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Rhode Island Monthly /  June 2008 /  Taking the Pulse /  Clinical Assessment

Clinical Assessment

What advice do you have for someone trying to choose a doctor?

The OB-GYN Word of mouth is huge. My patient base is a lot of “Oh, my friend so-and-so sent me,” and “My mother comes here and told me I had to come to you.” That’s the nicest thing. And it’s also nice when colleagues start pushing people on you. That’s the best way, if there is one.

The ER Doc For me, it’s totally different because when people come into the emergency room, they don’t have a choice. But for choosing a private practice, professional referrals are big because we know each other very well and know reputations.

The Cardiac Surgeon My specialty is different. Sometimes the patient doesn’t really have a choice. Otherwise, if it’s an elective operation involving a heart valve or a bypass, word of mouth is important. Patients talk to one another, they read stuff on the Internet and they’re educated. There also has to be a level of comfort and trust, especially in heart surgery. So it’s a combination of things: a level of trust, word of mouth and information on the Internet. 

The Family Practitioner I recently had to get a doctor. It’s a little different when you’re a primary care physician trying to find a primary care physician, because you don’t want to go see your friends necessarily, you know, it’s a little odd. Honestly, if I called their office and I was on hold for ten minutes or if I called their office and I got their answering service during the day and I couldn’t get the doctor to call me back,  that’s a big deal.

Are you ever offended when a patient wants a second opinion?

The OB-GYN I’m never offended.

The ER Doc It’s a little different for me because in the emergency room, I can go grab one of my colleagues and say “Hey, look at this rash.” If a patient wants a second opinion, that’s very simple. I can arrange for them to see a specialist or whoever they choose. So that never offends me.

The Cardiac Surgeon Usually it happens when the diagnosis is made and there are several treatments available. An example is lung cancer, whether or not a patient has chemotherapy or radiation first and then comes back for surgery. We’ll send the patient to the oncologist first or perhaps another surgeon and get their opinion. Sometimes it’s the comfort level of the patient and sometimes the physician feels the need to affirm his or her own feelings about treatment.  

How can a patient get in to see a busy specialist?

The Family Practitioner Have your primary care physician call. When you call  and either get an answering service or you leave a message and they call you back and let you know that you have an appointment in three months, that’s when a primary care physician can be helpful.

The OB-GYN On the other hand, when a patient is honest about what’s going on it’s very helpful. Most of the time problem visits get added on. If it’s an obstetrics issue, it’s added on that day. But there are a lot of people who feel, “Okay, I’ve decided that now it’s a problem,” and then expect that it’s done today, and that’s not always realistic because there are people who have been waiting three months for the annual visit. I’m happy to fit you in as quickly as I can, but I also don’t want to bump the truer emergency.

The Cardiac Surgeon Involving the primary care physician is critical. It’s nice to have a physician articulate what the problem is. That can really expedite things.

The ER Doc Unfortunately, the ER is often used as a fail-safe. I think that for the people that have waited for months and realized at two in the morning that now’s the lucky time when they want to get checked out, they show up in the emergency department. It’s unfortunate because there’s a lot of abuse of the system. The public’s pretty savvy too, and people will come into the ER simply to get a referral to a specialist. They understand that we refer people all the time, to orthopedics or gynecology or whomever, and if we refer them from the ER, they often get in a lot more quickly. So there are a lot of people who abuse the system that way, too.

What’s the biggest mistake people make when it comes to their health?

The ER Doc Hands down for me it’s smoking. It’s incredible to me the percentage of people who come into the emergency department that are actively smoking. It’s frustrating.

The OB-GYN I wish people would take more responsibility for their own actions. Everybody has their issues, whether it’s nicotine or alcohol, obesity. As a society, we have allowed people to make it not about what I can do for myself, but what can you do for me? And people come in with the perception that I’m going to fix stuff. Obesity is pandemic; it’s gotten out of hand. And I know that it’s difficult to expect people who have less to achieve some of these things. So for me to say, “Just go out and take a walk,” well, who’s watching the children?

The Family Practitioner It requires a change in priorities. I tell patients, “I can give you a pill for your blood pressure, I can give you a pill for your cholesterol, I can give you a pill for your stomach acting up. I can give you four or five pills, or you can go out and exercise half an hour every day, and come back to me in six months and you won’t need all these pills.”

What qualifies someone to be considered a “good patient”?

The OB-GYN It’s frustrating to have a day of feeling like “Why am I feeling like I care more about this than they do?” especially for some of the pregnant ladies who don’t show up for appointments, or come in late for prenatal care. Would that be a bad patient? Well, it’s not bad. I understand that a woman who’s had three children understands how to be pregnant. But there are so many things within each pregnancy, that for me it’s a bad situation when someone doesn’t come in, because there could be so many things going on. 

