Don’t Wanna Hear Any More … by Pat Conrad MD


Two decades ago in family practice residency, I had the first of recurrent experiences with different patients during my time there – and I’ll bet the farm the same thing happened to you. Middle-aged patient comes in with multiple medical problems, some of which are known or some unknown to him (or her, or now (insert your pronoun of choice)). You diligently work up every damn little thing, counsel him against smoking, write out his problem list and medications, remind him not to smoke, go to the sample closet (those reps left us such great lunches, how I miss ’em), come back with an otherwise very expensive bag of meds, put in patient’s hand, go over the written instructions and why each pill is important, remind him again not to smoke, and walk him to the lobby to schedule a follow up in 2 weeks. Said superstar returns having only taken the meds occasionally “when I feel bad”, or not at all, with no objective, measurable improvement in any vital sign, lab, chest x-ray, or physical finding. And he is, of course, still smoking. Thus was residency.

While the percentage of such patients might vary with geography and demographics, there will always be such in every primary care environment. And now the good ‘ol AAFP has published a way to deal with these patients through a nifty tool called the Self-Management Support (SMS) score.

20 “providers” in an ACO were interviewed, and divided into the top ten and bottom ten of who achieved the best “patient activation.” “Patient activation was defined as having the knowledge, skills, confidence and motivation to manage one’s health and health care.”

Those healers deemed to be the best performers all used the following 5 strategies: lifestyle behavior change, emphasizing patient ownership, partnering with patients, identifying small steps toward change, scheduling frequent follow-ups, and showing care and concern.

“Using psychometric testing”, researchers then used a 9-question scale to give each clinician a SMS score. Lower scores indicated less engaged providers, and higher indicated more engaged. Researchers stated that female providers had significantly higher SMS scores than the men. And I could speculate all damn day on the reasons for that disparity (and I would love to read your take!).

Researchers then applied SMS scores to patient charts to discover “significant but modest associations with their patients’ smoking cessation and weight loss (among obese patients).”

These academic pointy-heads also want to “investigate what other members of the health care team could do to support patient self-management”, given that the provider will now have even more useless crap to measure without any more time. And of course someone has to pay those other “team members.”

Do you see where all of this is heading? Providers will increasingly be herded and caged into this “quality” farce, which measurements and resultant reimbursements will be based on things like smoking cessation, BMI reduction, HgBA1c reduction, better BP control, etc. Given a link between one’s SMS score and likely patient improvements, a better SMS score – measured by, oh, I don’t know, an ABFM MOC module or a Medicare online questionnaire – will be required for those fleeting bonuses. A lower SMS score might well be used to justify penalties: “A better SMS score would have resulted in better patient compliance, and therefore better quality, ipso facto you cost Medicare/Medicaid/BCBS/Aetna/etc. more money in terms of the potential for increased hospitalizations, complications, and more collaborative co-morbidities, you damn poor excuse for a provider.”

In there ongoing mission to keep us all forever in residency, where its never the patient’s fault, the AAFP, ABFM, AMA, ABIM, et al will gleefully embrace this crap under the banner of “improving the provider-patient relationship.” When SMS becomes prevalent enough, and we all start faking it and studying for the test, it will more likely referred to as “save my shit.”

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 “Don’t Wanna Hear Any More … by Pat Conrad MD

  1. Kurt
    November 15, 2016 at 1:07 am

    Stay the F out of primary care and whatever a student needs to do
    is specialize. Nursemaid, guardian angel, secretary and health policemen
    I am not!

    Oh, I see the head of the ABFM now makes $808,000 a year. How much are you paying for this MOC crap and how much are you making working in the trenches?

  2. John Kelly, MD
    November 12, 2016 at 3:03 pm

    It is the aim of the IT sales forces to convince insurers and organizations that Big Data is vital to improvement and safety. Big Data performed so accurately in the recent election, one cannot deny it is vital. Anything that can be measured? Must be measured. That it is all a hypothetical construct and not likely to correctly model reality is ignored in order to give the organization which hired you the result of research it desires. As any consultant knows, you tell the payer what they want to hear or will not be consulted again. Meanwhile, no evaluation in business is meant to increase the amount paid to the front line provider. It is meant to demonstrate you do not deserve a raise in pay without appearing abusive or biased. This is science, damnit! How dare you suggest that the forgone conclusion is that you must be found wanting or else the employer must pay you more and further your career! But we must save money on you so that the manager can reach “certain financial goals,” and get their massive bonus contingent on those goals being met. They are not paid for being nice. The highest salaries are paid to folk who can live with being required to spout the party line with conviction, and act the bastard with their flock. Some of the savings will buy their second house in the Poconos. Nothing too ostentatious, mind you, unless they are CEO. And investors are the new customer of health, not the patients, silly!

  3. Thomas D Guastavino
    November 5, 2016 at 9:34 am

    Where is the 9 question scale.? I would love to see it.

  4. Steve O'
    November 5, 2016 at 7:01 am

    It’s an extension of the Retail Universe in America – the Customer Sets The Rules. Our new gods are the entities – corporations, healthcare monoliths like Mayo, Inc., and such. They are the source of all goodness, like the ancient rain god and sun god and such of tribal days.
    It is up to the bumbling stocking clerk / MD to provide the customer with the right shopping basket of goodies from the gods. By definition, if the customer is not satisfied, the clerk/MD has failed. I have had numerous patients “go to my manager” to complain about substandard service. Sadly, this attitude is being reinforced in spades. And it’s the same one that led to the “shocking opiate epidemic,” which is merely a case of the Customer Sets The Rules.
    I endorse delisting of all non-controlled medications, provide them over the counter – go ahead! If it’s just a case of picking what you want from the store, go right on in!
    It’s the same “experts” that have kept the quack medicine industry thriving. Patients come in to “ask your doctor” about high-priced nostrums from large corporations traded on the Stock Exchange – corporations with friendly organic natural names. I rarely offer advice, because patients seem more interested in ‘defeating the healthcare establishment’ in some pointless argument about grapefruit capsules, than in asking genuine questions. You want to pay $5.00 a day for grapefruit juice capsules? Go right ahead.
    The Retail Model has never worked for healthcare – it’s been tried for many decades. Go ahead, force it through, like other tyrants have forced their nonsense upon their citizen-victims! If it fails once again, it must be due to inadequate support and education of the line staff. Beat them!
    And as the Retail Model turns out to be as empty a god as the Proletarian Paradise of Lenin – punish the naysayers!
    That model of societal control’s as old as the written word. No bad idea’s too horrible to die. Bring it on.

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