<p>“Busdriver, so glad that you finally found a doctor that gave you the right diagnosis.”</p>
<p>Actually, after plenty of research on the internet, I made the diagnosis…and found the right specialist for my son. We were lucky he was an expert and researcher in that field.</p>
<p>It’s not that I think some doctors don’t know what they’re doing, it’s that you have to find the right person, and an expert. Sometimes it can be hard to get to that point. You have to find out everything you can about the illness, and not blindly trust anyone. People can be so ready to spend 30 seconds looking at your problem, and recommending just the most common treatment, which can be expensive and wrong for you.</p>
<p>Last year I had a 10K surgery to remove a benign lump. The surgeon could have just removed it in her office, and she would have realized it if she’d spent another minute or two actually looking at the lump and realizing it wasn’t attached to the bone. Maybe she would have done that if I hadn’t had insurance, or if there wasn’t a nice surgery center next door for an easy, high paying surgery. A few months ago, the head of podiatry set me up for surgery to correct a bunion instead of seeking other options, because I noted that I had foot pain. Yet he never even took a look at my shoes, or asked me if they were new shoes (they were), and the pain went away when I stopped wearing the shoes. Two minutes to take a look and recommend surgery, another case where they wouldn’t have done that if I didn’t have insurance.</p>
<p>I really don’t trust that anyone is spending the time to make the right call anymore.</p>
<p>Busdriver – maybe that “Cadillac” insurance policy you have is too good? Wonder if your doctors would be so quick to set you up for surgery if their billing departments thought they were facing 18 months of wrangling with some insurance company that would ultimately pay them pennies on the dollar for whatever they billed.</p>
<p>My personal philosophy has been that if the choice is between a simple, less-invasive, short term treatment and a more complex, more expensive or invasive, longer term treatment – I’ll try the less-invasive approach first, conventional or not. I’m not saying I would do crazy stuff – there has to be a plausible relation between the remedy and the condition it is treating – but I could probably write a small (and rather boring) book about all the times I have opted for the unconventional but easier approach and found that it worked for me or my family.</p>
<p>Obviously it depends on the underlying condition. I’m focusing more on chronic, non life-threatening conditions. If you know that the disease itself is a killer and progressing fast (e.g. cancer) – then you don’t have the luxury of waiting to see if something else works. But busdrivers’ bunion? Yeah, I think it does make sense to change shoes first. </p>
<p>I do feel that our health system would be a lot better overall if we took an integrated approach that included and incorporated non-medical interventions – things like more attention to diet, nutrition, exercise, lifestyle issues. The bigger problem that busdriver highlights is that our care system is structured around short visits to doctors who have hundreds of patients – so not much chance for the doctor to really get to know much about the patient or the patient’s lifestyle. A 10-minute office visit really isn’t enough. I respect the education that physicians have, but when it comes down to it, I often am relying on the expert opinion of someone who I have only just met, and who has only spent 3 minutes hearing me describe my problem or symptoms before registering their opinion. In my law practice I would spend much more time than that preparing an expert witness for deposition or trial – and it was very easy to see that all experts were fallible, and how their opinions might change with slightly different information before them.</p>
<p>I agree. But in this case, Shrinkrap is right about patients. I have no doubt that patients come into the doctor’s office looking for the quick fix, the quick drug that will make the problem go away.</p>
<p>I’ve been happy with the practice I visit and how they don’t recommend the quick fix when a simpler non-intervention might do the trick. A couple of months ago, I saw the doctor because I suddenly couldn’t see very well out of my right eye. Turned out it was a cornea injury. The doctor told me that a simple surgery would fix it, but she recommended putting some over-the-counter cream in the eye and waiting a couple of months to see if it healed itself. I followed the directions, impatiently, and sure enough after eight weeks or so it was good as new. And I may say I was pretty darn glad I didn’t have to have the “simple office procedure” that involved someone putting a scalpel to my eye.</p>
<p>I have off-and-on back pain, for which the doctors have steadfastly urged against surgery even when I asked about it. Yoga, when I do it which I haven’t been lately, has been a good treatment, and yoga doesn’t involve scalpels.</p>
<p>The Bloomberg ratings of health efficiency by country came out last week. They rank on only 3 factors: life expectancy, percentage of GDP spent on health and per capita health spending. The main weighted factor is life expectancy so it’s basically a metric of life expectancy in relation to spending. The number of places covered was limited: at least 5 million residents, GDP per capita over $5000 and life expectancy of 70 years minimum.</p>
<p>They ranked 48 countries. The US was 46th. Iran was 45th. Life expectancies ranged from 73 (in Iran) to 83.4 (in Hong Kong). The US</p>
<p>I have had increasing pain for about a year - thought once I rested the extremity, the inflammation would go away. Decided to go to doctor after extensive rest, ice and OTC pain relief hasn’t improved situation. It is getting worse by the day. </p>
<p>She spent less than 3 minutes with me. Sent me for xrays and set up a specialist referral. </p>
<p>In two weeks. </p>
<p>If it’s a hairline fracture, the condition will not improve with 2 more weeks of use and bearing weight on it. </p>
<p>I am glad about seeing specialist and hope it helps. It s annoying that the doctor didn’t ask more in-depth questions or even make more than a cursory glance at injury. But, it doesn’t surprise me with our health plan.</p>
