Thursday, October 17, 2013

The Cleanest Dirty Shirt

I'm an unabashed Howard Stern fan and have been listening since he came to Los Angeles terrestrial radio back in July of 1991 on KLSX. And of course I have migrated with him to Sirius satellite radio.

When Stern isn't broadcasting live in the morning on Sirius channel 100, or when I have already caught up on replays, I will explore his other Sirius channel, 101. One of my favorite programs on 101 is the Dr. Harry Fisch show.

Driving home from a meeting yesterday I was tuned into the Dr. Harry Fisch show, laughing hysterically as usual, while the good doctor, and his co-host, Shuli Egar, make humor out of the various men's health maladies that are presented while also giving medical advise.

Then one caller who apparently had called in previously sounded concerned. He said that he went to a urologist as Dr. Fisch had recommended but the doctor seemed to have dismissed his complaints rather summarily, and sent the patient packing without much confidence or discussion about his condition. In the meantime, the caller said, his symptoms seemed to have increased in frequency and magnitude.

Dr. Fisch then commented on the state of medicine in this country - that too many physicians spend too little time with their patients: they just don't listen.

Remember the stereotype of the "good old days" when doctors made house calls, and at least on television, were mild mannered, patient listeners who always had the right answer full of wisdom and knowledge? I'm sure that stereotype wasn't accurate, but at least it is an ideal that most people hold on to.

I was a source of repetitive medical attention as a child. Seems I was always doing something to risk life and limb, and about every six months some limb succumbed to my inaccurate risk assessment.

I was on a first name basis with the local orthopedist, Dr. Ed Wiater in San Pedro, CA. I was just a kid so my memories are probably clouded with sentimental optimism. Needless to say, I was fitted with quite a bit of plaster as a kid, but Dr. Wiater always seemed to have some time to talk to me about whatever was going on in my youthful mind.

I don't know how Dr. Wiater got paid - I'm sure we had some insurance. I don't know how many patients he saw daily, what his hospital rounds were like, how much he had on his social calendar, etc. I just know that when I broke something on my body Dr. Wiater spent some time with me, asking about my life, school, sports, etc. before directing the nurse to wet the plaster strips.

The motivations behind physician payment don't foster that kind of attention to patient interaction any longer it seems, and Dr. Fisch said as much yesterday. He commented that the business of the practice of medicine makes it very difficult for physicians to spend much time beyond diagnosis and treatment with the patient.

But it is the listening part that is most particularly healing to people. Some doctors are really good at this part of the job, and others not so good. I have to believe that physicians intuitively know whether they have the bedside manners to be a listener or not, and then choose their career paths accordingly.

Still, the bottom line is that doctors need to make a living, and since these are highly motivated, disciplined people (how else does one get through the grueling training to become an MD?) they are generally going to execute their jobs in the most financially efficient manner possible - which means seeing as many patients as possible within any given time period.

And patient interaction - i.e. listening - takes a hit.

I don't fault the medical profession for this at all. This is just a recognition of the reality of the business of medicine.

In workers' compensation, I often hear how the injured worker just needs someone to listen to him or her. It's not just the complaints of the injury, but the doubt, the questions, the unfamiliarity with processes, the scary forms and publications, tales of abandonment, and other discouraging or frightening ordeals.

The physician is the first line of communication for these concerns - but it seems that the path to such medical nirvana steers away from these primary needs.

Starting January 1, 2014 California moves to the Resource Based Relative Value Scale. This has been a long time in the making and isn't without controversy for sure.

But one of the key elements of the RBRVS is that there is greater reimbursement schedules for listening. The primary treating doctor is given higher regard under this schedule and specialists are relegated a back seat.

So specialists aren't too happy about moving to the RBRVS, and California employers aren't too happy because the initial costs are estimated to actually be higher than the current medical fee schedule.

But proponents argue that overall costs will decline over time, or at least the growth will slow down, because primary care physicians will be motivated to listen and perhaps better understand what is actually going on with the patient.

I don't know who to believe just yet. It's a complicated formula, and it's a reality. California is moving to the RBRVS and only time will tell whether sufficient numbers of physicians will participate in the system to meet the needs of the injured and their employers; and whether there is any impact on clinical quality and outcomes.

I think that what Don Schinske, a lobbyist for the Western Occupational and Environmental Medical Association, told WorkCompCentral is probably the best analysis - it’s not a perfect process, but it’s “the cleanest dirty shirt that’s out there.”


  1. Your analogy is flawed.

    Your doctor spent time with you because your parents paid the bill, and if he didn't do his best, and establish a relationship, they'd just find another doctor to better fit their needs.

    There was no party standing between you and the doctor playing Pater Familius, and threatening to withhold payment if things weren't done to THEIR specifications.

    It is never going to go back to that way of thinking until people are willing to pay their own way, and the single payor/ACA is just another layer that will divide the patient and the doctor.

    I can't blame a doctor for needing to be paid. Its just going to boil down to the question if patients want to be treated as people because they're paying for it or as part of an assembly line, because they've delegated the responsibility to others.

