Soundings Soundings

Perils of primary care

BMJ 1998; 316 doi: (Published 14 February 1998) Cite this as: BMJ 1998;316:635
  1. George Dunea, attending physician
  1. Cook County Hospital, Chicago, USA

    By all accounts Dr Fox should be happy in his profession. He graduated from a prestigious university and was courted by several academic departments, but thought that he would like treating people better. He accordingly opted for primary care, a line of work currently much favoured by managed care organisations, government bureaucrats, and healthcare philosophers.

    But Dr Fox is not happy. Too much has changed and too many people are telling him what to do. Government agencies now address him as “Dear provider” and even tell him how to write his notes: for a problem focused history his “documentation” must show the “patient's positive and pertinent negatives” for the system affected; for a detailed history he will be paid more but must show that at least 10 organ systems have been reviewed. Failure to comply could expose him to charges of “fraud and abuse.” Then there is the constant threat of being sued by a disgruntled patient, worse now since a higher court struck down the malpractice reform law setting limits on awards for “pain and sufferings.”

    His patients, often poor and living in the inner city, some taking drugs and constantly asking for pain pills, have become more demanding and also harder to communicate with or more suspicious. If he suggests a blood test they might argue that the previous doctor never ordered any. If he orders none they say that the previous doctor always did. A recommendation for surgery may result in a look that means “he really does not know what he is doing.” If he favours a conservative approach the patient wants a second opinion. If he withholds antibiotics he gets a strange look; if he refuses to prescribe vitamins the patient thinks he is totally out of his mind. He then consults another doctor but phones in a panic at 3 am to ask if he should go through with the operation the new doctor has recommended.

    In his office Dr Fox is swamped with paperwork: bills; letters of justification for services rendered; orders for visiting nurses, food supplements, wheelchairs, commodes, and walking canes. He is being named in a malpractice suit by the estate of a patient he has never seen. He also is forever filling out application forms for renewing licences or for reappointment to various institutions, and each time is asked if he has had medical or psychiatric or drug problems, or felony or criminal charges. All day the phones are ringing as managed care clerks request more documentation, more signatures—“How do you spell bromoscopy, doctor?” “Can that parathyroidectomy be done as an outpatient procedure?” About once a week the medical records librarian calls because she needs an “attestation” of his diagnosis. “And don't forget you have three incomplete records for dictation, doctor.”

    The other day Dr Fox ran into Mr Grubb, his accountant, whose daughter had been accepted at a prestigious medical school. She loves people and wants to do primary care. The annual tuition fee, with board and lodging, comes to over $40 000 (£25 000), says Mr Grubb, who has already seen her through four years of college. He has just read that “one of the nation's leading managed care companies has struck a groundbreaking deal with a prominent hospital that assigns primary care status, usually reserved to doctors, to a group of highly trained nurses who will be paid at doctor rates.” He interprets this as having to spend $200 000 so that this daughter will become a nurse, and has asked Dr Fox for advice what to do.

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