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The Joy of Practicing Medicine Outside the U.S.

Written by David Sprayberry MD

I recently spent 3 weeks serving at a mission hospital in Kenya. It was a highly challenging time, with a much greater severity of illness and greater limitation of resources than we have here, but it was the most rewarding thing I have ever done as a physician. The work I did was needed, difficult, and stressful, but I did not have to fight an insurance company once and I did not have to constantly worry about my documentation meeting the minutiae of coding regulations that, if not followed precisely, might lead to accusations of billing fraud. I was able to focus on taking care of patients who needed help without significant intrusions by insurance companies. I was able to document what was important to the care of the patient, not what the insurance company or government wants to see on paper. It was demanding and refreshing at the same time.

In Kenya, I was able to perform procedures and take care of rather complex patients because I was the most qualified person available. In the U.S., I am forced to refer patients to subspecialists for problems I can handle, because I would have great liability if a patient had a poor outcome and I had not referred them out. In Kenya, I took care of premies who required intensive care, I intubated and ventilated babies, and I set up and changed ventilators. I managed kids with severe hypoglycemia, severe malnutrition, severe dehydration, meningitis, sepsis, tuberculosis, malaria, and congestive heart failure, most of whom I would not have had an opportunity to care for here in the U.S. because a subspecialist would have had to be involved.

Despite the limited resources we had to work with and despite the heartbreaking events that occur when practicing medicine in the Third World, I must say that my experience in Kenya is why I went into medicine. It is comforting to know that I can go practice there if our government and our insurance companies ever make practice here unbearable. In fact, I could practice there now.

Dr. Sprayberry is a practicing pediatrician and believes there is more to medicine than shuffling patients in and out the door. To read more about Dr. Sprayberry’s medical trips to Kenya, visit his blog, Pediatrics Gone to the Dawgs.

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Docs not tech-savvy? Not so fast…

By David Sullo, MD
Electronic medical records (EMRs) are slowly making headway into both hospitals and doctor’s offices.  My office has now been paperless for six years, and there are many benefits.  However, I cringe when I see the mainstream media declaring “if those old-fashioned doctors would just get with the times, medicine could all be electronic!”  There are legitimate reasons why many pediatric offices have not gone electronic, most of which get overlooked in the press.  Here’s a few:

Cost

Yes, these systems are quite expensive.  There is software, computer terminals, a wireless network, antivirus software, several printers, a central server to hold the information, a battery backup for said server in case the power goes out…you get the idea.  Usually we’re talking six figures when all is said and done.

Lack of standards

Right now, each EMR has it’s own way of storing data.  As a result, it is nearly impossible to share data from one system to another.  If a practice buys one system, and is displeased, switching systems means losing data, or printing every chart out of the old record and scanning it into the new system.  As you can imagine, this makes doctors highly apprehensive about buying a system and getting stuck with a lemon.

The outside world

Some local pharmacies still do not e-prescribe.  We are able to access information about a patient’s insurance plan (copays, etc) electronically from some insurers, but not from others.  Summer camps require health information “on their form only,” even though we can print out the same information from our system.  My favorite is the state, which is receiving federal funds to encourage EMR adoption, and then decides that things must also be “on their form only!”

Skewed incentives

The federal government has allocated funds to partially reimburse offices which have gone paperless.  However, the criteria to receive these funds are heavily weighted against pediatricians.  An office is required to have a certain percentage of Medicaid patients, of which most pediatric offices fall short.  Even if they qualify, they are still only eligible for 2/3 of the money that an internal medicine office would receive through Medicare for the same program.  So pediatrics, which is the lowest paid medical specialty, also gets the least help in subsidizing purchase of an EMR.I hope it is clearer now why doctors, and pediatricians in particular, might be slow to adopt this new technology.  Rather than aggressively pushing adoption of an imperfect system, we should improve the system until incentives are not needed.  In my next post, I’ll talk about a few basic fixes that could achieve this.

Dr. Sullo is a board-certified pediatrician and a Fellow of the American Academy of Pediatrics. He is a practicing pediatrician in Rochester, New York

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Is Finding a Pediatrician Like Buying a New Car?

Written By Nelson Branco M.D., FAAP

Several weeks ago, a posting on The Huffington Post by Meredith Lopez titled “An Open Letter to Pediatricians” generated lots of commentary and discussion among pediatricians.  Ms. Lopez described her experiences with her son’s (former) pediatrician, who was apparently not available to answer her phone calls in the middle of the night or on a holiday, and was unable to diagnose and cure her son’s diaper rash despite several visits. When I read Ms. Lopez’s blog post, I see a relationship between a mother and pediatrician that just isn’t working because they aren’t communicating.As a practicing pediatrician, I know that not every visit leads to a definitive diagnosis and cure.  I also know that being available, professional, knowledgeable and compassionate are just as important as how quickly I can come to the correct diagnosis and recommended treatments. Communication is at the heart of all that we do in medicine.  If you can’t listen effectively and let the patient or parent know that they have been listened to, you have not really taken care of them.

