Wow. My husband has been dealing with these healthcare changes for some time. He is on his third G P in three years. It is very upsetting after having the same doctor for 30 years. Especially if you have multiple medical issues.
Thank you so much for this. I have never had a u t I. But my best friend and the gal across the street constantly have them. I think I'm very lucky. I've also been celibate for the last 20 years, and that might help, too. I'm 81.
Mary, this is the first time I've heard the word "hospitalists" . . . and I feel like you've offered a **huge** amount of insight into how generalists and specialists co-operate (and not co-operate) with patients . . . about how patient privacy has changed / prevented coordination of care . . . which all trickles down into a much different patient experience that was had for those of us who were around 40 years ago. I appreciate the gentle plain spoken way you approach these difficult conversations . . .
Thank you, Neil! I've only been in practice 24 years and the change has been monumental. It's not the job I signed for up for in substantial ways. Efficiency and complexity and true quality* have been gained, but not without a loss, too.
*There is no question that people live through things now that would have killed them 20 years ago, for example.
Retired MD here… very thorough and well presented. One other thing for your patient to be aware of… the ever-present threat of her specialist being sued into the next century if he/she strays a bit outside their area of expertise. A near slam-dunk for the plaintiff’s bar. These vultures have ruined the physician-patient relationship in so many ways.
When I first started my career there was a family doctor (GP) that was truly a FAMILY doctor. Generally a he (but in my case a she) that cared for the whole family. Most practices were a one or two doctor practice. They knew you from a young age on. As they aged out a "young whippersnapper" was brought into the practice and were brought up speed quickly.
Then the advent of increased specializations started fracture this structure.
Then insurance companies started sticking their noses in, becoming a gatekeeper that interfered with doctor/patient relationships and TRUST.
Then the hospitalist was whelped. WTH, just when the patient was most vulnerable, they lost there known doctor and they had to deal with a stranger. This sucks big time!
And I see the necessity of hospitalists. Hosspital medicine and office medicine are both big enough fields that it is hard to do either well excellently and I don't think I could do both excellently, but I very much miss the interactions and collegiality and continuity that happened when I went to the hospital in the olden days.
Yes, I've heard all the reasons for having hospitalists, and they are valid.
But, they do not know the patient and their history--particularly, if they have comorbidities. You combine that with the arrogance of some "doctor's know best" types, it gravely impacts trust.
The doc whose practice I largely took over had practiced in one office for 35 years. He was delivering the babies of people that he himself had delivered, which is such a beautiful ideal. Our pediatrician, before she retired, was also taking care of the second generation of her patients.
To see a patient's and a community's life intimately from multiple angles is one of the greatest gifts of being a doctor, in my opinion.
I enjoy your posts so much. I’m a retired ( but still licensed) primary care naturopathic physician and still appreciate the clinical pearls you offer. I miss the days of picking up the phone to consult with a trusted specialist or giving background on a patient when I make a referral. The medical system in this country is broken in so many ways but my own experience with Medicare has given me some hope that good and compassionate care still exists.
Thank you. Thats actually why I used the word provider instead of dr or physician. As long as they are able to deliver concise instructions and dont have to go running back to the doctor to answer questions as an RN I am more than comfortable talking to anotber RN or NP.
And this is why having a small group of doctors and a small group of nurses provides better (if less efficent) care. Many of my nurses know exactly what I'm going to say to whom and under what circumstances bc they have worked with me long enough to have figured me out. (If only they would share that info with me so that I would have myself figured out!)
Less efficient? That surprises me. How please, if you have the time. Yes, that is a quality nursing for sure. I feel sometimeslike I spend equal time fighting for a positive vies of medicine and criticizing the things about it that make me crazy. I finally withdrew from the vaccine argument. Antivaxers are not interested in being educated, at least vua social media.
I never worked for a doctor during my RN career but I would have liked to. My experience of nursing as a child was more similar to public health nursing, although Central African missionary nursing really has no equivalent in this country. My experience with those nurses was significant and impactful.
I think less efficient bc if you have 16 nurses working a task list, you'll have a shorter list than if you have 2 teams of 8 nurses. Today, P team's list happens to have only 40% of the overall calls on it, and R's has 60% of the calls so the P nurses are not being "fully utilized." They're done earlier than the R nurses. They could be calling the R list's patients, but are instead eating bonbons and gossipping (so goes the story).
African missionary nursing sounds like a good Substack!
I've never been a Kaiser patient or doc. There are many things to like about a big, all-inclusive system, as well as many things to dislike. Ihave a number of friends hwo live in the SF Bay area and many of them like it, but not all. I have not figured out the pattern, Ken. I would not like meeting a new doc every time or not seeing my own patients.
I spent a year on Kaiser (with Kaiser?) here in Atlanta when Blue Cross left metro Atlanta and my husband, business partner and his wife all went on Medicare. Having grown up as a “Navy Junior”, I found that the Kaiser system echoed some of the unpleasant aspects of Navy healthcare. I was so happy to return to a private healthcare provider about 13 years ago. Facts have faded in my memory, but the feeling remains!
