Growing Mushrooms by Pat Conrad MD

mushrooms

While going through the latest stack of bills, I was just about to throw the usual stack of junk mail in the can when a line caught my eye: “Med students: Look up from your EMR’s”, a guest editorial in The Journal of Family Practice. So the journal doesn’t want students scope-locked on their computers, huh? I read on.

The author Jeffrey Unger, MD, wrote about his experience with acute appendicitis, and the grossly inadequate history and physical techniques on the part of the med students. Apparently the poor 4th-year assigned to the surgical rotation directed a lot more energy and attention to getting the right checks in the right boxes, than he did toward doing a complete exam. This crusty old FP of considerable experience would not let him leave the bedside, and kept directing him to the items he missed. Of course Dr. Unger also wanted his feet examined, because he is a long-standing diabetic – and specializes in treating diabetes, and has published textbooks on diabetic management – and also demanded the student ask him what his most recent HgBA1c was, and whether he had had any long-term microvascular complications (I guess when you always carry a hammer…). Dr. Unger was concerned that the student didn’t check him for peritoneal signs, and also wanted his eyes and mouth checked. Angry at this point, he recalled, “The student was more interested in inputting data into the EMR than learning about acute abdomens and type I diabetes.” The doctor-patient later complained about the attendings trying to remove his insulin pump until his wife fired them, started directing his own IV therapy, and laments that had he not been an experienced FP he would likely have suffered a fatal post-operative event.

Dr. Unger states that in his practice he only uses an EMR to e-prescribe, has chosen not to participate in submitting meaningful use data to the government, otherwise takes all his “notes on scratch paper” (not sure what he does with those later), and brags: “I only order tests to confirm a suspected diagnosis, not as a primary means of evaluating patients.”

And isn’t that the kind of doc we thought we were trained to be? Unger’s last thought was that med students unplug their smart phones, and train with “old-time docs who still work with their hands…rather than texting and data entry. We’ll show these students how to become caring, intelligent, and dedicated clinicians.”

But cynical bastard that I am, I suspect that the various insurance companies do not accept his notes on scratch paper. Dr. Unger is 62, graduated from med school in 1980, and from residency in 1983. According to Healthgrades.com, he accepts Aetna, Cigna, Blue Cross, and various other PPO’s and HMO’s. Beside his picture it says he is the director of a “Concierge Medical Group.” Does this mean DPC? I don’t know. I also note that for all his eyeballs-and-fingertips bedside exam advocacy, Unger’s website also advertises telemedicine consultations in Nevada and California.

What I’m left with is the suspicion that, despite his laudable comments, Unger is a member of a medical generation and primary care establishment that does not take responsibility for what they created. They want the med student to be a great clinician, yet they have supported those institutions that now force him to waste time on non-clinical garbage. My suspicion is that the ones complaining are the very same who have grown that mushroom.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  4 comments for “Growing Mushrooms by Pat Conrad MD

  1. Bridget Reidy MD
    October 23, 2015 at 1:52 am

    Did Dr. Unger consider challenging the notion that a random question about each organ system adds something to patient care when he was a student/resident? Was he among those who howled with indignation when in 1995 the AMA (inpatient-oriented faculty who believed if their residents charted it at 3AM it must have been done?) thought it constitutes complex care, while only 4 questions about the relevant concern does, and having patients who have trouble answering necessary questions, ramble, or have multiple needs no longer does? Where was he in the nineties when someone did a study in a Detroit ER that showed female Detroit ER patients are often domestic violence victims and someone somehow turned all ER docs into screeners for a condition not of their expertise and usually not of their patient’s interest that we never proved we could help? Did he like most docs in effect say “I can and will do that additional thing you want done at every visit in zero minutes” and then falsify records or voluntarily decrease his schedule and income to do it, instead of writing the family practice journal objecting to the non evidence based “expert” content? (AFP would frequently have articles saying things like every middle aged woman should be asked if she has caregiver stress back then, probably still does but I quit reading.). Did he explain to the med student that actually knowing the exact amount of microvascular disease a diabetic has will help prevent bad outcomes after appendectomy? (Or would it?) If not, he was part of the culture that made all this possible and he should apologize to the med student for allowing the profession to be ruined. I’ll admit my part in it too.

  2. Ken
    October 19, 2015 at 1:59 pm

    And yet another reason that no one wants to be an FP–role models who are terrible
    Think what this encounter could have been like: Dr Unger consoles the overworked and abused medical student, treats him with kindness while suggesting a few things to think about regarding his case, and let the poor guy get on to the next patient. Instead, he just pimped him, and added to his burn out for the sole reason of being a bully.

  3. Perry
    October 19, 2015 at 12:04 pm

    Interesting, the good Dr. Unger bypassed the system and went straight for the imaging test.

  4. Steve O'
    October 19, 2015 at 8:42 am

    Yep, I’d say so –

    They want the med student to be a great clinician, yet they have supported those institutions that now force him to waste time on non-clinical garbage. My suspicion is that the ones complaining are the very same who have grown that mushroom.

    There’s a concept from good management – “One you add a task, delete a task.” There’s no pretense any longer that physicians can complete all the tasks due in the care of the patient. The ones of lesser importance are, as they say in the Army, “pencil-whipped.”
    Questions are not learned so as to diagnose and treat a patient – they are asked for liability avoidance. Worse, students are not learning the instincts for asking and examining what is important in the care of the patient. Dutifully detailing ten sets of three questions for the review of systems is more important than getting the diagnosis right, if the purpose of the whole interaction is billing.

    …had he not been an experienced FP he would likely have suffered a fatal post-operative event.

    But, thanks to his decades of letting things slide, he should accept that something’s gotta give, and that’s his life. Nature takes its course, no? If he didn’t preserve its value as a doctor, he should be looking down the barrel of his creation as a patient. The good news is, his death certificate is FAR easier to code. That’s what ICD-10 was designed for, death certificates. It’s gonna improve those documents a lot, you’ll see.

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