I’ve practiced in cities, suburbs and rural areas.  Many times, patients, family and friends ask “Should I go into the city for this?”  For me, that city has been Boston, Providence, Albuquerque, Denver, San Francisco and Phoenix.   Which city doesn’t matter – what drives them is the desire to get their care from “the best” for whatever problem they are having.  My answer to them is always the same – the best doctor for your problem is the one you can communicate with, the one who is available to answer your questions and the one who makes you feel like they can take care of you and your problem.  Sometimes that person is right here in your own backyard, and sometimes that person is at the biggest hospital in the biggest city with the biggest reputation.  But you should do your homework to find out who that is, and part of that homework is calling your pediatrician.

Part of my job is to direct my patients to the right specialist.  In the days when HMO insurances were more popular, primary care doctors were the so-called ‘gatekeepers,’ and many patients felt that their doctor was trying to deny them access to specialists.  Now, with PPO and EPO insurance plans being the norm, primary care doctors are not necessarily involved in their patients decision to visit a specialist.  That isn’t good medicine or good care for your child.  My job as your primary care physician is to take care of all your problems – including getting help from a specialist when we need it.  I need to know where you are going for your care so that I can get information from the specialist, help you understand it and integrate it with any other issues or conditions you might have.  It’s also my responsibility to lead you in the right direction, and send you to the specialist who will help you get to the bottom of the problem.  Often, that means referring you to the person that fits your needs and personality; I know you and usually I know the specialists.  I may not be a professional matchmaker, but I usually have a good idea who you’ll work well with.

The other advantage to local care when it is appropriate is that it can be much easier to get.  All physicians know that a medication prescribed twice a day will be taken much more consistently than a medication prescribed three or four times a day.  So it is with visits, tests and follow up visits that you can do close to home.   What about when those specialists aren’t available close to home?  Or if there is only one choice for a particular specialty?  That’s the time when it’s most important to have me working alongside the specialist.  When there is only one Child Neurologist, they will be busy and won’t be able to see you frequently.  Then it becomes my job to communicate with them about questions, concerns or issues that may come up.

The bottom line is that it is important to pick the right pediatrician for you and your child.  Their personality, communication style, office setup and availability are all important.  Ask your friends, your family and co-workers.  Check the practice website, call the office and see if they are set up to do a prenatal or ‘meet and greet’ visit and meet with the doctor if you can.  Most pediatricians are kind, caring and dedicated – you’ll find the right one for you, if you look.

Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP.
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Legistupid

Written by:  Suzanne Berman MD

Having lived in the South for much of my life, I have a healthy respect for states’ rights.  Local governments are more sensitive to their constituents’ issues, as well as better judges of how to manage them, than a well-meaning but massively out-of-touch federal government, whose legislative mandates might make perfect sense in one community but pose a significant burden to another.

Diversity also promotes some healthy competition.  Two states, struggling with the same issue, come up with different approaches to the same problem.  Take the Massachusetts model  and the Utah model for health insurance exchanges.   Health economists and politicians argue their relative merits but seem to forget the good news: we need not choose one over the other.  Because we have Massachusetts and we have Utah, we can have two different designs, executed simultaneously, each serving their citizens as they see fit.   Lois McMaster Bujold’s  heroine  Cordelia Vorkosigan describes this continuous parallel experimentation phenomenon as fifty-one sociopolitical culture dishes.

I’m thus reluctant to sneer at a regulation which I might perceive as poorly thought through, if not downright goofy, as long as it’s in another state, and that state’s citizenry is willing to give it a whirl.  I’m willing to grant you a modicum of grace without smirking as long as you don’t laugh too loud as we in Tennessee try to work through our own legislative kinks.

With that said, when a bill or regulation proposed in another state’s legislature is so ill-reasoned, it blasts right past stupid into scary.  Every newly-opened legislative season has its own particular crop of two-standard-deviations-beyond-the-mean-of-crazy.

Ah, yes, speaking of open season…  A proposed Florida law would make it a felony  for pediatricians to discuss gun access with families.

First of all, a felony?  Five years in jail or $5 million for following a national standard of pediatric preventive care?

Interestingly, this started as a pediatrician exercising his right to terminate the physician/patient relationship when his patient steadfastly refused to communicate with him about guns.  Since this bill would make it illegal to discharge such a patient from one’s practice, a physician would lose his say in whom he treats.

Not only could doctors not ask about guns, they would be forbidden to put any notation in a chart or tell anyone else.  If a child came to my emergency room with a bullet wound, I would not be permitted to ask how it happened, or let law enforcement know my findings.   I’m curious to know if the bill’s sponsor thinks physicians are just waiting to release tabulated data on gun owners to Big Brother. But I’m even more curious to know how this felony could be prosecuted, since my medical records are protected as confidential.