It’s very frustrating that visits are only 20 minutes long and doctors are typing into their EMRs at the same time I’m asking questions. I’ve also had three female PCPs who left their practices, one to move to a boutique practice. Yet I’m sympathetic to doctors’ plights these days where medicine seems like an assembly line, and many doctors burning out, some taking their lives. The system is broken.
The system is very broken, Barbara. I am very lucky that I can type fairly quickly without looking so I can type while maintaining eye contact. I hate to type while I'm in the room with the patient, but if I don't, I end up with even more work to take home than the WAY too much I already have.
We have not. Our health insurance is so terrible and expensive that ain't no way my employer would pay for one. There are many priorities higher than improving my life (some justifiably so, some maybe not, lol).
We've experimented briefly w AI, but it was not reliable enough to use. The very worst, catastrophic outcome was that it failed to listen, despite appearing to, and I didn't take notes bc I didn't think I needed to and then I had to do ALL the work well after the fact. Could it have been operator error? Of course; isn't it always? I could not tolerate that failure and felt it was just better to keep doing things the way I was.
Back in the days before managed care, you just made an appointment and went to the doctor. You didn’t wait months for an appointment, and doctors didn’t charge an arm and a leg. Some made house calls. The insurance industry did away with that, and healthcare is full of denied treatment with poorer outcomes in some cases. Doctors didn’t have a lot of paperwork. This is the one of the only things I would want to go back to the ‘50s and ‘60s for (and music).
I agree, Barbara, although I am lucky enough to have found an employer that will let me do some home visits under some circumstances. The paperwork, however, no one seems to have a solution for.
Wow. My husband has been dealing with these healthcare changes for some time. He is on his third G P in three years. It is very upsetting after having the same doctor for 30 years. Especially if you have multiple medical issues.
Your article was very helpful.
Thank you so much for this. I have never had a u t I. But my best friend and the gal across the street constantly have them. I think I'm very lucky. I've also been celibate for the last 20 years, and that might help, too. I'm 81.
This is an extremely helpful glimpse into the background of medical care in our time.
Thank you, Kathleen! There are a lot of thing that we medical folks take for granted that are actually kinda crazy !
What did her culture grow out with the UTI?
Great question, MaryV.
You’ll have to wait for me to write about her again to find out!
If you write a prescription and don’t talk to the patient, 99214 which in Doctor talk means you get paid the same as talking for 20 minutes.
Mary, this is the first time I've heard the word "hospitalists" . . . and I feel like you've offered a **huge** amount of insight into how generalists and specialists co-operate (and not co-operate) with patients . . . about how patient privacy has changed / prevented coordination of care . . . which all trickles down into a much different patient experience that was had for those of us who were around 40 years ago. I appreciate the gentle plain spoken way you approach these difficult conversations . . .
Thank you, Neil! I've only been in practice 24 years and the change has been monumental. It's not the job I signed for up for in substantial ways. Efficiency and complexity and true quality* have been gained, but not without a loss, too.
*There is no question that people live through things now that would have killed them 20 years ago, for example.
Retired MD here… very thorough and well presented. One other thing for your patient to be aware of… the ever-present threat of her specialist being sued into the next century if he/she strays a bit outside their area of expertise. A near slam-dunk for the plaintiff’s bar. These vultures have ruined the physician-patient relationship in so many ways.
If only we all had doctors like you...
When I first started my career there was a family doctor (GP) that was truly a FAMILY doctor. Generally a he (but in my case a she) that cared for the whole family. Most practices were a one or two doctor practice. They knew you from a young age on. As they aged out a "young whippersnapper" was brought into the practice and were brought up speed quickly.
Then the advent of increased specializations started fracture this structure.
Then insurance companies started sticking their noses in, becoming a gatekeeper that interfered with doctor/patient relationships and TRUST.
Then the hospitalist was whelped. WTH, just when the patient was most vulnerable, they lost there known doctor and they had to deal with a stranger. This sucks big time!
I am not a fan of the hospitalist...
And I see the necessity of hospitalists. Hosspital medicine and office medicine are both big enough fields that it is hard to do either well excellently and I don't think I could do both excellently, but I very much miss the interactions and collegiality and continuity that happened when I went to the hospital in the olden days.
Yes, I've heard all the reasons for having hospitalists, and they are valid.
But, they do not know the patient and their history--particularly, if they have comorbidities. You combine that with the arrogance of some "doctor's know best" types, it gravely impacts trust.
For the patient there is something lost.
The doc whose practice I largely took over had practiced in one office for 35 years. He was delivering the babies of people that he himself had delivered, which is such a beautiful ideal. Our pediatrician, before she retired, was also taking care of the second generation of her patients.
To see a patient's and a community's life intimately from multiple angles is one of the greatest gifts of being a doctor, in my opinion.