  2. Attorneys also need to listen. That's why I've always liked the title "'Counselor' at Law."

  3. David,
    My doctor was Dr. Flett, a Kaiser doctor. You're right. As kids we were ignorant of what was going on. All I knew was that when I got hurt or was sick, my parents and I went to Kaiser and Dr. Flett was always there. Oh well...those were the days. Better or worse is irrelevant. Those days are gone forever.

    Today, RBRVS or not, many, many doctors choose to be employees rather than solo or small group practitioners. They choose to let loose of the control your Dr. Wiater may have had, in order to get paid a salary, have time off and a "more balanced life." Good for them adn great for their families.

    The large majority of California’s injured workers are treated at big primary care groups (US Healthworks/Divinity, Kaiser on the Job, Concentra, etc.). Primary care is delivered at these occ. med clinics by physicians, physician assistants and others who are employees. I am not taking issue with the quality of care delivered in these places because some of it is pretty good. However, no one should make the mistake of assuming that any increase in reimbursement due to the impending conversion to the Medicare fee schedule will translate into either more time with patients or an incentive for these very capable individuals to listen more. It would be foolish for their employers to waste a 20 or 30% increase in evaluation and management (office visit) revenue by allowing the doctors to slow production by taking more time per visit and seeing fewer patients each day. And, chances are extremely remote that these corporate medical groups will pass through anything but perhaps a small fraction of the millions in added revenue that they will be paid. The new revenue could end up simply re-establishing past salary cuts. The corporate owners will bank the majority of their new revenue, use it to expand, improve, re-pay investors or acquisition costs and enhance shareholder value.

    To be clear, I am not faulting these large primary care groups for using their increased revenue any way they see fit. However, just as it is unrealistic to expect the days of your Dr. Wiater and my Dr. Flett to somehow reappear, no one should think that California’s injured workers will all of a sudden be treated any differently than they ever were…for better or worse...just because the fee schedule will be based on the Medicare/RBRVS system.

    As a side-note, when a more complicated or lengthy case presents itself, it is very common for the clinics to refer out to specialists who are independent contractors to the medical group – the clinic retains the revenue that way. While the visit revenue to these specialists will go up just as with the primary care doctors, the procedure revenue will drop dramatically. Since the specialists are commonly paid around half of the revenue they generate, one might expect that clinics could end up having a hard time finding enough specialists who are willing to work for half of the reduced reimbursement that results when the Medicare fee schedule is in effect. This will be an interesting access issue to watch unfold. I hope I am wrong.

    1. Thanks for the insight Steve. Frankly, I hope you're wrong too...

  4. David,
    Your experience as a young patient is most certainly relevant in today's climate of Doctor patient report or the lack of due to time constraints. If the injured worker does not feel safe with their doctors initial treatment plan from a lack of being heard as a whole person not just the injury it's self. If the injured workers feel as though they are heard by their treating doctor etc., they are more likely to be receptive to the proposed treatment plan and less likely to fear the doctors only job is to get them back to work as soon as possible negating concern for the whole person. The stigma of poor or worse yet inadequate treatment plans for injured workers will continue to shape the opinions of the injured workers and future injured workers. I would suggest making use of interns/volunteers from the local medical community. There can be a workable solution by soliciting medical students etc to become work injury related advocates for the injured worker to feel heard and all concerns addressed by either the advocate or a round table discussion with the treating doctors and providing answers for the injured worker, which can be presented back to the patient at follow up appointment or a phone call. For the volunteer the rewards can be as simple as learning the values in bedside manners while learning the importance of time management in their futures as independent treating physians. There can also be a certificate awarded for this position, maybe extra credit or other recognition for they valuable contributions.

    In addition by having a noticeable positive injured worker outcome I would be inclined to reason the additional monetary gain seen by the award for additional time spent with the injured worker as incentive for the specialist that may have to take a pay cut. If this were to show evidence of better outcomes such as injured workers overall experience as a positive one with successful treatment plan durations staying on track and reporting back to the population we could see the trend turning from increased attorney retention to a decrease legal fees for the insurer and more flexibility in the reserves per injured worker. It would seem to me that the portion of billable time spent with each injured worker spent treating the injury and less time listening to patients complaints not heard in the beginning. Injured workers tend to trust specialists more than primary occupational doctors that have not displayed concerns for the whole person. If the advocacy program were to show a significant difference then the allocated funds could become a paid position and seen as a benefit to all participants in the treatment plan for each injured worker. These advocates would become their go to person for complaints and concerns.
    These non paid positions could serve for multiple purposes as patient advocates which would allow each injured workers complaints,concerns and possible hardships in relation to their injury all being heard by their advocate knowing they will be addressed. Many times injured worker are on the defense from the beginning are are intimidated by the rushed doctors schedule. By the implantation of a injured workers own advocate they will begin to see the bigger picture, my work comp doctors office really does care they have someone that actually listened to me about everything going on and I didn't feel rushed and I was able to tell my advocate everything that's been bothering me etc. and feel comfortable knowing their medical concerns will be addressed by their treating doctor and their emotional concerns are being heard and addressed appropriately within the guidelines for overall care of the whole person. In return these advocates will have access to important data, such as what was the events and mind set just prior to the injury, how the injury happened, what could have potentially been done different to avoid the injury, how they feel about their injury, did it allow for wanted time off with pay, did this injury cause additional problems in the work place or home life.