I am so frustrated. I think I should say that right up front and get it over with. I can’t quite put my finger on the source of my frustration, but it is somehow centered around the following vignette.
Today I read my JAMA, The Journal of the American Medical Association. In the Clinician’s Corner section, I reviewed “Colorectal Cancer Screening: Clinical Applications. I knew this applied to my practice and I want to be up to date. The upshot of this article is that colorectal screening in some form from fecal occult blood testing(FOBT) to colonoscopy is recommended for patients over the age of 50. Also, a study in 1999 showed that only 20.6% of eligible patients had undergone FOBT and 33.6% had undergone some type of endoscopy. One of the barriers to improving compliance with this recommendation is the physician. The physician may be confused about recommendations or the physician does not communicate or educate the patient effectively. Recommendations include physicians providing educational videos and materials and physicians discussing and recommending screening procedures.
So, what does this mean to me? It means one more thing to add to my list of diligent discussions and evaluations I want to provide for my patients. This one more straw and can I bear it? Here is the reality of it for me.
Mr. Smith is 50 years old. I have followed him every 3 months for several years for his medical problems which include Hypertension and Type II Diabetes Mellitus. We meet every 3 months for a 15 minute follow up visit which includes a review of his current status, a review of his current meds, a review of his home glucose measurements and a limited physical exam. I will then determine which lab studies need to be drawn and will make a plan with him for follow up. In the next 2or 3 days I will review his laboratory results and let him know results and any further changes that need to be made.
Once a year I schedule Mr. Smith for a 45-minute physical exam in addition to review of his usual chronic medical problems. I begin this exam with a review of his current problems or concerns. We then review his past medical history, his medications, his habits including documentation of his ongoing smoking. We review his family history, his social history and a review of systems where I specifically ask him questions about the major organ systems such as are you having any chest pain, shortness of breath, nausea, vomiting, bowel changes, voiding problems, blood in your urine, swelling, etc. More details are asked if any questions are answered yes. This first portion of the exam must happen in about 15 minutes.
Mr. Smith then gets undressed while I step out of the room, begin my dictation and look at his urine under the microscope.
I return to the room and begin a thorough physical exam which begins with a look at the sclera and conjunctiva of the eye, includes a look at the throat and the teeth, exam of the neck, chest, heart, carotid arteries, abdomen, groin, legs, lower extremity pulses, neurological system and rectal/prostate exam. This must be done in about 15 minutes.
I step out and allow Mr. Smith to get dressed while I add to my dictation and talk to the nurse about what labs will need to be drawn and what tests should be scheduled.
I return to the room and talk with Mr. Smith about any physical findings and discuss any plans for his medicines and problems. For Mr. Smith this would include a discussion of his Hypertension, current meds for it, the effectiveness and side effects of any of his meds. If any changes need to be made, we would discuss those and any potential side effects of new medicines. We would discuss his Diabetes, diabetic control, home glucose monitoring, dietary compliance, diabetic complications and the need for regular ophthalmology follow up, foot care, possible ACEI therapy and constant vigilance for kidney disease. I would counsel him once again about smoking cessation and would try to encourage him to consider nicotine gum, patches or medicine to help him stop smoking. We would discuss the importance of exercise and current AMA recommendations. We would discuss a low fat diet and plans to review his current lipid studies. We would discuss prostate screening and the PSA particularly since he will have to sign a paper that says that he understands that Medicare may not pay for this test.
And now, my last straw, I must be diligent and discuss with him his risk for colorectal cancer and the importance of screening for it. We can discuss fecal occult blood testing (FOBT) and the nurse can give him stool cards. I will also discuss the benefit of screening colonoscopy and if he is agreeable to it, then we will decide which gastroenterologist he wants to see, and I will ask the nurse to also schedule this appointment for him.
All of this discussion must take place in no more than 15 minutes.
At some later point I will get the results of Mr. Smith’s labs, and I will either call him or send him a letter to let him know the results and any change in plans.
This 45-minute visit to address Mr. Smith’s Hypertension, Diabetes and yearly evaluation will be coded with a 99214 which from Medicare will reimburse my nurse and myself $76 or, if Mr. Smith has Blue Cross Blue Shield, $80. If I am aggressive and code the highest office visit level at 99215 my nurse and I can be reimbursed $111.
Now here is my dilemma…I want to take excellent care of Mr. Smith. I want to thoroughly evaluate him and make sure that I address all of his current problems and concerns. I want to make sure that I offer him any and all screening tests that would help to prevent him from any complications or new problems in the future. I want to encourage him to have that colonoscopy if it is recommended and it will benefit him. I want to be diligent about using all of the right medicines for him. I want to educate him about smoking, Hypertension, Diabetes, kidney disease, diet, exercise. But it is hard to meet all of those requirements in 45 minutes and as it is I will have trouble paying my nurse, myself, my malpractice liability, my light bill with the $76 from Medicare. And the worst part of it is that next week I will pick up JAMA and there will be another article that says that only 20 % of men are doing testicular self-exams and clearly early detection of testicular masses is critical to the ability to cure men of testicular cancer. If physicians would do a better job in examining testicles and educating men about Testicular Self- Exam (TSE), then this problem could be solved.
Next week it may be the last straw for me.
I would like the public to know that I, like the vast majority of physicians, am working hard at being diligent. Although, I, like the vast majority of physicians, have been sued for malpractice and am sure to be named again in a suit if I continue to practice.
I also know that try hard as I might I will NEVER know it all and will NEVER be able to effectively communicate all of the right information to the right patient at the right time. And, perhaps even more disheartening than disappointing my patients is the daily reminder that I disappoint myself because I can’t get it all right. JAMA reminds me of that weekly.