I enjoy your posts so much. I’m a retired ( but still licensed) primary care naturopathic physician and still appreciate the clinical pearls you offer. I miss the days of picking up the phone to consult with a trusted specialist or giving background on a patient when I make a referral. The medical system in this country is broken in so many ways but my own experience with Medicare has given me some hope that good and compassionate care still exists.
Thank you, Pam. I'm glad you are able to find a good corner of the health care system to get your care in. It's getting harder and harder to find!
Excellent article. Informal exchange of medicine and collegiality were once foundations of good medical care. I miss those days.
Me, too!
I think the thing I miss most is a return phone call from a provider when I am sick. The last thing I want to do when I am sick is go to urgent care.
I agree, Joyce, about urgent care! Although I must admit I rarely call patients, my nurses are very good about getting back to people.
Thank you. Thats actually why I used the word provider instead of dr or physician. As long as they are able to deliver concise instructions and dont have to go running back to the doctor to answer questions as an RN I am more than comfortable talking to anotber RN or NP.
And this is why having a small group of doctors and a small group of nurses provides better (if less efficent) care. Many of my nurses know exactly what I'm going to say to whom and under what circumstances bc they have worked with me long enough to have figured me out. (If only they would share that info with me so that I would have myself figured out!)
Less efficient? That surprises me. How please, if you have the time. Yes, that is a quality nursing for sure. I feel sometimeslike I spend equal time fighting for a positive vies of medicine and criticizing the things about it that make me crazy. I finally withdrew from the vaccine argument. Antivaxers are not interested in being educated, at least vua social media.
I never worked for a doctor during my RN career but I would have liked to. My experience of nursing as a child was more similar to public health nursing, although Central African missionary nursing really has no equivalent in this country. My experience with those nurses was significant and impactful.
I think less efficient bc if you have 16 nurses working a task list, you'll have a shorter list than if you have 2 teams of 8 nurses. Today, P team's list happens to have only 40% of the overall calls on it, and R's has 60% of the calls so the P nurses are not being "fully utilized." They're done earlier than the R nurses. They could be calling the R list's patients, but are instead eating bonbons and gossipping (so goes the story).
African missionary nursing sounds like a good Substack!
Are they not qualified/licensed to make the other calls? A problem of "not my job"?
Excellent article. I couldn’t have said it better myself.
Thank you, Gerridoc!
LOL if seeing a different doctor every time you come in bothers you —
Don’t sign up with Kaiser!
I've never been a Kaiser patient or doc. There are many things to like about a big, all-inclusive system, as well as many things to dislike. Ihave a number of friends hwo live in the SF Bay area and many of them like it, but not all. I have not figured out the pattern, Ken. I would not like meeting a new doc every time or not seeing my own patients.
I spent a year on Kaiser (with Kaiser?) here in Atlanta when Blue Cross left metro Atlanta and my husband, business partner and his wife all went on Medicare. Having grown up as a “Navy Junior”, I found that the Kaiser system echoed some of the unpleasant aspects of Navy healthcare. I was so happy to return to a private healthcare provider about 13 years ago. Facts have faded in my memory, but the feeling remains!
I have a friend in Oregan that uses Kaiser and always sees her own doctors. Mostly specialty unfortunately, she has parkinsons.
Fabulous article. Thank you for confirming my suspicions.
Thank you, EuphmanKB. I'm curious; your suspcions of what?
It’s very frustrating that visits are only 20 minutes long and doctors are typing into their EMRs at the same time I’m asking questions. I’ve also had three female PCPs who left their practices, one to move to a boutique practice. Yet I’m sympathetic to doctors’ plights these days where medicine seems like an assembly line, and many doctors burning out, some taking their lives. The system is broken.
The system is very broken, Barbara. I am very lucky that I can type fairly quickly without looking so I can type while maintaining eye contact. I hate to type while I'm in the room with the patient, but if I don't, I end up with even more work to take home than the WAY too much I already have.
Have you considered a medical scribe? Our ENTs use one and it was helpful for that purpose.
We have not. Our health insurance is so terrible and expensive that ain't no way my employer would pay for one. There are many priorities higher than improving my life (some justifiably so, some maybe not, lol).
We've experimented briefly w AI, but it was not reliable enough to use. The very worst, catastrophic outcome was that it failed to listen, despite appearing to, and I didn't take notes bc I didn't think I needed to and then I had to do ALL the work well after the fact. Could it have been operator error? Of course; isn't it always? I could not tolerate that failure and felt it was just better to keep doing things the way I was.
Back in the days before managed care, you just made an appointment and went to the doctor. You didn’t wait months for an appointment, and doctors didn’t charge an arm and a leg. Some made house calls. The insurance industry did away with that, and healthcare is full of denied treatment with poorer outcomes in some cases. Doctors didn’t have a lot of paperwork. This is the one of the only things I would want to go back to the ‘50s and ‘60s for (and music).
I agree, Barbara, although I am lucky enough to have found an employer that will let me do some home visits under some circumstances. The paperwork, however, no one seems to have a solution for.