Sunday, September 25, 2011

Better Bedside Manners? What's It's Worth To You?

How much are good bedside manners worth? Would you double your copay if you could be guaranteed an extra measure of TLC from your physician? Can we put price on a physician’s warm smile, an understanding nod or a reassuring hand on your shoulder? Do patients have to contract with a concierge medical practice to receive this treatment?

I agree that our bedside manners with patients need some rejuvenation. It’s not fair, however, to isolate this issue out of context. Physicians today are facing crunching pressures from various sources that we cannot always compartmentalize when we are facing our patients – even though we should. Most folks believe that the bedside manners of the prior generation of physicians were superior to ours. Were our predecessors simply more compassionate and caring human beings than we are? I don’t think so. I think the medical profession was a different beast then. I hypothesize that if these wizened physicians entered the profession today, that they would behave differently.

Context is so critical when examining any issue. Many physicians find today’s patients to be demanding and entitled. Again, before pronouncing a verdict here, there are reasons and explanations behind this that need to be aired. Patients and physicians are both different today because the culture and nature of the profession has changed. How would Marcus Welby behave if he weren’t making house calls with a black bag 40 years ago, but were now an employed physician in a large clinic who was sued every few years and whose medical ‘quality’ was monitored by bureaucrats who determined his reimbursement?

Again, I’m not excusing deficient bedside manners, but the issue has nuance and complexity.

A Chicago couple, Matthew and Carolyn Bucksbaum, believe that bedside manners are worth a lot. These philanthropists are donating $42 million to the University of Chicago which will create an institute under their names which will be devoted to teaching medical students good bedside manners. The hope is to ingrain values of compassion and empathy deeply enough into medical students that they will not be contaminated when they enter the medical arena later. The training would function like a suit of armor to protect young physicians from bedside manner decay and attack.

This is a fantastic initiative and I hope that other donors and medical institutions emulate the Chicago program. While medical schools do teach bedside manners and the importance of the doctor-patient relationship, it was undervalued, at least in my day. Younger physician readers can comment if times have changed.

Can you really teach compassion or do you have to be born with it? A Chicago couple has wagered in a big way that it’s nurture, not nature.

Sunday, September 18, 2011

Minute Clinics Threaten Doctors: Who Wins?

All of us have been to fast food establishments. We go there because we are in a hurry and it’s cheap. We love the convenience. We expect that the quality of the cuisine will be several rungs lower than fine dining.


We now have a fast medicine option available to us. Across the country, there are over 1000 ‘minute-clinics’ that are being set up in pharmacies, supermarkets and other retail store chains. These clinics are staffed by nurse practitioners who have prescribing authority, under the loose oversight of a physician who is likely off sight. These nurses will see patients with simple medical issues and will adhere to strict guidelines so they will not treat beyond their medical knowledge. For example, if a man comes in clutching his chest and gasping, the nurse will know not to just give him some Rolaids and wish him well. At least, that’s the plan.

Primary care physicians are concerned over the metastases of ‘minute-clinics’ nationwide. Of course, they argue from a patient safety standpoint, but there are powerful parochial issues worrying physicians. They are losing business. They have a point that patients should be rightly concerned about medical errors and missed diagnoses at these medical care drive-ins. These nurses, even with their advanced training, are not doctors. It is also true serious or even life threatening conditions can masquerade as innocent medical complaints and might not be recognized by a nurse who treats colds and ankle sprains.

The Annals of Internal Medicine, a prestigious medical journal, reported on the quality of these retail clinics and concluded that the quality of care for ear infections, sore throats and urinary tract infections in fast-medicine outlets was similar to that in physicians’ offices, but at lower cost. While this is ammo for fast-med aficionados, it doesn’t address a more important point. I’ll concede that if I take my kid with an ear infection to a Wal-Mart clinic or the pediatrician, then the outcome will be similar. (Many experienced Moms would also know what to do.) The tricky part is when the symptom is murky and the range of medical possibilities is broad. If my kid were having stomach pain, for example, I want a physician to decide if this is simple constipation, intestinal gas or acute appendicitis that needs urgent surgery.

