Blogfinger

The New Yorker.

By Paul Goldfinger, MD, FACC.   Original post Sept. 2023.

And I also posted a piece about communication in healthcare in October 2023.  I apologize for any duplication and for the length of this post, but I am angry!

https://wp.me/pqmj2-SEp

I am a retired physician who has now experienced healthcare at the receiving end and I am not happy.  When Obamacare rolled in I wrote editorials on my site--Blogfinger.net,  predicting that quality will be negatively  affected, and my conclusions were  based on the ancient concept of always placing the patient first:

I find that the changes which are rapidly taking hold in healthcare  may result in declining aspects of  quality.  I don’t want to be unfair, but often when I interact with healthcare  I look around and  find issues to complain about.

It’s usually not a problem of technology or facilities—that has been remarkable, but it has more to do with basics that are the same now as 50 years ago when I started working as a doctor and it is  now often about new management methods  mandated by corporate healthcare giants.  I read of one company in the midwest which owned 100 hospitals.

These companies want to change everything. Sometimes the changes are innovative, but often they are about maximizing profit, leaving patients wondering “why?”   And management medical decisions may not include input by physicians.

Four  of my favorite Monmouth County doctors have left practice early.  At a national level, doctors are leaving medicine in droves, many suffering burnout, and most practicing doctors would not pursue medical careers again according to one survey.

Protect yourself by questioning and doubting what you are experiencing regarding your diagnoses, treatment, access too care, and doctor-patient relationships. If you can’t ask questions find someone, a patient advocate,  who will help you navigate your situation.

When in doubt, get a second opinion.*

Here is an incomplete list of some of my concerns. Consider this a warning flare bursting in the sky.

a. Doctors often no longer own their practices, so they are now employees who must take orders, such as my pulmonologist who was ordered to spend only 10 minutes with each office patient. That is ridiculous. Physician  flexibility and control  are being compromised.  Only a small percent of practicing doctors, perhaps less than 30%, actually own their  practices.

The management of medical  practices is often via corporate  efficiency experts whose main priority is to maximize reimbursements..

b. You can call a medical  office and ask to receive a call-back from your doctor, but you often receive resistance, deflection, or else a “physician assistant” or just “assistant”  calls back and her priority often seems to come between you and the doctor.   It is unusual for the doctor to call you back these days, and the person calling you back may not even be a nurse. So who will answer your questions? Better make an appointment if you can get one soon.

Speaking to the patient on the phone is discouraged because it doesn’t pay.  Sometimes an office may make you wait 2-3 days before returning a call. And this may occur when the situation warrants an immediate call back. Phone consultations may provide a solution to an issue without having to have an office visit, but that approach has been buried.  Saying that the doctor is very busy, “seeing patients,”  or is in another office may be the truth, but those excuses  should not be acceptable answers.

If you call an office you may be greeted by a computerized triage system where someone with no medical training is empowered to make  decisions about your care such as when you might be safely seen by the doctor.

Front desk phone answerers may, without any medical credentials, ask you questions such as, “Where is your pain and what does it feel like.?”   Sometimes you are given an appointment which may be scheduled for one or two months away.  (“We have an opening.”)   Who is making that triage decision?   To me this is practicing medicine without a license.

I recently spoke to one of those front desk flunkies.  I wanted her to leave a message for the doctor to call me back, but I needed to speak to someone medically responsible to run with the ball.  As I tried to explain to her why it was essential to be responsive to my concerns, she got angry at my questions and she hung up.  I had to speak to the office manager to make sure that someone responsible would call me back.

c.  If you seek a physician’s care you may be offered a nurse or a PA as if they are” just as skilled as a doctor.”   That is a lie, and the AMA agrees with me.

d.   Some doctors belong to medical groups which have affiliated with a large  corporation, such as the Robert Wood Johnson Barnabas Health.   This company, based in New Brunswick,  has been striving to access patients from Monmouth County and they have their eyes on our area including Ocean Grove and Fort Monmouth.

What you are seeing  is corporate takeover of healthcare in communities.  It’s been awhile since I have heard the name  “regional healthcare planning.”

Some  physicians who have  contractural affiliations, such as with RWJBarnabas Health,  may have a conflict of interest by insisting that the patient go, for example, to Monmouth Hospital instead of Jersey Shore or by referring patients for specialized attention to their referral centers out of this community.

For instance, RWJ provides some specialized services in New Brunswick. You could be sent to such a place when there are  providers nearer your home. Going to New Brunswick can be difficult especially where RWJ hospital is located. What about placing the patients best interests first?

e.  And who is providing your care at Jersey Shore University hospital?   I have been to the Jersey Shore ER  recently  where highly qualified attending physicians/specialists were not visible despite the hospital’s list of consultants.  And the ER staff was overwhelmed.