The Family Practitioner You know the ultimate bad patient is the patient who comes in who is trying to get something from you for their own personal gain and not really in a health situation at all. Maybe a drug-seeking patient or something like that. But that patient has a problem and that’s where your job is to try and get to the bottom of that problem for their health. 

The ER Doc The patients that I find most disruptive are the patients that genuinely have a medical issue that is an emergency but show up in the ER and seem to think they’re the only patients there and not recognize that there are many other patients there equally sick or injured or what have you. And there are some patients, just by their personality or whatever it is, who demand a lot of their caregivers’ time in a fashion that’s not really reasonable for why they’re there.

The Cardiac Surgeon In heart surgery, we don’t really have good and bad patients. They’re scared and I think that it’s hard to label someone a bad patient when they’re still smoking after surgery and they’re still obese and trying to lose weight and their cholesterol is high and they’re not taking their meds. Smoking’s an addiction, so someone’s maybe having a hard time quitting, but does that make them a bad patient? I don’t think so. So at least in my specialty, it doesn’t really apply.

How do you feel about patients self-diagnosing on websites like WebMD?

The Family Practitioner In my practice, for the most part, it’s been helpful. Most patients have enough suspicion of what they see on the Web that it’s a resource. They don’t look at it as their other doctor. I have not yet had somebody who said, “Well, I went on the Web and I figured it wasn’t that bad.”

The ER Doc I think it’s great for patients to be self-informed and do their research before they are seen by a physician. It gives them all the more correct questions to ask. At the same time, I would never recommend that people just go online if they have chest pain or abdominal pain and diagnose themselves and not seek the appropriate medical attention in a timely fashion.

Do you think doctors today tend to overtest when looking for a problem?

The OB-GYN I think that’s the nature of the beast these days. Malpractice is becoming an elephant in the room, and those of us who are newer are more scared about it. So my knee-jerk response is if in doubt, if this patient is going to have any question, regardless of how much I tell them that this screening test hasn’t been shown to be that effective, I want it. And if their insurance is covering it, I will do it, not necessarily because I think it’s the best choice, but because it is a choice.

The ER Doc The medical system is so overburdened because of the cost of unnecessary testing because of the potential for litigation. I think that in many ways it has contributed to the downfall of medicine in this country. I can’t tell you how many $1,000 CAT scans I order in a day in the ER for patients that may or may not need them. But that’s the expectation. And it’s progressively becoming the standard of care. So if I didn’t do it and there was a bad outcome, it would land on me. 

The OB-GYN And God forbid you tell the patient, “If you were fifty pounds lighter, I’d have an easier time feeling your abdomen and doing a pelvic exam.”

The Family Practitioner I probably over-test too, because you have very limited time with the patient. So rather than sit down and ask them an hour’s worth of questions about their specific problem and do a half-hour exam, you’re cramming that all into fifteen minutes. It’s a vicious cycle, because when you rely on testing so much you lose your physical diagnosis skills.

So the threat of malpractice is in the back of your mind at all times?

The Family Practitioner It’s become integrated into how we practice; it’s more than just looming over your head. It determines how we practice medicine now, on a certain level.

The ER Doc Every single patient I see, in addition to trying to diagnose them and do the right thing, I always have in the back of my head the potential for litigation.

The OB-GYN It’s depressing.

The Family Practitioner It is depressing, because you want to think about the best outcome for your patient when you’re thinking about the worst thing that could be happening and you can’t not think about (the threat of litigation).

How do Rhode Island’s hospitals really stack up against those in the rest of the country?

The ER Doc I think it’s pretty well known that third-party insurers reimburse physicians in hospitals at a lower rate in this state than anywhere else in the country and certainly in New England. So I’m not sure how that translates down to quality of care that’s provided to patients, but I think it’s unfortunate. I’ve seen several of my colleagues leave to move out of state because they can’t afford to pay the $100,000 a year it costs to get malpractice insurance, or they can’t afford to see patients because the reimbursement for patients is so low that they just feel like they’re not providing the kind of care that they want to provide.

The Family Practitioner The flip side is that a lot of these physicians are leaving and no new physicians are coming in to take their spot because the word’s out: Rhode Island’s not a good place to practice as far as reimbursement.

Do big teaching hospitals really provide any better care than smaller hospitals?

