The Executive Suite: My last patient

Max Burger, MD

My last patient was a challenge, as all patients always seemed to be at the end of the day. Was it fatigue, impatience, or exasperation, or all of the above that made me want to complain to him about spoiling my last day? He was late, so he was asked to wait, which he did without a fight-because not only did he come late often, but he frequently missed appointments and the visits lasted longer as I played catch-up to deal with what was unfinished from previous visits. He had chronic lung disease, asthma, heart disease, and poor circulation, but he reassured me that he was trying to stop smoking, as we discussed at every visit. He was well aware that cigarette smoking exacerbated many of his problems. He may not have been aware that discussing smoking cessation was part of a quality improvement measure for which I could and should bill at every visit. For some patients, their insurance would demand I show that I did counseling but would not pay for the "procedure," so I was in the unfortunate position of often failing to include this "quality" measure (all detected by a billing code) for fear that my patients would be charged. In this fee-for-each-service, insurance paid after-the-fact medical system, I and the patients both lost. I was not given credit for the time spent discussing their needs and the patients were in fear of yet more charges for a visit, so they were reluctant to come and reluctant to talk.

Nevertheless, after the discussion about considering choices for how to stop smoking, I moved on to quantify how often he was using his inhalers. This was a way to measure his compliance and how bad he was feeling, but the answer was confounded: he used the inhalers sparingly since his drug co-pays were high and he didn’t want to run out when he “really” needed them. When I listened to his lungs, his wheezing was less than during his “emergency” visits, which were usually more frequent and dramatic than today's "maintenance" visit. Here was a man who had lousy insurance where the cost of his drugs decreased his use of them, increased his need for often emergent medical care, (which we all pay for one way or another), and decreased his ability to feel well, function and, simply, to breathe. I had long ago given up on providing samples of expensive drugs because I knew that the samples would eventually run out, so I tried to prescribe the cheapest generics available. Albuterol, an old mainstay of inhalers was, ironically, more expensive now because there was no generic. It used to cost $5-10 with insurance., but the previous propellant used (CFCs) was banned because of environmental concerns. Now the brand inhalers, with a new propellant and same active drug, $5-50 with insurance and $30-60 without, not because the active drug cost more, but because the pharmaceutical companies held the patents on the new "delivery system" and could charge more. Another argument for drug cost regulations. Free markets do not work.

His wife had just been discharged from the hospital for pneumonia. It was still cold, so he planned on taking her down to Florida to visit his daughter who had breast cancer. He needed refills on all his medications because he wasn’t sure how long he would be down there and had not selected a new physician yet. I surmised that this was a “last licks” visit. Nevertheless, I wrote prescriptions for him to last a while since I knew he would not be back to see anyone soon if he could help it.

His chest pain was infrequent as were his leg cramps from his decreased circulation, although they worsened in the cold weather, as was his back pain. Yes, he needed some pain medication since there were days he was more stiff getting in and out of the cars in the cold parking lots where he was warehousing all day, so I gave him some codeine. He had been sensitive to anti-inflammatories like ibuprofen, which had a greater risk of exacerbating his heart disease than the codeine. I would probably be flagged by his insurance's pharmacy benefit manager algorithm as being a dangerous prescriber contributing to the opioid epidemic.

He had a toothache and wanted antibiotics, so he would not have to see a dentist since, like most patients I saw, he did not have a dental plan. I had given him antibiotics before when the swelling was so severe that I was worried he would get an abscess and a blood infection. But this time, since there would be no follow up with me and no evidence of an abscess on examination, only bad gums and teeth with many cavities, I declined and told him to see a dentist. He knew that was going to be my answer, but he had tried anyway. Antibiotics as the answer for many ailments was a constant demand in my and all primary care practices. Our patients learned over many years that we were previously eager to please to get them out of the office and to avoid an expensive and inconvenient revisit. Despite our experience of how dangerous and devastating drug resistance is, we are still besieged for the "magic bullet."