I’m feeling a lot of hostility oozing out the edges of this bill.  And I don’t get it.  I practice in a rural, gun-dense area; we discuss this right along with car safety seats, swimming pools, and medication safety.  Even dads who come in wearing NRA LIFE MEMBER caps see it as an opportunity to train their kids to respect the power of firearms.

I get the bit about how this is a Second Amendment issue.  However, were this law passed, Florida would trample the Eighth, Thirteenth, and Fourth Amendments.  And that, of course, that would violate the first section of the Fourteenth Amendment and work against the Tenth, which allows us to our sociopolitical culture dishes to flourish.

Dr. Berman  is a practicing pediatrician in rural Tennessee.  She enjoys finding applications of science fiction quotations to medical practice.

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Why do I have to wait so long to see the doctor?

Written by: Herschel Lessin MD
Recently I had a frank conversation with a mom who told me “I have been dying to ask a doctor this question for years and I think you might be able to give me a reasonable answer, so here it goes:  Why do I have to wait so long to see the doctor? Is there any good reason? A patient’s time is valuable too! 

During my 30 years of practice, Our office has been trying our best to remedy this chronic problem with some degree of success, but some degree of failure as well.  As I thought about the question, I realized that it has a multitude of answers and explanations, as anyone who has ever worked in a medical office realizes.  When I run behind schedule, it makes me absolutely crazy.  The patients are angry, the staff is harried and I hate feeling rushed.. Here are just a few of the factors, which add up to a most difficult problem:

1.  Unpredictability – When I walk into a room to see a child, I have no idea whether that child will have a minor illness or a major problem.  Most kids are healthy, but when they are sick, they are often VERY sick.  All it takes is one of these complex patients to completely disrupt a patient schedule.  It is not like you can tell a family that you don’t have enough time to admit their child to the hospital today.

2.  Seasonality – If you come in the middle of winter, there are going to be lots and lots of sick kids.  We rarely, if ever, refuse to see a sick child on a same day basis. While we leave open many slots for same day calls, and are open until 9 pm every night, if it is winter, it will be busier and you may have to wait longer.  If you come in the summer months, it seems every child in the universe needs a physical for camp or school.  Certain laws and misguided insurance company policies make this problem even worse.   If you can do your check up any other time, please do so. In summer it will be busy, and you do not want to be told that you cannot have your form filled out because we are completely booked up.  We try to hire more doctors when we seem busier, but when the crunch time comes, we just have to get the job done.  You don’t want your child to be ineligible for sports or miss the first day of school.

3.  Human nature – This issue applies both to patients and doctors.  Some doctors seem to think that it’s OK if they are late, but not if the patients are late.  Your doctor should show up on time and start on time.  But patients are subject to human nature as well.  No one wants to take their child out of school or miss too much work, so I am often sitting around doing nothing from 1-3 pm while it is totally swamped from 3-5 pm. It is kind of like rush hour.  If you don’t want rush hour traffic, try to drive some other time.  It is always busier on Mondays and after school than any other times of the week.  If you have an infant, don’t schedule your check up in the late afternoon for the reasons above.  Our office does time and motion studies to try to figure out where the problem lies.  We have discovered that a good part of the problem (assuming the doctor is arrives and starts on time) is patients coming 10 minutes early or 10 minutes late.  That doesn’t seem like much, but it has enormous impact on the ability to see patients in a timely fashion. This will blow the schedule out of the water and disruption builds as the day goes on. Believe it or not, if everyone actually showed up on time both doctors and patients, things would be a great deal better for everyone.

So, I ask all of you to try to understand.  Running an office on time is better for patients and their doctors.  Scheduling enough time to discuss the problem is critical.  You cannot expect to have your child’s chronic stomachaches for the past 6 months be properly addressed in a same day sick visit.  There is not enough time scheduled.  A good doctor will make you come back and schedule enough time to evaluate your child properly.  Most doctors hate running late as much as their patients do.  If we all could try to understand the above issues and work together a bit better, we would all be much happier.

Dr. Lessin has been practicing Pediatrician in the Hudson Valley since 1982. He is a founding partner and serves as both Medical Director and Director of Clinical Research at the Children’s Medical Group

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Hello world!

Frustrated by the poor representation that physicians (particularly pediatricians) get, we decided to take matters into our own hands. This blog is about giving pediatricians a voice and a presence on the web. We wish to participate in the discussion, be included at the table, and share our ideas.

We feel that we can provide a unique perspective that often gets overlooked when healthcare issues are discussed; which is the perspective of front line pediatricians.

Between politicians, interest groups, lobbyist, pharma companies, insurance companies and many others, front line pediatricians are not being heard. After all, we are the ones that provide care for the children of America. Should we not be heard?

We think so.