The OB-GYN I go to both and I love being affiliated with both. I think both are very different, but each has its benefits. In a teaching hospital you have the advantage of change and growth and technology. On the flip side, a community hospital is a place that’s like a family in a way that I don’t think the bigger institutions are.

The Family Practitioner When it comes down to being a patient in the hospital, again your experience is going to be different. In a teaching hospital, you’re going to have a couple of extra hands and eyes and brains thinking about your problem, which can be a very good thing. In a community hospital, you’re going to have your physician that you know coming in to see you.

The Cardiac Surgeon What patients may not know, in certain specialties like heart surgery, is that all of our outcomes, all of the statistics like mortality rates and morbidity rates, are public data and they’re available on the Internet. And they frankly shut you down if you don’t have excellent results. There needs to be an understanding that there’s no connection between physician quality and the underserved area where a hospital may be located. That’s just not the case.

If the proposed merger between Lifespan and Care New England goes through (which will create a seven hospital conglomerate), will this affect patient care?

The OB-GYN I don’t think patient care is ever a question because I think we are insane people who do these jobs. It’s not about how we’re going to take care of somebody else. How we’re going to take care of ourselves is sometimes what we have to decide.

How will this affect doctors?

The ER Doc We’re not going to know that until it happens and all of the pieces kind of fall out.

The OB-GYN There are so many rumors and so much innuendo. Places closing, units closing in specific hospitals. There are so many things this could affect. How much will it affect? We don’t know.

The Family Practitioner It’s difficult because I think a lot of the fear in the community hospitals is that care is going to become more centralized. I can’t see that happening because it’s already become too centralized. The big hospitals are getting too much business at times. The ERs are kind of overrun. But I think a lot of the rumors are just that. I’m hoping that they’re going to be good changes, that there’s going to be more of an academic exchange between the hospitals.

How do you feel about universal healthcare vs. what’s in place now? Is one better than the other?

The ER Doc I think that some sort of hybrid system has to work somehow. I’m sure it’s going to involve raising taxes somewhat, but it’s gotta happen somehow. And it may not be universal health coverage either, it may be at least universal healthcare coverage for people who absolutely cannot afford it, like children and so forth.

The Family Practitioner I’m more on the side of universal healthcare than the system we have now. I see a lot of waste in the fractured management of healthcare in the United States. The mailings I get from different health insurers, just the mailings alone, forcing me to change patients to different medications because their preferences have changed because the deals with the different pharmaceutical companies have changed, so you have to change your patient’s cholesterol medication to a different one. Which means then I have to have them come into the office and the insurance company’s going to have to pay for their visit. Plus, I’m going to have to retest their labs in a month to make sure that the new medication’s working the same and it’s not hurting their liver. It affects so many people, and it’s such an added cost.

Have you ever had to deny someone treatment because their insurance company wouldn’t okay it?

The ER Doc By federal law, I’m required to see every patient that comes into the ER regardless of insurance status or lack thereof. What I do see is a that lot of people who are uninsured or underinsured simply do not have access to the same treatments that folks with insurance do.

The OB-GYN Most private practices would probably not accept a patient, a new patient, without insurance, unless they’re private pay, which is accepted prior to the visit. We’re not going to order all of the procedures that we may normally do; I’ll order the pretty important ones. In Rhode Island, if you’re pregnant, there’s always a way to get care. There’re very good clinics, and there’s very good insurance that is retroactive.

The ER Doc I think as providers too, we sometimes have to tailor the way we care for patients, taking their insurance or lack thereof into consideration. For example, I see a patient in the ER who has an infection that I think would be best treated by a certain antibiotic, but if the patient has no insurance and has to pay cash, that may be several hundred dollars which they may not have. So I might be forced to choose a less effective antibiotic, a generic or what have you, and that can negatively affect the outcome of a patient.

The Family Practitioner The other day, I had a mom whose kid was sick and throwing up and a bit dehydrated, and I said to her, “Here’s the medication to make the child stop throwing up and you’ve really got to hydrate well at home,” rather than sending him to the ER to get hydrated knowing that they have no insurance and knowing that that’s going to be a huge burden. You do that, you alter how you give medicine.

Do you feel like you get enough time with your patients? Or do things like paperwork take away from that?

The ER Doc Well, it’s not only paperwork, it’s also trying to maintain a standard of living and your income as a group and an individual, and as the reimbursements go down and down, you have to see more and more patients in the same time frame.

The Cardiac Surgeon If you’re going to have heart surgery, you want to be able to talk to your doctor. So I do take the time. You have to.
The OB-GYN Informed consent is a very important part of what we do.