These clinics are proliferating because the market demands them. The fundamental cause is the inadequate number of primary care physicians in this country. This shortage will become more acute when Obamacare extends coverage to tens of millions of uninsured. Massachusetts discovered this a few years ago when they provided coverage to the uninsured, but didn’t have enough primary care physicians to care for them. These clinics are also providing a service that physicians have been unable or unwilling to match. They offer evening and weekend hours at low prices. Patients come at their convenience and are seen without waiting.

Pharmacies and big box stores benefit from minute clinics. They bring shoppers into the store who are likely to purchase other items after their scraped knee is bandaged. And if a prescription is needed, guess where it gets filled? From a patient’s point of view, this experience sure beats an emergency room adventure.

Are these clinics a good idea? It doesn’t matter because they’re coming and they can’t be stopped. They fill a legitimate need that the medical profession cannot address and the public demands. Market forces created the opportunity and will monitor its success.

Will they survive? Remind me, how long have McDonalds, Burger King and all the rest been around?

Sunday, September 11, 2011

Sunday, September 4, 2011

Overtreatment Alert! Antibiotics Fuel Medical Overutilization

A good friend of mine and Whistleblower reader contracted the sniffles and received a prescription for antibiotics at a local urgent care center. Nothing newsworthy here. So far this quotidian event sounds like a 'dog bites man' story. Had antibiotics been denied, this would have been 'man bites dog', as this denial would be a radical departure of standard medical practice, particularly in the urgent care universe.

No doubt, my friend was not assigned the dismissive diagnosis of 'the sniffles', but was likely given a more ominous diagnosis of 'acute upper respiratory infection', a term that sounds so serious that he might have feared that a 911 call had already been made.

Why are antibiotics prescribed so casually and so frequently? Choose from the following answers. There may be more than one correct response.

  • Antibiotics are the appropriate 'shock & awe' response to sniffle syndromes.
  • Patients demand antibiotics and offer evidence of necessity that their prior physician always prescribed them for the exact same symptoms.
  • Prescribing antibiotics is a sure method for increasing patient satisfaction.
  • Antibiotics are extremely safe and only rarely cause adverse reactions.
  • Patients fear that a delay in antibiotics could bring them to the brink of an infectious calamity.
  • Drug reps and direct-to-consumer advertising create a climate to prescribe medications including antibiotics.
  • It takes a physician 10 seconds to zap an antibiotic prescription to the pharmacy, but could take 10 or 15 minutes to explain why they're not indicated.
  • Antibiotic drug samples in physicians' offices encourage written prescriptions for patients.
  • Since physicians can't reliably distinguish viral infections from bacterial attacks, it's safer to prescribe antibiotics just to be sure that a bacterial infection isn't left untreated.
I'm sure that readers could add many other reasons that contribute to the antibiotic avalanche that is burying us, and I hope you will comment below. Infectious disease specialists and primary care physicians know that the majority of infections seen in outpatient visits are viruses - common colds - which do not respond to antibiotics; yet they are often prescribed for these illnesses. Changing this practice won't be easy and will take time. Look how long the public resisted buckling up in the car and using bicycle helmets, which are now universally accepted practices.

Antibiotic overutilization has real consequences.
  • It costs money.
  • It fosters a climate of medical overutilization.
  • Antibiotics can cause severe side-effects including C, difficile (C. diff) infections, which can be fatal.
  • It leads to the proliferation of resistant bacteria - superbugs - which won't respond to any available antibiotic. Care to be infected with one of these germs?
The Chief Complaint in medicine refers to the patient's summary statement explaining the reason for the medical visit. Typical Chief Complaints include:
  • Fever and cough
  • Chest pain
  • Abdominal Pain
  • Trouble breathing
These days, many patients have created their own version of the Chief Complaint (CC). Instead of describing their symptoms, they are now directing the treatment. See below.


Traditional CC: "I have a sore throat and a cough."

New & Improved CC: "I need an antibiotic."

Medical overutilization is my Chief Complaint.

Add this