I have 2 stories to tell. One was a patient I saw, the other, a family physician colleague. I won’t say which is which.
A middle-aged woman showed up in an ER complaining of lower abdominal pain. Other acute details really don’t matter much. The physician and nurses were suspcious for several reasons. She had been to this facility in the past with an essentially negative work up for the same complaint. She had been CT scanned 4 times in the last 5 weeks at just this facility. Each scan found minor abnormalities that did not provide an explanation for her severe pain. In each ER trip, she recieved several rounds of morphine and dilaudid (IV narcotics).
The physician looked up her narcotic usage on a state pharmacy database and her list of narcotic prescriptions was 19 pages long. Before she settled into her ER room, the nurses had asked her to pee in a cup. The urine was pink. After the ER patient room was closed, they went to the bathroom and found a lancet (used for pricking one’s finger) and bloody paper towel in the trash can. The lancet was not the brand this hospital used. When the doctor was in the middle of looking up the narcotic usage, she walked out of the patient room in her street clothes, in no distress, and signed herself out. Maybe she heard some of the conversation of the ER doctor, or maybe she had an internal clock based on experience telling her how long of a delay before the doctor enters the room meant she got busted?
This is a great example of Dr. Iona Heath’s (former president of the Royal College of General Practitioners) exhortation to British policy makers that they showed no understanding that patients can be abusive, manipulative, and self-destructive. The bureaucrats are worse in the U.S. At least the British administrators have some inkling what GPs do, since 80% of outpatient visits in Britain are to GPs.
I wonder what this physician’s patient satisfaction score will be for this visit?
The second story is of a 60-year-old man whose chief concern according to what he told the front desk people was about his blood pressure, but when it was just the patient and his family physician, the man said he wanted a genetic test to prove whether or not the man who raised him was his father. After just a few questions about the basics of what was going on, the physician learned that the father was dead and that there was no easily available fatherly genetic material available. The physician asked the patient, “Do you think he loved you?”
The patient proceeded to talk of a happy childhood with strong feelings of love and support from this man. After hearing this, the physician said, “After all that you have told me, I can tell you medically that there is a 99% chance that this man was your biological father.” The patient was happy, relieved that this angst about his past could now fade away. This journey of his life was over and he could get back to focusing on caring for his own family.
Of course, there is no scientific evidence that this 99% estimate has any validity, but it doesn’t matter. Through true agape love of this physician for his patient, the right and the best outcome was achieved. It had nothing to do with a single-disease guideline or specialty society pronouncement of the best management of anxiety or genetic testing. The physician did what family physicians do multiple times per day: he made a judgment call taking into account almost innumerable factors. This is how family physicians deliver better care at a lower cost.
Of course, neither of the important physician decisional factors is included in any existing quality metric or scorecard. In the first case, a patient was not given what she wanted both to protect her from herself (future abdominal cancers from radiation exposure from the CT scans) and to protect healthcare system resources. In the second case, a patient was given exactly what he needed, but this will never appear on any quality scorecard and you wont’ find it on any ologist society guidelines.
Family medicine. It’s too complex for business-oriented bureaucrats to ever really understand, which is both the magic and joy of what we do and our downfall.
No one is a more enthusiastic, uncritical cheerleader for quality measures, P4P, value-based payment than the AAFP. Ignoring multiple requests from the membership, they refuse to explain why. Go figure.