The Family Practitioner But specialist reimbursement versus primary care reimbursement is very different. To maintain a practice, to maintain a profit, the margin’s pretty small. In primary care, it’s gotten smaller and smaller. There are proposals to cut primary care reimbursement every year. Several times a year, we have to call our legislators and say, “No, no, no. We’ll have to deny care for Medicare patients, we’ll have to stop taking Medicaid patients.” So every year they say, “Okay, we’re not cutting you 10 percent, we’ll raise you .5 percent.” So we get excited about that.

How often do you meet with drug company reps?

The ER Doc Pharmaceutical representatives are not allowed on hospital grounds anymore.

The Family Practitioner They sneak in, though.

The ER Doc Not in the ER so much. That being said, I certainly go out to pharmaceutical dinners sometimes, but I make an effort to go to ones that have nothing to do with what I do. 

The OB-GYN I tend not to go. We do have a few people whose products we do use, and they restock our samples and they will bring us treats occasionally. But the treats I ask for are things that I can bring to the hospital and give to the students. 

The Family Practitioner I have samples that I can give to patients and I can say, “No, you don’t have to go on the generic medication that doesn’t have as much evidence for preventing you going back into a heart failure situation; you can stay on this for the next three months because I have samples.” Personally, I don’t think I get too swayed by them.

What’s the most stressful situation you’ve been in as a doctor?

The ER Doc Right out of residency, I had to care for a four-and-a-half or five-year-old girl who died in the emergency department. She was a healthy girl; she had just seen her pediatrician for what sounded like a viral illness. She went home and she died in her sleep. I don’t cry too often, but I cried that day right there in front of the family. That was such a stressful thing. Everyone I think gets a little bit more stressed out when it’s a child.

The Cardiac Surgeon I was doing a heart transplant on a patient. And I knew this guy really well because I tried for several months to get him a heart. He rejected on the table and he died shortly thereafter. As surgeons, we appreciate the technical aspects of the job, and it’s elegant and you become technically good at doing it because we do it every day. But when you have an emotional attachment to someone you’ve seen over and over again and you’re really trying to get him or her that heart because they’re going to die without it, and that day finally comes and they don’t make it, that day takes a toll on you. 

The OB-GYN With obstetrics and gynecology, fortunately most of the time it’s pretty happy, but when there’s a baby that’s not expected to be sick that’s born, those are always issues that are stressful. Fairly recently, I was operating with an oncologist on a woman who we thought had ovarian cancer. So I went in with my partner and it was completely different than what we were expecting. It was like tumor soup. It was a very aggressive form of ovarian cancer and it ended up being a seven hour surgery.  

What’s the worst ethical lapse you’ve ever witnessed?

The Family Practitioner In my residency, there was a woman who came in pre-term labor and she was given this magnesium, which in small doses can help stop labor, but in large doses can kill you. That’s what happened with her. It was an ethical problem because somebody went back into the record and tried to change it to make it seem like she was given the right dosage.

How has healthcare changed in the past twenty years?

The Cardiac Surgeon In my specialty, it’s changed dramatically. It used to be we were operating on someone in their sixties and that was considered old. Now, most of my patients are octogenarians. People are living longer and because they’re living longer, they present for specialty care in which there’s a potential for domino effect. One system failure leads to another system failure. I think it actually demands a higher level of attention and it’s much harder than it used to be.

The OB-GYN I would agree. I think the longevity of patients has added to things. The thing that I see is that women are becoming sexually active at a much earlier age and with many more partners. And we’re seeing a higher prevalence of sexually transmitted diseases.

The Family Practitioner As people live longer, preventative medicine has become much more important. Twenty years ago, somebody who seemed perfectly healthy wasn’t on any medication, but now someone who seems perfectly healthy may be on blood pressure medication. Preventative medicine has become a specialty.

The OB-GYN And I think part of that is that we also are becoming lazier, and obesity again has affected every aspect of how we care for people because it is so prominent. We’d sooner make bigger airplane chairs than tell people to drop weight.

What do you see for the future of medicine?

The Cardiac Surgeon As a physician, it’s an incredible time to practice medicine. I think eventually we’re going to be able to replace organs, and transplantation will become more mainstream.

The OB-GYN People are educated and allowing themselves to learn more, and I think that’s really important. I’m very optimistic, and I hope that continues.

The ER Doc I think the insurance issue will come into play. I’m optimistic that our healthcare system will be changed for the better somehow. I hope that in five or ten years there will be a better environment.

The Family Practitioner I’m looking forward to the day when I can write down on my prescription pad what a patient needs and they go to the pharmacy and get one pill. Electronic health records and things like that are going to help us deliver better, faster, more accurate care.

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