dunlap, M.D. said “Our latest survey once again points out a critical characteristic of health care in the Commonwealth. While we’ve achieved success in securing insurance coverage for nearly all of our residents, coverage doesn’t guarantee access to care. The concern is that limited and delayed access can lead to undesirable results, as people will seek more costly care at emergency rooms, delay care too long, or not seek care at all.”

Primary Care The 2013 study shows wait times for new patient appointments with primary care physicians remain long in the Commonwealth, with the average time to see a family medicine physician at 39 days (down from 45 days in 2012) and the average wait time to see an internal medicine physician at 50 days (up from 44 days in 2012). (New patient wait times reflect the total number of calendar days, including holidays and weekends, between the interview and next available appointment.)

The study also showed that only about half or less of primary care practices – 51% of family physicians and 45% of internists – are accepting new patients in 2013. Continue reading

Why Primary Care Matters

Third year medical student Joe Nelson (with his family) writes about why primary care is key to fixing the broken health care system.

Primary Care Progress is a two-year-old Cambridge-based nonprofit that seeks to revitalize the primary care field and motivate more medical students to enter the primary care fold — with passion.

One of those students, Joe Nelson, in his third year at Baylor College of Medicine in Houston, recently wrote eloquently about why he is pursuing a career as a family physician and why primary care is the key to fixing the broken health care system.

Nelson’s “aha” moment, he writes, involves his own father, a biomedical engineer who lost his health insurance and so delayed seeking followup medical attention on an abnormal colonoscopy that revealed some pre-cancerous polyps. A few years after the test, Nelson’s dad, now experiencing some troubling symptoms like weight loss, weakness and fatigue, sought advice from his medical-student son.

Nelson writes:

In what kind of health care system can a learned, health-literate individual make an educated decision not to seek medical care in such a high-risk situation? Why is a man like my dad relegated to asking medical students for health advice?

In the medical community, we talk about access to care as though it were a separate issue from medical costs. In fact, we usually refuse to discuss cost at all. Instead, we have behemoth yet inadequate government programs like Medicaid, CHIP, and Medicare to help improve access to the care that we’ve been told is fundamentally expensive. But the elephant in the room is that if medical care were inexpensive, everyone would be able to access it. Continue reading