Dr.Will dr.will at FUSE.NET
Thu Sep 5 20:07:55 UTC 2013

Yes Aaron I believe you are accurate in your assessment!

 We are at a crossroad in medicine: Do we pay the PCP the same rate as the
subspecialist so they can see fewer patients/day and spend more time per
patient? Or accept the payment model the insurance industry has crafted and
hope the medical schools are paid for the percentage of students who finish
a PCP residency (not start one)? Giving up should NOT be an option.

Imagine if the CEOs of every health insurer would chip in 50% of their
annual salary (~ $3 billion?) and pay the PCPs directly as an annual "Thank
you" for your service(some would say sacrifice).

Holding out some hope that we begin to approximate population health
management and pay the PCP adequately for it. This was the model my first 3
years in practice ('86-'89) and I have not made anywhere near the same since
and have had much less detail on which patients the insurance company
believes I am responsible for their care.

Thank  you for the catharsis(sp?)

Will Sawyer,MD 



From: lorri Zipperer [mailto:zipperer_info at YAHOO.COM] 
Sent: Tuesday, September 03, 2013 12:58 PM
Subject: [IMPROVEDX] Thoughts


**Forwarded by Moderator**


akassoffmd at writes:


I have been following the Email discussions with interest and am impressed
that that so many  contributors have spent much time and effort in
developing their views and impressions. The suggested approaches are well
thought out and presented, based both on individual experiences and research
as well as familiarity with the literature published in this area.


As someone who has just been introduced to these discussions, I am
impressed, not only by the concern so many individuals have regarding this
important problem but by the efforts that have been made to introduce
measures to address it. I do have some suggestions that I would submit,
perhaps to broaden a perspective.


It seems to me, based upon these discussions, that some recognition should
be given to what I believe are fundamental impediments contributing to
medical errors that have not been given warranted focus. Regarding the
general practice of medicine, gleaned in most part from discussions that I
have had with patients unhappy with their general medical care, there seems
to be an unwillingness to spend time listening to patients' complaints and
their perceptions regarding such complaints. They often sense a tone of
arrogance on the part of the physician, interpreted as a demeaning of their
knowledge and understanding and a projected attitude that the physician can
understand a problem fully even before hearing them out. This tends to close
down further discussion and conversation and leaves the patient frustrated
in their opportunity to have their history and symptoms fully explained. To
the degree that this is true, all the paradigms that may be put forth to
improve the accuracy of diagnosis will be for naught as the clues that might
lead the diagnostician to a correct diagnosis may well be missed.


Secondly, in this regard, in the current state of reimbursement, with
declining income and  the rising costs of practice, I sense that in many
cases, there is an effort to compensate for this by seeing more patients in
a given day, allotting less time for each visit. This sense of urgency on
the part of the physician is often portrayed by, as patients express it, as
the doctor standing and moving toward the door before the patient feels that
the story has been fully told or questions being asked. In my personal
experience, this has not infrequently led to being asked my advice about
something such as a problem with a knee which, as an ophthalmologist, I am
ill equipped to answer. When I inquire as to why I am being asked, I am
inevitably told that their general physician or specialist seemed to be in a
hurry and their visit seemed to have been incomplete.


On another topic addressed in the on-line discussions, that of medical
teaching, my thoughts are these. Whatever the method utilized, there are
good and bad teachers. I have little doubt that the knowledge of the teacher
is less important than the ability to teach effectively. Whatever approach
is taken, it is critical that the teacher have a dedication to the
imparting, not only a body of knowledge but an system of utilizing it which
would lessen the chance of medical error. It is not only the ability of a
student to provide a differential diagnosis but an approach to enable the
student to apply a logical mental process to sorting it out, which is of
critical importance. I believe that the clinical experience , to varying
degrees, is left in the hands of practitioners who may or may not have a
commitment to teaching. They may be part of a rotation with an obligation to
lead rounds but without an appetite or skills to effectively teach. When I
read polls suggesting that a sizable percentage of individuals in private
practice are unhappy, with plans to retire early, of that they would
dissuade their children from entering the field of medicine, it speaks to me
of the need to keep such "teachers" away from students who I can only
believe have chosen the field of medicine for the best of reasons. To have
enthusiasm poisoned by individuals who are disgruntled can only influence
young and impressionable physicians in a way that will lessen intellectual
stimulation and commitment that will impact negatively in future behavior.
This can only and surely perpetuate an environment which will diminish the
quality of medicine as it is practiced (leading to errors in diagnosis and



Aaron Kassoff MD

Albany NY

akassoffmd at




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