motivations for the right dx

Alan Morris Alan.Morris at IMAIL.ORG
Thu Jan 23 16:40:38 UTC 2014


Dr. Goodson:
You identify a number of elements in our healthcare system that suffer
from what many call perverse incentives.  One that I would add is the need
for time to review medications.  In the past, when I had patients bring
all their medications (prescription  and over the counter) in large brown
paper bags, I spent 15 minutes reviewing all medications - with a number
of remarkable observations that were important for the patient's health.
That can no longer be done.
Have  a nice day.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Director Urban Central Region Blood Gas and Pulmonary Laboratories
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
Mobile Phone: 801-718-1283
Fax: 801-507-4699
e-mail: alan.morris at imail.org
e-mail: alanhmorris at gmail.com


On 1/22/14 10:05 PM, "Goodson, William, M.D." <GoodsoW at CPMCRI.ORG> wrote:

>Hi Victoria,
>
>You have identified what should be the primary issue, "we the patients"
>whereas Karen has identified the pressure on the other side to do more
>with less in less time.
>
>There is a lot of talk of patient satisfaction surveys, but these focus
>more on who smiles the most.
>
>Since doctors are graded on the outcomes, for example control of Hba1c in
>diabetics or BP in people with hypertension, perhaps patients should
>complete a post office visit survey with questions like:
>1.  Did your doctor ask about your general health?
>2.  Did your doctor ask how much (or if) alcohol you drink?
>3.  Did your doctor ask how much exercise you get?
>...and so forth on smoking, weight change, dietary calcium, and the whole
>long list of things that are involved in assessing a person's health.
>
>or for an acute disease such as an upper respiratory infection:
>1.  Have you had fever?
>2.  have you had muscle aches?
>3. have you had nausea?
>... and the things that should be asked to decide if it is likely to be
>the flu.
>
>If a person is going to be graded by their patients,  then they will do
>what they must.  But I think the result that will come out of this is
>that there is often not enough time to ask the basic questions.  The
>beauty of this is that someone could prepare the list of questions and
>then test how long to allow to ask the questions, let the patient answer,
>and then examine the patient.  Thismight give someinisight into why
>doctors seemed so rushed and they miss the uncommon things.
>
>I've done research on the time to do breast exams.  It takes a minimum of
>2 minutes to do a good CBE of a supine patient, not even including
>palpating nodes which has an extremely low yield when cancer is present
>and the mammogram is negative (~1/1400).  We could allow for the time to
>listen to the patient's chest in at least six different locations and
>pause long enough to hear a few breaths.  Even paying for the few extra
>minutes would be cheaper than a chest x-ray.
>
>I apologize or thinking out loud a bit, but I don't think anyone has
>tried to measure how long it does to do a good exam for a series of
>common patient encounters.  This would be a bit like the original
>research for the RBRVS, and for that reason a bit subject to inflated
>ideas of how fast one can be if they really do it right.
>
>Anyway, does this strike a chord with anyone?
>
>Bill Goodson
>
>William H. Goodson III, MD
>Senior Clinical Research Scientist
>California Pacific Medical Center Research Institute
>2100 Webster St, #401
>San Francisco, CA 94115
>415.923.3925
>FAX 415.776.1977
>www.drwilliamgoodson.com
>
>________________________________________
>From: Vic Nicholls [nichollsvi2 at GMAIL.COM]
>Sent: Wednesday, January 22, 2014 11:42 AM
>To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>Subject: Re: [IMPROVEDX] motivations for the right dx
>
>I have heard about the "productivity" issue. Does it help if you all
>code by the level of complexity? For example, if you have 3
>older/diabetes/hypertension/obesity consults and a heart/cancer patient,
>I would think that would require a longer visit. How can you all be
>expected to get that in without scrimping elsewhere?
>
>Does it matter if we the patients tell the bosses thank you for spending
>a few moments with us?
>
>My thinking is that if we can help you all better, you all will help us
>better.
>
>Victoria
>
>On 1/22/2014 11:11 AM, Karen Cosby wrote:
>> I'd like to think most doctors always want to be right for many
>> reasons.  First, the ability to make the right diagnosis goes to the
>> heart of their professional skills.  Secondly, doctors need to be
>> confident because they have to trust their skills in moments when
>> their decisions can impact life and death.  I don't think most doctors
>> need any more incentive than that!  However, perhaps more importantly,
>> they need freedom from disincentives.  Increasingly doctors are pushed
>> by limits on times, and limits of testing.  I know my productivity is
>> being watched and measured, and my administration isn't shy to
>> embarrass or punish me for not seeing enough patient's per hour or
>> ordering too many tests.  Many groups offer bonuses based on
>> productivity. However, I have never known anyone to be rewarded for a
>> "good save" or "timely diagnosis" beyond their own personal
>> satisfaction (which is more than enough!).
>>
>
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