November 24, 2014

Editor's Page

Quality of Care

Mark R. Howard | 9/1/2004
I heard my favorite story about the practice of medicine from a doctor I once knew in Nashville. As a young resident at a teaching hospital, he was making his rounds when a colleague collared him and asked him if he'd seen the "green lady." The colleague wasn't joking. The hospital had admitted an elderly woman who lived alone in a rural area. And her skin, in fact, was as green as the fairway on a golf course.

The green lady was, of course, the object of all kinds of diagnostic efforts. A parade of specialists examined her, and predictably, each specialist's theory had to do with his or her specialty. The dermatologist, of course, suspected a skin condition; the nephrologist, a kidney ailment; the endocrinologist figured it had to be a glandular problem. And so forth.

Meanwhile, a young intern drove out to the woman's house in the country and nosed around. When he looked in a window, the mystery of the green lady resolved itself. Littering the room were dozens of bottles of a well-known, green-tinged, over-the-counter throat spray. She'd obviously become addicted to either the painkiller or the alcohol in the stuff and had consumed enough of it to tint herself.

He reported his findings to the hospital. The specialists rolled their eyes, decided to wait and watch, and after a few days the woman's skin returned to its normal hue.

The specialists were not, of course, incompetent. The problem was that the woman entered the treatment ladder on the wrong rung. She didn't have a local physician who knew her well enough to get her appropriate help earlier and ended up in the hands of physicians who knew her only as a set of symptoms.

Different, but equally fragmented versions of the same scenario play out all the time, egged on by a health insurance system that provides no incentives for patients to consume less healthcare and no incentives for doctors to provide real "care" rather than just treatment.

The Florida Academy of Family Physicians has begun an effort to re-engineer the education and clinical practices of family physicians to reduce some of the complexity and fragmentation in the healthcare system -- and to try to make sure that every patient has a "medical home" with a family physician. The group's effort could establish it in a national leadership role. And it's certainly refreshing to hear a group of doctors talk collectively about patient care rather than groan about medical-malpractice suits and trial lawyers.

Some of the academy's goals involve more use of technology -- increased use of electronic health records, for example, to better coordinate treatment, and use of e-mail to facilitate communication between doctor and patient. Other goals involve increased training for family physicians.

The group also wants family physicians to adopt a more organized approach to case management: After patients get a prescription, they'd get prompt follow-up calls from the doctor to make sure they're taking their medications and to check whether the drugs are working as they should.

Dr. Fleur Sack, a family physician in Miami, describes another approach in the new model -- the use of group sessions for people with the same conditions. She treats a number of her diabetic patients, she says, in groups. The setting enables her to get the same information to a large number of patients at the same time, she says. Just as important, a question from one gets heard by all, and the groups offer a kind of collective support for all. Often, she says, "what a patient hears from another patient with the same condition can have a bigger impact than what I may say" in terms of getting someone to stay on medication or take it properly.

The group's goals are admirable, if sometimes a little vague -- "support continuous healing relationships," for example, and "evidence based" care rather than "experienced based" care.

And the academy won't get far if it can't figure out how doctors can make a living at it -- how they'll get paid for responding to e-mails from patients and holding those group sessions.

My own doctor, Gigi Lefebvre, is a terrific, caring family physician who provides exactly the "medical home" and quality of care that the academy aspires to. She responds quickly when needed, spends a half-hour on each patient appointment and visits each hospitalized patient once a day. She keeps such detailed notes that I never have to go back over the details of my last visit. And after a checkup, I never have the sense that she's hearing whatever additional questions I have with one foot out the door on her way to her next patient.

But Dr. Lefebvre has grown so frustrated with HMOs and insurance plans that she chooses to operate mostly outside the usual insurance reimbursement system. She just rejected an offer from Blue Cross Blue Shield that would reimburse her at less than the Medicare rates of two years ago.

In the process of trying to provide what she views as quality care, she has just about worked herself into the ground and seen her practice go broke. A few months back, she sent her patients a letter, full of frustration, advising that she'd have to begin charging for phone consultations and for having her staff order drug refills over the phone. Those are eminently reasonable requests but anguishing to her because the current system simply doesn't support the quality of care she provides.

She rolls her eyes a bit when she hears about suggestions for more computerization -- that expense would just about break her, she says. "A lot of what the academy is talking about is more complex and expensive than it needs to be," she says. She believes that until the system compensates doctors adequately for spending enough time with patients to really get to know them, the patients will continue to be shuffled around to one degree or another as a set of symptoms rather than a person.

Dr. Lefebvre's case poses a question for the academy: If she's already providing the kind of care the academy aspires to and can't make a good living at it, how is the academy going to get where it wants to go? Is the system so broken that there's no model that can make both doctors and patients feel better?

Tags: Editor's column, Healthcare

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