By Paul Goldfinger, MD, FACC. Editor @Blogfinger.net.
In a NY Times piece recently a young physician argued that experience in medicine is overrated and that smart young physicians, armed with technology, can do a better job in diagnosis and treatment than silver haired professors steeped in Hippocratic values.
In 2016, I posted a piece called “The Case of the Hypokalemic High Jumper.” (link below) It was a difficult situation where all the technology available could not produce a diagnosis, but a careful history taken at the bedside by a physician was all that was necessary.
The case of the hypokalemic high jumper
In the New Yorker cartoon above, an alert doctor took a good look and made the diagnosis.
In medical school, in the second year, we all took a course called “Physical Diagnosis.” It taught us how to take a proper history—very detailed, but customized to suit the needs of an individual patient. We also learned how to conduct a sensitive physical examination—how to feel a spleen, palpate a liver and listen to the heart and lungs—in fact how to accurately assess the whole body. We were taught that such skills have been used by physicians going back to the Greeks and that we could learn so much using those basic tools.
During my cardiology residency, we were trained to be meticulous in auscultating the heart (ie listening with a stethoscope.) We used stethoscopes with 3 heads to help sort it all out. We made recordings of heart sounds where we could measure intervals down to fractions of a second in order to figure out how narrow a heart valve might be. It was a source of great pride to be able to use just our ears and minds to determine if someone needed heart surgery or not and then to help a medical student who couldn’t appreciate the subtleties of the cardiac examination.
But now, I am afraid that doctors are becoming too complacent in using technology to replace the traditional tools. These skills are still helpful in assembling all the pieces of a puzzle and then following the progress of the patient at the bedside or long term in the office. I see doctors doing a poor job in taking a history, a process which has been replaced in large part by computer check lists. Garbage in, garbage out. And the same concern exists for the physical examination.
I was present when a patient went to a local ER with a painful, swollen knee. The Physician Assistant took a cursory history (he had no idea that a real doctor was observing) and ordered an X Ray. He did not properly examine the knee. And he never bothered to review the patient’s medication list. He was functioning like a robot via an algorithm. If he had done a proper history, he would have learned that the patient was on a blood thinner and might have a hemarthrosis (bleeding into the knee.) The problem was diagnosed with a proper history and physical exam by a careful physician and corrected by aspirating the joint with a needle and adjusting the medication.
Yes, the new technologies are remarkable, but each patient is different, and the physician must use all the tools available at his disposal including his eyes, head, ears and hands. And, experience is perhaps the best tool of all.
RUFUS WAINWRIGHT “Heartburn.” This is a peculiar song, but it makes the point that doctors need to remember that psychological factors can mimic heart burn or something much more serious—like a derailed roller coaster. A doctor must take a good history to pick up on this situation.
“Is this heartbreak or is this heartburn?
Can I be spared from being so dramatic?
Gotta learn the difference when I love ya
The difference when I love ya and that derailed roller-coaster”
Prior authorization is a major practice burden for doctors. Have you heard of it? Have you experienced it?
Posted in Blogfinger Medical Reports, Blogfinger Presents, tagged Blogfinger medical commentary on April 14, 2018| Leave a Comment »
Internet cartoon.
Medical practices spend an average of two business days a week per physician to comply with health plans’ inefficient and overused prior-authorization (PA) protocols. One-third of practices employ staffers who spend every second of their working hours on PA requests and follow-ups. But some relief appears to be coming, as the AMA and joins forces with some payers to fix this broken process. Read more at AMA Wire®.
This quote is from the AMA Morning Rounds: “Physicians have, for many years, expected to face prior-authorization hurdles for a few new or unusually expensive medications or tests. But, more recently, insurers have rapidly added PA requirements to more and more treatments,”
Blogfinger Medical Commentary: Paul Goldfinger, MD, FACC
Some of you may have experienced rejection of a particular prescription drug by your drug plan. But such rejections typically get reversed by enlisting your doctor’s help, and that would require his time and that of his staff to deal with the insurance company. The process is called “prior-authorization.”
In the article above, from the AMA, they discuss the problem from the perspective of the physician, but I have experienced it myself, from the perspective of the patient.
And, without a doubt, the episodes of prior authorization have increased noticeably for patients, but, as discussed above, also for the prescribing physician and his staff.
And now we see insurance companies questioning even cheap generics or chronically used stable medications, and the issue isn’t always the drug choice itself.
For example, I recently ran into this situation related to my use of a high blood pressure medication that is perhaps the number one or number two choice prescribed by doctors for their patients with hypertension.
In my case, I was doing very nicely with two 5 mg. tablets each morning of that drug (10 mg per day)—lisinopril, an ACE inhibitor. However recently my doctor wanted me to increase the dose from two tabs each day to two tabs twice per day (20 mg per day), ie 4 tabs per day instead of 2.
So I would need 360 tabs per 90 days instead of 180 tabs per 90 days—-a perfectly reasonable dose change. I was notified that they would not send me my medication because it required the prior authorization process. Meanwhile I was running out of medications while the plan would try to get my doctor to respond. And the drug plan was contacting me by mail and phone messages to raise the PA alarm.
I couldn’t understand why this innocuous dose change was a problem—it’s a cheap drug with a zero copay. I was baffled, so I called the company, but the customer service representative couldn’t figure out why prior authorization was being applied to my prescription. She advised me to wait for the process to play out. This was unacceptable.
I thought about the problem, and it dawned on me that maybe the number of pills was the issue, and not the medication itself.
Maybe the problem was the 360 tablet requirement, every 90 days. Being a physician I was able to call and speak to a pharmacist at the mail order plan. He verified that the number of pills was the problem, not the dose.
So I asked if we could change the tablet size from 5 mg. to 10 mg, making the daily dose two tabs each day. He said “fine” and a few days later I received 180 of the 10 mg tabs.
But the warning letters and phone messages continued. Finally I called the “prior authorization” department and told her that I fixed the problem myself. And she said, “Oh, when you get the letters and phone calls just ignore them until the matter is fully resolved.”
The best resolution available for most patients is to make sure that your doctor’s office staff has done their job with the paper work. It might be easier to resolve if you buy your meds from a local pharmacy. If you have a mail order pharmacy, as I do, and you are running out of pills, one of the local pharmacies will help you get a temporary supply, assuming that the left hand and the right hand at your drug company can resolve the problem.
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