October 19, 2012
Writing about medical practices is fun, but far from easy. Presently, medical practice seems in a state of flux. There has always been some jealousy among doctors, but not like we are seeing today. Many medical organizations are feeling that they are superior to others and applying pressures to state legislatures to limit or prevent new ideas from gaining a solid foothold in the medical community.
It is also surprising that some states have provided opportunities for different ideas to flourish, and other states use various means to try to restrict or limit new ideas. Several states in the early days of concierge medicine worked hard to prevent it from getting started. Two states invoked insurance fraud and claimed the practices would avoid state policies of medicine without insurance and they succeeded for a couple of years until challenged in court.
Concierge medicine is growing and becoming a larger force yearly. When two or more doctors join together in a practice, they can often afford a nurse acting in several capacities. When I wrote this blog, I was not sure I would ever be involved with one. However, I am a volunteer peer mentor for type 2 diabetes patients with a concierge practice and know of four other peer mentors working with another practice. I have also added another physician practice that I now serve as a peer mentor for type 2 diabetes patients.
Telemedicine is another growing area that some practices are working hard to expand and again many state legislatures are being lobbied heavily to limit the scope of practice allowed. I have said this before, but it is worth repeating, the word reciprocity is not in the vocabulary of the medical associations. Any patient that has a regular doctor and travels to another state should have the right to confer with their doctor back home over the telephone, Internet, or other electronic media without worry about some doctor in that state complaining that he/she was denied access to treating the patient. Yet this is where it seems headed.
Yet telemedicine is growing. Even some private practices are utilizing telemedicine and using physician assistants, nurse practitioners, and nurses in areas low in doctors to do the examinations and then either passing this information onto their primary care doctors, or when none are available, writing the prescriptions electronically. Most are in states admittedly allowing this and encouraging this. Some universities are also following this practice and have centers organized to do this – Kansas and Tennessee are two such states.
Although individual practices are becoming harder to find, there are still a few in existence, but for how much longer is the question. Hospitals are slowly putting the stranglehold on private practices and becoming increasingly monopolistic in their operations. They either hire the doctors out of practices or buy out the practice and establish a clinic. Many are concerned about the ethics involved as in some areas of the country hospitals are establishing clinics and moving hospitals to new areas, thus abandoning the inner city areas where they have been. Under the current Affordable Care Act, will the physicians be able to survive financially? Only time will expose the answer.
A simplistic, but accurate description of the various forms of medical practices that a physician can opt for are:
1. Academician: He/she can become an academician and start teaching medical students.
2. Single specialty doctor: The doctor may decide to specialize in a certain field and then carry on practice in that field.
3. Multi-specialty: This happens when within the same company, several medical specialties are employed who are in charge of different fields.
4. Solo: The medical practice may decide to set up his/her own clinic, which is a common practice in dentists.
5. Industry: The physician may decide to work for the research based activities taking place in the industry and work for pharmacological companies, research labs, and equipment manufacturers.
6. Hospitalist: Employed and works for a hospital.
Some doctors may fit within two or more of the practices listed above or may have two or more specialties that he/she is qualified to practice.
I find the following statistics very interesting and will quote, “According to the Bureau of Labor statistics, there were nearly 700,000 doctors in the United States in 2008. There are many ways to break down the types of doctors who practice medicine in the country. Increasingly, more and more medical doctors are becoming specialists, and the number of specialists has grown rapidly in the last four decades. According to the American Board of Medical Specialties, there are now 24 different categories of specialists that branch off into a total of 147 and different doctors who can be board certified in their specialty. But to handle the doctors in the country in a more manageable number, there are 6 different medical doctors who see patients somewhere in the country every day.
1. Doctor of Medicine. This is an allopathic doctor, the one who earns an MD degree from medical school and represents about 70 percent of all medical school graduates. Many study specialties that concentrate on different areas of the body, such as cardiology, gastroenterology and pulmonology.
2. Doctor of Osteopathy. This is the second type of medical doctor who attends a medical school and becomes an osteopathic doctor. These doctors attend an osteopathic medical school, which is outnumbered by allopathic medical schools by about 12 to 1. There is virtually no difference any more in the training between the two disciplines, other than a technique called Osteopathic Manipulative Medicine. This involves manipulation of the joints and body parts to help in the diagnosis of injury or disease. Many medical doctors with a D.O. degree go on to general practices, in areas like family medicine.
