The gassy winds of change

So. The year is winding up. I am buffeted more by the winds of full-time working mommyhood at the holidays than I am by the winds of change in primary care. I am, though, getting cards and contact from old patients. Oh, how ambivalent I am about this. I am delighted to hear from these beloved folk, but so many tell me tales of woe. No callbacks about tests. Doctor in and out in five minutes. No explanation for an emergency referrals, sometimes no knowledge about the referral until the specialist's office called to find out why the patient missed the appointment. Inexplicable expensive tests based on miniscule probably benign findings. Where are the good primary care providers?

I know what physicians who are reading are thinking. "Iced, you weren't there. You don't know what happened." True, so true. But these aren't nutty patients. They're wonderful patients who never, ever brought anything but joy to my office. I'm only hearing the bad stuff, too. There's selection bias. Nevertheless, the stories make my hair and toes curl. I'm mad. I feel badly, and just a little guilty, not that I can do much about a corporation ramming an office closure down my throat with about 3 minutes notice. Grrrrrrr.....

In this context, I read this:

Primary care physicians spending longer time with patients.

Well, thought I, that's encouraging. Turns out it's only 3 more minutes, which isn't much when you're managing diabetes, hypertension, ordering labs, addressing depression and insomnia, arranging a mammogram, and asking about the kids, but it's something. But wait! During the time visits increased by 3 minutes revenue decreased by 10%. Physicians don't get paid by the hour, but by the patient. Spending 3 more minutes with each patient means I can see less patients in a day--20 patients a day times 3 more minutes=one whole hour lost. Can't make as much bacon. Oh, this burns my breeches. Bend over and receive a special award: Paycut. Yes, yes, but Dr. Latte, you still have a job. Many of your patients aren't having to suffer with paycuts 'cause of course, they don't have pay to cut. Yep. Read above, however, and see how your care is already suffering. The time has to come from somewhere. Didn't get a callback? Doctor had to see three patients rather than explain to you what happens now with your melanoma? Can't get in until three months from now? Have to go to Urgent Care because your doctor is 1. Out of business or 2. Out of appointments?

BUT! Help is on the way; change we can believe in. Two thousand billion pages of health care reform are coming our way sometime in the next hundred years maybe, and it's possible that if you don't have insurance now that you might be able to get insurance maybe in five years possibly and it might not matter than you had a pre-existing condition like fatigue 10 years ago. Here's my predication. Medicare works well for patients; not so well for physicians who are already losing money at it. Particularly if private insurance expands, more primary care docs--if they can without going to jail--will opt out. It's already completely, utterly impossible to know how to code 100% correctly for Medicare, and to not code correctly is to risk going to prison. Add 8000 pages of statutes and physicians rightly will run out of the room screaming.

That is, however, not to say that the present system shouldn't be napalmed, bulldozed, infected with H1N1 and left to die in a ditch full of vomit. To have to see a patient for a cold with 52 million pages of ICD-9 or -10, E&Ms and CPTs, Obama-Care EMR documentation laws attached just isn't going to be feasible for the average physician. Or even the super-human MD. I'm not hopeful. You can't get a straight answer now out of HCFA about some routine matters. How is that going to get better?

But here's something cool: Science. Pure, elegant, lovely, exciting science. From NPR an interview with a researcher who discusses the successful alteration of memory traces after they are accessed, and what that might mean for people with painful, traumatic memories:

Erasing fears by thinking about them.

Hats off! Wow. I'm smiling from ear to ear. Consolidation and reconsolidation. Shining the beautiful hard light of science at a nebulous subject, memory formation. Memory is a fluid, shifting thing, but here is evidence that it can actively be shaped in a more positive light. A little scarey with regard to the corallary--that you'd be able to shape a good memory to be bad--but to help all of us feel safe about traumatic episodes? That's powerful. I think there's some hope that I might be able to get over my medical school Gyn-Onc rotation after all.

One last thing. For now. First, let me be clear about my bias. I will use any excuse to continue to buy books often on Amazon. Here is proof that it is actually good for me and for my brain. I make my living using my brain. Thus, it is not just good, it is necessary for me to continue to shop:

Can neuroscience make you a better writer?

Yes, yes, you might be thinking, there are some caveats at the end about activation maybe not being an always all-good thing, but I'm going to ignore that because I want to continue to shop.

Oops, here's really the last thing. I see patients for a living, and usually twice in every patient encounter--before I lay my healing hands upon the patient and right after I am done--I use hand sanitizer. See twenty patients, that's ah, like 40 Purells a day. In reality, it's more, 'cause I reach for it reflexively after every sneeze or walk in the hall. I do WASH my hands, too, so don't go getting all jiggy on me, but I gotta tell ya. In the days I washed my hands 20-plus times a day the skin was falling off by mid-October and no amount of Vaseline, steroids, and socks would make it better until the following May. Hand sanitizer has made that better, although if you looked at my hands now, mid-December, you might be tempted to think that I am molting. So in my personal study of one, Purell isn't as bad for my skin as washing my hands 50,000 times a day. But how about the nails? The chemists at Beauty Brains have figured it out so you don't have to:

Are hand sanitizers bad for nails?

That's all for now!