What’s Wrong With This Picture?
There are a lot of problems in our healthcare system and many are not easily solved. That is probably why this blog has been going daily for 16 years. When I read things I do it with a critical eye because many issues go unnoticed by others. Take for instance this article written by a Dr. Pelzman in MedPage Today. Right off the bat there is lunacy that shouts out at me. It is in the section Building the Patient-Centered Medical Home and the title is Right-Sizing the Medical Office – Good patient care means having enough people to answer their calls and greet them in the office. Think about this for a second. The Patient-Centered Medical Home is such a made-up term and the whole discussion of the article is about having someone answer the phone? I repeat, an article is being written because they can’t find someone to answer the phone.
Now for some more fun. By paragraph three he blurts out his Press Ganey scores and by paragraph four he talks about having “gone to our administrators and said look at this, is there something we can do about this, somehow the math of hiring more people to answer the phones just hasn’t worked out”.
Listen I am not trying to make fun of this doctor. I don’t know him. But I also didn’t write this. He did and he put this out there. Look at some of this stuff:
- What business would put up with the fact that 30% of its customers are unable to reach them when they want to do business with them?
- Despite years of complaints and multiple consultants telling us that we are woefully under-staffed with our telephone operators, the finance people have always said that according to the number of patients we see and the number of providers in practice, we should have plenty of people to answer the phones.
- But the bottom line is that if we are going to innovate, improve, and reinvigorate the world of primary care, we’re going to need more support.
- We going to need more space, more people to help manage population health, to address the specific needs of a group of patients who may be underserved, as well as the individual patient who is seeing us here today.
- With all the bells and whistles of a fancy new electronic health record, and a system that gets our phone answered every time and increases the efficiency of our scheduling, we run the very real risk of only creating downstream work for people who are already overburdened by what they have to do today.
- So no matter what, we need to turn things around, to do today’s work today, to find ways to overcome barriers instead of putting more of them up in front of our patients as we try to move them towards a better state of health.
- If we can’t do this, if we can’t totally change the way we practice, the way we’ve built this clunky healthcare system into a monstrosity that just doesn’t work, then we’ve failed our patients, we’ve failed ourselves, and we’ve failed the future generation of healthcare providers who are coming up the line, hoping to be inspired to do what we do today.
Dr. Pelzman, the answers are there. You wrote them but just can’t see them. Let’s list them:
- Press Ganey Scores
- Going to our administrators
- Ask the finance people
- Fancy new electronic health record
- Downstream work
Get rid of them! Everything you “complain” about can be removed. DPC has proven that. Listen, not everyone is ready to leave the system. I get that. But if you think you can change the system from the inside then you are delusional. The Press Ganey scores, the administrators, the finance people, the EHRs and the downstream work aren’t going anywhere. In fact, they are getting worse.
Oh, and we always have a human answer the phone in DPC. Every time.
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“somehow the math of hiring more people to answer the phones just hasn’t worked out”
Duh! Hello? It’s because you can’t afford to hire more people and add extra lines because PAYMENT FOR DOCTORS IS SO TERRIBLE!!!! Under Medicare and Insurance, if you add more staff, your doctors won’t get paid at all!!
You get what you pay for. If you underpay doctors, they won’t have the staff to talk to you. It’s basic math. These guys in their ivory towers never get it!
I’ve followed Dr. Perlman’s blog for over 10 years. It’s been so sad to see him fight the windmills and bureaucratic fog over all those years and still have all of those problems that never seem to get resolved. He is a testament to the feckless struggles of current day physicians just trying to do their jobs.
I’m retired now, but if I were just starting out in practice, Dr. Perlman’s blogs would be enough to convince me to try DPC. I guess that at least he has a never ending supply of fodder for his blogs!
To understand problems, one needs to look at the foundations. The difference between DPC and the rest of medicine is a moral difference. Do human beings matter, or not? As much as “real medicine” regurgitates the platitudes of humanism, it is fundamentally anti-human. Until one accepts that, one cannot understand the shocking nature of most of modern American medicine.
Arthur Koestler, Darkness at Noon
The rules of arithmetic of public health and large veterinary medicine, are what drives modern American medicine. There are obvious and horrible consequences, but we decide not to look at them as a society.
Looking at the medical pyramid at the next layer above, there is a palpable sense of universal contempt. The patients sense it, but the doctors and nurses and personnel perceive this contempt.
Dr. Pelzman shares the obvious – Good patient care means having enough people to answer their calls and greet them in the office. One might as well say that good patient care means not leaving deadly hazards in the waiting room, for its unspeakable obviousness. The fact that he has the urge to state this shows that something is very very wrong in modern American medicine.
To inflict control upon the contemptible, one resorts to savage measures, and this has been tried in many systems, all of which ultimately fail. Whether Stalinism, scientific management or resolution of “the Indian Problem” in the settlement of the US West, contempt requires the crushing of the opposition.
These methods do not respond to requests for improvement to do the job better. All of the resources are there, by definition. The only need is to crush the lazy scum so that they do their job.
This is a nearly universal business model in the United States. It is so ubiquitous, it is almost impossible to see. It thrives on complaints and failure, not success and improvement. The modern American business model states, in not so many words, that if the clinic personnel, especially the doctors, were not so lazy and selfish, then the clinics would be just fine.
Quality measures demand the identification of some sort of failure, otherwise they are unmasked for what they are, instruments of punishment. Similarly, like a poorly-run prison, the system thrives on the inmates snitching on each other. Whether lying or telling the truth, snitches identify a target. Destroying ten innocent targets to destroy one guilty one were good numbers for Stalin; they also work for Press Gainey.
Those few layers at the very base of the pyramid show how this system has been re-invented in medicine, what its goals are, and that it fails – and how it fails – every time that it is implemented.
The system makes sense. The question of why we have implemented it, does not.
Dr. Pelzman’s blog is worth reading just so you can learn what not to do as a practicing physician. It’s probably the worst run practice in the world, but they’re being subsidized by some big grant to push on with the PCMH crap. He spends his time in meetings out the wazoo, but they can’t answer the pones.
Dr. Doug,
If I could do it all over again I’d do DPC! Kudos to you and others for your advocacy! I recommend it to students I teach at Wake Forest considering FM, but so many have such debt they have to start working for “The Man” before they can consider going on their own. I’m still a little confused…Why typically cut off your patient “panel” at 600? Anyway, I finally have a renter for my empty medical building after the hospital stiffed me and pulled out…a pain management guy who’s getting 30 new referrals a week and needs more space! While he moves in, I’m going to the Virginia Film Festival in C’ville!!
DPC doc typically cutoff in the neighborhood of 600 because with 1000s of administrators and beaurocratic BS in the way, we can sustain a practice, pay the phycisian a decent wage, and take EXCELLENT care of patients at that patient load.
And the amount of debt a resident has should NOT stop them from DPC. I had $450K in school debt when I jumped ship to DPC, as have many others. It can be done.