<p>That is total bs Samurai. I hate that you are in pain. I will drink an extra glass of wine for you tonight in solidarity. Can you call the specialist and tell him/her that you are in quite a bit of pain? Maybe they will move up the appointment if you express the urgency to them.</p>
<p>If the xrays show a fracture, it seems like perhaps they’d hurry that appointment along?</p>
<p>our care system is structured around short visits to doctors who have hundreds of patients – so not much chance for the doctor to really get to know much about the patient or the patient’s lifestyle. A 10-minute office visit really isn’t enough. I respect the education that physicians have, but when it comes down to it, I often am relying on the expert opinion of someone who I have only just met, and who has only spent 3 minutes hearing me describe my problem or symptoms before registering their opinion."</p>
<p>Totally agree with that! They just want to get you out of the door.</p>
<p>I hate that the AMA is working hard to prevent us from seeing other health care professionals like nurse practitioners, hospice nurses and midwives, who could perfectly well handle many routine medical needs, and spend more time with us too.</p>
<p>Just saying. There are some conditions where one or two movement or touch tests can identify the need to take the problem to the specialist level. If the complaint was heard (and this is the isolated thing that brought you to the doc,) it’s possible no further interview is really needed. </p>
<p>But I have to say, again, my experience- and that of my family and older mother- is not the cursory 10 minute visit. With one exception: a routine RX check.</p>
<p>TexasPG – Medicare intermediaries usually handle a cluster of states, though some states (California, I think) might be split between two intermediaries.</p>
<p>And, there can be separate intermediaries for Hospital claims, doctor claims, durable equipment claims and PT/OT claims. We got a real education on how Medicare is not even close to a “single payor”.</p>
<p>My doc talks about protocol flowcharts for a lot of common conditions – starting with simplest, usually least expensive therapies, and working up from there systematically. I’m fine with this – it seems like good medicine. </p>
<p>The practice also has a NP who has been great. One of the big changes they’re working on related to the ACA and medical homes is creating a lot more same day slots – I had to go in last week, and was really pleased to get an appointment a couple hours later. There goal is to avoid a lot of urgent care visits that otherwise get used when people can’t get in quickly when something hurts.</p>
<p>“I hate that the AMA is working hard to prevent us from seeing other health care professionals like nurse practitioners, hospice nurses and midwives, who could perfectly well handle many routine medical needs, and spend more time with us too”</p>
<p>Cardinal Fang, I would like to see the evidence supporting the impact of that. They might be working hard, but “represent” such a small fraction of physicians. </p>
<p>I’ve heard they were “representing” physicians support of ACA as well, but most of us know that can’t work without a lot of care being provided by “extenders”, while physicians sign off on it based on reading the charts of a percentage of cases as defined by each state. Maybe that is how the AMA is working to prevent it; by saying at least some of the cases have to be reviewed by physicians. </p>
<p>I am sure you can imagine what I’m hearing is different, but biased. I’m guessing bias is said to be less of, or no concern with your sources.</p>
<p>Nurse practitioners who otherwise would be seeing patients for routine care are sitting idle in states where the AMA has succeeded in preventing them from practicing. The AMA sues nurses who practice not under a doctor’s supervision:</p>
<p>I’m not sure what else you want to see to convince you that the AMA has succeeded in making it illegal for midwives and nurses to have solo practices in many states, and that if the AMA had not done that, more licensed non-physician practitioners would be seeing patients every day.</p>
<p>I see. That makes sense. Still, its hard for ME to imagine how PA’s and NP’s could be seeing any more patients in my community. Several of the docs here have three PA’s working with just one physicians, and the patients never actually see the physician.It seems you can’t make it any other way. I’m sure that is just referral bias. Maybe they just refer more patient to me. </p>
<p>Anyway, I am pretty sure the tides, they are a changing. I think one of the ramifications of ACA will be more patients seeing non-MD’s with the MD’s signing off on as many as cases as each state allows.</p>
<p>We stopped going to a pediatrician’s office because they kept saying doctors worked only mornings and only nurse practitioners were available in the afternoons when we could visit after school.</p>
<p>Most of the kids at this practice were predominantly on the State Medicaid. I don’t think they bill any less for an NP and so it begs the question - are they trying to push lower trained people on poorer people because Medicaid reimbursements might be lower?</p>
<p>Our local grocery store chain has a string of clinics staffed by NPs and PAs. Its easy to visit them to get immunizations or get physicals signed off.</p>
<p>^ That’s one way to think about it. Another way to think about it is that having the MD’s only see the cases the NP’s and PA’s think they need to, is how to make this work. </p>
<p>Not as expensive or time consuming to train, in many situations they are just as good, and they take more time. </p>
<p>The trick will be in figuring out how everyone will get the right experiences they need to know when and if the extra years of training makes a difference. I believe psychiatry is way ahead of the journey in this regard, although we are just beginning to see the consequences</p>
<p>My doctor works with a nurse practitioner. Maybe the practice sees some poor people, but I live in an affluent area, so this is definitely not a case of making poor people see a nurse practitioner instead of a doctor. </p>
<p>I’m happy to see a nurse practitioner, and I’d be happy to bring a child to a nurse practitioner. Most things pediatricians see are pretty darn routine.</p>