3. Doctor of Dental Medicine. Most people are familiar with dentists, who attend 4 years of dental medical school and handle the medical care of the teeth and gums and have a DMD or in their title. There also are doctors of dental surgery who specialize in dental surgery and have a DDS in their title. Many dentists specialize further into areas such as endodontics, orthodontics and pediatric dentistry. This requires additional schooling.
4. Doctor of Chiropractic. These medical doctors go to 4 years of chiropractic medical college and specialize in joint pain anywhere in the body. They have a DCM in their title. Many chiropractic treatments involve the manipulation of the spine and chiropractic doctors work on the principle that misalignments trickle down to affect the nervous system.
5. Doctor of Optometry. This medical doctor attends four years of optometric medical college and has an OD in his or her title. They are the primary doctors for the diagnosis and treatment of eye diseases and conditions.
6. Doctor of Podiatric Medicine. This medical doctor undergoes 4 years of podiatric medical college and then a residency program of 2 to 4 years to be able to diagnose and treat diseases and injuries to the lower leg, including the foot and ankle. In 2008, there were 8 accredited podiatric medical colleges in the country, awarding a DPM to graduates.”
October 17, 2012
Having written this blog about assumptions patients should not make, I need to revisit the topic to add a few more assumptions not to make and a few things that it is better to avoid. Some of these ideas have appeared in other publications.
Never assume you are receiving continuity of care.
This is more difficult especially when you have multiple chronic diseases or illnesses where you need to see a variety of specialists. This is a problem area that requires vigilance on the part of the patient and/or family members. This should be something that you consult heavily with your pharmacist to prevent conflicts of medications. Some doctors are great in looking at your records before issuing a prescription, but others can upset the best plans and it only takes one to mess it up and put you in grave danger.
Never insist on self-diagnosis or self-treatment.
While we know our bodies better than anyone, self-diagnosis by the patient can be deadly and is not recommended. It is better to write down all the symptoms that you notice and hand them to the doctor. A diary of symptoms can be a lifesaver when doctors put you off and make unwarranted assumptions. Sometimes these assumptions can be correct, but often they may not be completely correct and the partial treatments may mask the real problems. Let the doctor ask some questions and start eliminating possible problems. The doctor can then order any tests necessary to confirm or rule out illnesses.
Never assume your doctor is always right.
This is a problem for many patients. We do not want to believe that our doctor could be wrong. If you are one of these patients like me, just spend a few months watching the “Discovery - Fit and Health” channel and the “Mystery Diagnosis” program. Yes, most doctors haven't a clue of what is going on as we are talking about rare medical conditions, but the way these doctors handle these cases almost makes you want to reach into the TV and choke the doctor. Patients are often accused of wanting attention or are letting their imaginations get the better of them. While these are the extreme, I hear stories like this from people around me when they are angry with their doctor for ignoring them or not taking them seriously.
Do not assume that the doctor has preformed all the necessary tests.
As a patient, this may be impossible to know whether the necessary tests have been done. This is one time you, as the patient, may need to ask some very direct questions. Never mind what the doctor thinks, it is your health and these questions may save your life. How do you know what to ask? First, you need to ask what tests have been done and what they determined, if anything. Second, ask what other tests could be run. If the doctor starts dodging the questions, you know that there are more tests that may be of value, but this doctor does not know enough about them to be comfortable using them. This is when you know that you may need to seek another doctor.
Do not assume that the doctor is giving you the correct medication or dosage.
Many doctors will give you the best medication after evaluating you and your condition. They will ask questions and probably use some tests to make this determination. If the medication is new to you, make sure you get the correct spelling and then look it up in the Internet to determine if this is an established medication or whether you are being used as a guinea pig for a new medication. Some new medications may be excellent for you, but always be alert for unusual side effects and do not be afraid to talk to your doctor about taking you off the new medication and to an established medication. Read this by Trisha Torrey as she has some good discussion points for you to ask the doctor. It may be in your best health interest not to be a guinea pig for a new medication.
The next question is whether you are receiving the correct dosage. Most doctors will start with a lesser dosage and increase the dose if needed. Be cautious if you are started on the highest dosage and the doctor does not want to discuss his reasons with you or discuss alternative medications. I was considering changing doctors, but during the first appointment, the new doctor insisted that all my medications would need to be changed. When he ignored that I received many medications through the Veterans Administration and stated that I would be coming off insulin and go on oral medications for diabetes, I knew this was not a doctor I could work with. When he stated that my A1c of 6.1 was too low and that I should be between 6.5 to 7.5, I admit I went a little overboard when I asked if he had gotten his medical degree as a prize in a cracker jack box. I said that if he objected to one hypoglycemic reading of 63 mg/dl, then he had no understanding of diabetes and I would keep my endocrinologist and other doctors. That was the end of my appointment, and I suspect by mutual agreement.