He was depressed. His wife was still sick, and he thought his daughter was dying. He had no money and hated his job and wanted to retire, but he was not sure he could afford to. He had anxiety attacks, the last when he was stuck in an elevator in the hospital in Florida while visiting his daughter. He wanted something for his anxiety. This was not the first time I had heard and seen that he was depressed or anxious, and I wanted to give him an antidepressant. But I wouldn’t be able to monitor the effects of the medication and he likely wouldn’t seek out or be able to find a counselor who would take Medicare, so instead I gave him a low dose of Alprazolam and warned him to use it only for "emergencies." He was good at that since he only used medication when he thought he needed it. Again, I was aware I could be flagged for prescribing the potentially dangerous combination of codeine and benzodiazepines to an elderly patient, but I assessed his risk as low since, as his personal physician, I had known him for years.

I heard and saw his apprehension about my leaving. I glanced back at him from the screen of my EHR when he said key words like "pain" and "sad," looking at his face to assess him rather than the computer display. After 16 years of using a much simpler and user-friendly program, I hated the new EHR I was using, which was the choice of the hospital group that had bought my practice. Many other hospitals and large medical groups were using it, not because it was useful for the end-users, but because it fulfilled requirements that large organizations were told they needed. I had to jump between multiple fields to get the details and the whole story down, all the while correcting data and his prescription list that had been incorrectly loaded from previous visits or sloppily recorded by staff. Renewing each medication was a painful series of multiple steps for each prescription.

I ignored the “metrics” sections that flashed in front of me and urged me to do more health maintenance. The program had failed to accurately transfer the information from the previous system and required so much more time to correct and update that it was another distraction from really taking the time and caring for my patient. I knew what health maintenance he needed, the EMR didn't.

I finally finished his note by entering his ICD-10 codes for his “diagnoses” which were used to bill the visit, and inexactly and insufficiently describe the state of his illnesses. To correct the imprecision, the number of codes to search had been increased from the ICD-9's 13,000 to ICD-10's 68,000. What the wonks called "granularity." It did not address his emotional state, or how he or I felt he was doing. It required even more effort for me to search the proper diagnoses, even with the computer's search module, so to save time (my patient was still there), I settled for any close code. So much for granularity.

Once I had completed that, I entered the CPT billing, codes which insufficiently described the work I had done. This data would be provided to him in a summary, including his medications and instructions for any further care and a plan for the next visit. This required more time since someone else was going to see him and those notes. The data would then be stored and could be "analyzed" by anyone who presumed the numbers measured "quality" and "outcomes" and "value."

Despite all the time I spent processing his data and not attending to him, he thanked me for the care I had given him through the years. We hugged, and I reminded him to be compliant, stop smoking, and see a new doctor soon.

It took me days after my last clinical hours to finish all those notes from the last few weeks because saying goodbye simply took longer. I had been fully booked the past month, and there were others who realized I was leaving and still wanted to see me. I felt wanted and appreciated, accepting all the greeting cards and small gifts and saying goodbye to those well-wishers who just dropped in between patients.

Why was I retiring? I liked my interactions with my patients, my long-term relationships, and the mental and psychological challenges, but the overwhelming pressure of productivity, documentation, recording data, and "meeting metrics" had worn me down. It had begun a few years before I sold my practice, when I saw a sudden downturn in visits because of new insurance plans with higher deductibles and co-pays and fewer benefits that well-preceded Obamacare. I knew I had to catch up with the changes the insurers were forcing on me and my patients. The Affordable Care Act helped to decrease the pain of cost and decreased accessibility for some, but the effect of the widespread insurance companies increase in patient-shared costs for the majority of Americans could not be staunched by that weak band-aid.

It got worse when I was offered a potential increase in income by enrolling in the Patient Centered Medical Home (PCMH) initiative started by a semi-private organization and supported by some insurers to "improve" care by demonstrating quality and adding "value." I gave up trying when I spent too many hours filling out online forms and could not get answers as to what more they needed for me to show quality. They did not guarantee any increase in income.

Fooled once, I tried again when I enrolled in the Comprehensive Primary Care Initiative (CPCI), a pilot study initiated for Medicare and Medicaid to also "improve" care and make "providers" more attentive to patients' needs. I actually got paid more for providing more "data." Although I demonstrated that their definitions of patients needs for care were being met, I was sure my patients did not see a difference except that I was more stressed and inattentive to them.

