You still matter...

[Guest guest]

Hello all:

I wanted to share a recent experience to encourage you to keep slugging

along...it can be worth it.

59 yo. Vietnam vet joined my practice 2 months ago. MI 5 years ago with two

stents placed. Smoking a pack per day, BP 180/120, LDL 160 and taking zero meds

(i.e. not even aspirin for the stents). Primary reason for not taking the meds

was that he'd been placed on a number of non-generic meds Toprol XL, Plavix,

Crestor, a non-generic ACE etc. His prescription bills would have been over

$200 per month in copays alone.

The notes I received from his previous provider were typical template nonsense:

a bunch of check boxes not amended from visit to visit, a " smoking cessation "

recommendation checked in every plan section, all of the appropriate diagnostic

ICD codes for CAD, HTN, hypercholesterolemia etc. automatically generated for

every visit. All the P4P crap appropriately tagged and not addressed. There

are probably 15 seemingly identical visits billed to Blue Cross Blue Shield with

absolutely no evidence that anything was ever done for the conditions. Most of

these were probably 99214 visits so the doc got paid somewhere North of $120 x

15 for apparently doing nothing but visiting with a patient for 8 minutes or so

per visit and submitting a templated and barely amended chart note. Of course

his abnormal and completely unchanging cholesterol was checked every 2 months or

so along with non-evidence based comprehensive metabolic profiles and other

random labs. All paid for by over-priced and wasteful insurance. Ridiculous.

Over the first month we got him on aspirin, generic metoprolol, pravachol, and

lisinopril/HCTZ. Total med cost $16 per month with or without insurance. His

pressure normalized and he quit smoking. Unfortunately, he developed atypical

chest pain two weeks ago and his stress echo was positive.

Here's where a relationship like those the docs on this listserve have with

their patients can matter. I have no way of knowing where or even if fault lies

on either person, but the patient and the cardiologist who gave the stress test

news did't get along. The patient walked out of the clinic with chest pain to

catch a flight to visit a relative. Fortunately, he called me before he left,

and we were able to talk through the risks of traveling and make it his decision

on what to do. He stayed in town, developed persistent pain that night,

presented to the ER and was admitted for catheterization.

I went to the hospital where I don't have privileges to monitor his admission

process. The docs there had no way of accessing his med list, no way of

accessing his previous cardiac records, etc. They couldn't even locate the

stress echo results that had been done 24 hours earlier in the same hospital

system. It was typical admission chaos when I walked in. Doctors and nurses

asking a patient lying on a gurney the details of a complex medical history

while adjusting his nitro drip. Within a few minutes I printed his complete

medical record off the internet (thanks PracticeFusion), helped the patient

understand what was going to happen, and gave the docs/nurses the appropriate

contact info for his family and myself. I wish I had a picture of the cardiac

fellow's face when he saw me access a patient record over the internet. This

guy probably banks on-line, socializes via FaceBook and Googles restaurants on

his iphone, but in the realm of healthcare he was staring at me like I was an

absolute magician for using their computer to get medical records from an

outside server.

The interventional cardiologist later told him that in 20 years of practice he

had never seen a non-admitting physician come to the hospital to facilitate

care. I didn't think it was a big deal at all - took me about 45 minutes on a

Saturday morning to be sure my patient was getting excellent, well-coordinated

care. How is it possible that in the " Best Health Care System in the World " as

the AMA likes to describe it a practicing cardiologist in a major city had

" Never " seen a primary care doctor come to the hospital when one of his or her

patients was admitted? During my training, it was an absolute expectation that

we would make " social rounds " (i.e. care coordination) rounds on our primary

patients if they were in the hospital on another service. Where did that

expectation go?

The patient ended up getting a minimally invasive single vessel bypass a week

ago and is already home. I made a house call on him yesterday and he's doing

very well. Of course, the hospital discharge made him an appointment with the

cardiologist he didn't like in the first place. We'll be changing that

appointment today to make sure we continue to provide relationship-based care.

When you get tired of beating your head against the wall of this mess we call

U.S. healthcare, please remember that what you do matters. Our patients still

need us.

Cheers,

Chad Costley

Ponce Preventive Care

402 W. Ponce de Leon Ave.

Decatur, GA 30030

www.poncepreventive.com