Do not assume that your doctor will give you a referral if one is needed.
This can be a delicate issue. Some doctors are willing to refer you to a specialist. Other doctors are so puffed up with their own importance that they feel that they are the only source of medical care you need. Still others will just tell you to find another doctor if you ask for a referral. The last two types are doctors you need to avoid if at all possible. Be cautious if you live a long distance from your primary care doctor and it is even farther to the specialist or another primary care doctor. This article is a good review of possibly how to approach the topic, but be careful if you suspect you have a doctor mentioned above. Some doctors may seem hard to approach; however, done properly, you may get the referral needed. If you know that the referral is necessary, then you may need to request it and replace doctors if necessary. One alternative I have found that works is talking to my medical insurance company and explaining the situation. I was sent a list of acceptable primary care doctors and even a few specialists that I could see without a referral. I may have been fortunate with the person I talked to, but everything worked out for the best when I needed it.
I will continue to look for additional ideas for another blog on this topic.
October 15, 2012
This blog got its start quite by accident and not one putting anyone or me in the hospital this time. In discussing patient centered care with David Mendosa, I rather exploded about hospital care. David, in his calm and collected way asked if I had read any of Dr. Bernstein and I had to admit I have not. David said he would provide me with a link to his blog about a letter to get signed when entering the hospital. After reading this, I may have to get up the courage to read Dr. Bernstein’s book. Unless there is something that I am researching, I seldom take time to read a book for the pleasure of reading. Since I do a lot of research about type 2 diabetes, I am not reading much published on the type 1 side of the spectrum. No one to blame but myself.
Back to hospitals and why they are on my list of “avoid if at all possible”. It is understandable that hospitals and doctors have an aversion to lawsuits and this drives many of the healthcare decisions they make. People with diabetes is one group that pays dearly for this aversion. Hypoglycemia is the fear that draws attention and dictates much of the policy for care when person with diabetes is hospitalized. The term that is used for most healthcare is defensive medicine. For patients with diabetes, this means allowing blood glucose levels to be maintained at levels that slow healing and can lead to increasing the risk for complications to develop. Thus the hospitals are caught in conundrum for care. The chance of hypoglycemia depends on the medication and if the patient is on insulin or sulfonylureas the hospitals use a level of blood glucose that will generally avoid hypoglycemia and is in the hyperglycemia range. Most, but not all, hospitals want the lower limit of blood glucose to be 180 mg/dl (10.0 mmol/l) or slightly higher. The longer your blood glucose levels remain at this level, the more you are at risk for complications. Because of the smaller likelihood of you developing complications while under hospital care, this is the goal of most hospitals.
Another area that patients with diabetes need to be concerned about is diet while in the hospital. Forget that you have diabetes and please do yourself a favor and do not request the diabetic menu. Because the dietitians for the hospital follow the American Diabetes Association in diet planning, the menu is high in carbohydrates and low in fat. This creates all sorts of problems for patients with diabetes. Those on oral medications will have extra problems because of lack of movement or any type of exercise. Those on insulin (which most that are hospitalized are converted to at least while hospitalized) will run blood glucose levels of 180 mg/dl or higher. The one procedure I will commend hospitals for is giving rapid or short acting insulin after meals so that if the patient does not or is not able to eat a meal, hypoglycemia is averted by not giving an insulin shot.
If you are scheduled for an operation or admitted to the hospital in an emergency situation, please be aware of the above problems and consider the letter in David Mendosa's blog. Even if it is an emergency admittance, if a family member or a close friend can advocate for you and have the letter presented, this may help. A reminder, you may have to stand your ground as most hospitals will refuse to allow you, the patient, to treat yourself for diabetes because they do not want the liability of something going wrong. I dislike saying this, but you are are higher risk of surgery complications and even death if the hospital keeps you on their diabetes regimen. Studies have shown this to be true and as a patient you need to be aware that this can happen.
I have a friend that lost about $300 because a nurse confiscated his insulin and testing supplies and destroyed them. Horror stories like this abound and this is because the hospital medical staff lack the training in diabetes care and some just don't care. Others do care and if you are mentally capable of managing your diabetes, they will allow this to happen even against hospital policy. So do consider the letter in David's blog and if needed adapt it to fit your needs. You will benefit your health by managing your diabetes versus letting the hospital manage it.