In the past, if you  were a  patient in an ER  or medical surgical hospital in-patient  unit, you could expect your doctor and/or consulted specialists to manage your care in person.

One medical  group in Ocean has affiliated with RWJBarnabus Health and resigned from Jersey Shore.  As a result, they do not go to Jersey Shore even if you are brought there as an emergency.  And if you live in Ocean Grove and need surgery you will be sent to Monmouth Hospital by that group.  Taking such decisions out of the patient’s  hands is not in the patient’s best interest and there is a glaring conflict of interest interfering with quality care.

And if you are an inpatient, find out who is the attending physician named on your chart and see if he comes to see you or if your care is by unknown unmarked  proxies:  resident physicians  or medical assistants.  And such practitioners are of uncertain competence, and you often are not informed as to who is who. Not knowing who is in charge of your case is scary.

See if board certified specialized care is available  and then demand such attention if needed.  Patients need to pay attention to try and judge the quality of their care ins the hospital.

And take a look at who is billing your insurance company for your care.  Look at your EOB’s (explanation of benefits.) Are some doctors billing who never actually showed up at the hospital, relying instead on covering house staff  who are not fully trained or poorly trained.  This is obscene, and Medicare should investigate.

And don’t believe billboards:   Monmouth Hospital says that it among the best in the country at  educating doctors, and Jersey Shore says that it is one of the best hospitals in New Jersey.  Never believe those phony surveys.  And that includes those lists of “best doctors.”

f . Record keeping  has become onerous for  doctors in the office typing on a computer keyboard while trying to take a complete history, perform a physical exam, analyze your case, and give you advice. There is never enough time.

The doc is expected to create a competent and complete chart note before you leave. Some actually do, but they may not succeed with that, but who is going to judge the result?   Request those notes, especially if a consultant is involved.  Those notes should explain the diagnosis, the prognosis,  treatment options, and the current plan.   Once reason for the long notes is that insurance companies won’t pay unless the office submits  reports that meet expectations.  That’s why your dermatologist may check your pulse and BP, use a stethoscope, and ask about COVID vaccine boosters.  Do doctors sometimes say they did it, when they didn’t?

Some practices use scribes to take care of the chart work freeing up the doctor.  But are such chart  notes trustworthy?  You can read  those scribed notes, but unless you are a physician you won’t be able to judge the result very well. Ideally the doctor should create the chart notes.

In my group practice we were compulsive about charts  and we had 2 full time typists working on our notes which we dictated, often in the presence of the patient.

Many doctors’ offices, run by efficiency experts, encourage passing patient care tasks down to a lower level.  For example, a “mid-level” may be ordering meds from pharmacies without supervision.  I know of such a case where the assistant was not careful and ordered the wrong drug.

If there is a consultant involved, request a copy of the  consultation report.

The use of “My Chart” apps has advantages, but they will text or email you repeatedly and pressure you to keep responding to their electronic messages, and I find that badgering to be oppressive.

g.     Watch for manipulative marketing such as the billboard in Red Bank which says that Monmouth Hospital is one of America’s best “teaching hospitals.”     Or the cynical use of the term “university hospital.”  Be aware that the best interests of patients may not be the top priority by your providers who may become more “mad men” than physicians.

h.   Watch your billing.  The hospitals are now beginning to bill you or alert you  on line for services you haven’t yet received. Make sure that they have all your insurance documentation.  For example if you have Medicare, make sure that they know your secondary coverage.

Some incompetent billing offices fail to bill your secondary insurance. Then you will be balance billed and you don’t want to deal with billers who are out to collect and make you crazy.

And keep in mind that some providers like hospitals may be “up-coding” to get the most from insurance companies. This scandal will emerge soon…..I hope. Ultimately it will affect the cost of care and the cost of your health insurance premiums.

Here is a link to a Blogfinger post about second opinions:*

Second opinions BF article.  *

And there is much more.  Watch for more posts as I make discoveries in the swamp known as American healthcare.

Make sure that you choose wisely for those who would watch over the health of you and yours.

Phillip Smith is a world famous trumpet musician, formerly with the NY Philharmonic Orchestra who spends his summers in the Grove, and here he is with Joseph Turrin on piano:   Gershwin’s “Someone to Watch Over Me.”  He has performed this piece in the Great Auditorium.

Phillip Smith of Ocean Grove and the NY Philharmonic Orchestra.