I was spending even more of my time on documentation and metrics, things that lower trained staff could do if I hired them and used the "increased" income to pay them. I had hired a part-time nurse "care manager" who loved her job, but her only impact was to improve my numbers. My other staff was pressed to do the same and they were stressed as well, even if they were paid more overtime. I was reaching burnout.

If this was the future of medicine, I thought to myself, I needed to have more help from a bigger organization, so I sold to the local hospital, not an unusual move for small practices, and still a continuing trend. (The number of solo and small primary care practices has fallen from 40.5 percent in 1984 to 17.1 percent in 2014.) There I thought I could practice without as many of the extraneous duties since someone in that big organization should be organizing and delegating the tasks that were not the practice of medicine. Fool me three times because they did not have the manpower or the understanding of what these new initiatives were intended to do. One of the key points of the PCMH and CPCI programs was to make each "provider" (I hate the term-I used to be a doctor) responsible and responsive to their patients in a team, but no one in my practice was trained in that kind of teamwork beyond what I had already done. They were discouraged from spending more time to be a team since it did not fit their job descriptions. One of my best medical assistants left in frustration, succeeded by a series of "temps" and then "professional" hospital employees who used the administrative rules to avoid extra work. It became even more painful when the new EHR was introduced and I, as others in the group, left, overwhelmed by the awful technology.

We are all besieged by the demands of management of costs, time, and ultimately, the priorities we set for our lives and the lives of our patients. I can understand that we need to change how we practice medicine and deliver care. I have confidence that the right technology will help and that, although we are failing in all the alternatives, we will ultimately find the right solution.

A universal, single payer healthcare system would help. The fee-for-service, insurance-based model has failed and has cost us more in healthcare expenditures and quality than most other nations. The percent of the USA's Gross Domestic Product (GDP) expenditure for healthcare is 17.2 percent. The range of cost for most other developed countries, especially those more successful in WHO healthcare measures is 9.3-11.5 percent of GDP. Our ranking in the WHO list is 35, France is first (GDP 11.5 percent), Canada is 30 (GDP 10.4 percent) and the UK is 18 (GDP 9.7 percent). All three have a universal health system. Where is all the money going? As I described above, huge amounts of time and money is spent saying what we did, imperfectly, and still more is paid to middlemen (insurers) to process those payments.

Healthcare should not be discrete episodes of care but comprehensive and continuous and integrated. Primary care physicians often don't know what specialists and hospitals, urgent care centers, minute clinics and now, pharmacies, have done and vice versa. We still need a unified, standardized, interoperable, simply interfaced, well-constructed EHR system, supported by adequate staff.

As I demonstrated, I and my fellow physicians, have become the most expensive component of the medical data entry system, spending precious time away from treating patients. There have been some experiments with "scribes" who can enter patient and physician interactions, but the other support staff, including physician assistants, nurse practitioners, nurses, medical assistants, dietitians, psychiatric and social work counselors, physiatrists, and other office staff, have to be part of the team.

We need more primary care physicians. Most developed countries that have been successful in delivering cost-effective care by most measures have .64-1.29 primary care physicians per 1000 of the population. We have .31 per 1000! Medical schools have been part of the problem. From the cost of education, to the bias of training in the schools for specialty and hospital-based systems, and the dearth of ambulatory-based primary care residencies, they have perpetuated the system. I was a foreign medical graduate from Ireland, and from day one I was trained with the perspective that I would be a primary care physician. I benefited from that perspective and training. There is no good reason that every American medical school should not have that same perspective. Congratulations to New York University for taking the right step of free medical education and the University of Texas at Houston for declaring primary care training as its goal. There should be more of that.

Retirement was inevitable as are taxes and death, hopefully in that order. I have no regrets, but I do have concerns, as I did for my last patient. When I hear a politician say we have the best healthcare system in the world, I can only think he or she is talking about their Congressional healthcare benefits. Most other Americans don't have that or feel that way. I still don't have that or feel that way. We can and should do better.