Aspirin May Reduce Colorectal Cancer Risk

A 1957 Veterans Administration research paper showed that men over 45 years-old who took an aspirin a day had fewer heart attacks and strokes than veterans who did not. This opened the opportunity for people to begin taking aspirin to protect against heart attacks and strokes.

Over the years, the research has been refined with more recent studies separating aspirin use and reserving it for those who have “known” coronary artery disease and stroke as opposed to those with no documented disease just looking to prevent an event.

The United States Preventive Task Force (USPTF) announced that the risk of bleeding in individuals without documented coronary artery disease or stroke outweighed the benefit of prevention taking the aspirin. This conclusion and recommendation ignored the fact that daily aspirin reduced the risk of premalignant colonic polyps, reduced the risk of colon cancer and reduced the risk of several skin cancers.

A publication in the February 15, 2024, Journal of Gastroenterology supported the usage of low dose aspirin to prevent colorectal cancer. A study in Norway covering 10.9 years looked at 2,186,390 individuals. From that group, almost 580,000 took a daily low dose of aspirin. During that period, 38,577 (just under 7%) were diagnosed with colorectal cancer which was a much lower number than expected.

The conclusion is that low dose aspirin daily reduces the risk of developing colon cancer. It does produce an increased risk of bleeding. I will continue to take my daily aspirin and live with the bleeding risk.

Healthy Lifestyle’s Importance for Older Adults with Dementia

Several  years ago, I attended a lecture about preventing dementia. It was delivered  by a geriatrician who chaired the Harvard and Massachusetts General Hospital Geriatric programs.

She began her talk by asking the audience, composed of physicians and nurses, how many of us asked our patients to play brain teaser games, do puzzles and other brain games to prevent the advancement of cognitive dysfunction. Hands shot up into the air all over the room. The lecturer responded, “It looks like we are going to have a great many dementia patients who are great at solving puzzles.”  The balance of her lecture was comprised of praising the importance of socialization with friends and family, regular exercise, eating correctly, avoiding smoking tobacco and limiting your alcohol intake if you wished to remain independent and cognitively intact.

Her viewpoints in the lecture were supported by a recent study published February 2024 in the journal JAMA Neurology. The Rush Memory and Aging Project followed 754 individuals for just under 25 years who all developed dementia. The average patient died at 91 years old, and their brains were donated for autopsy and examination for beta-amyloid load, phosphorylated tau tangles and Alzheimer’s pathology. The patients were evaluated for health of lifestyle with points assigned for not smoking, getting 150 minutes of physical activity per week, limiting alcohol consumption, and eating a healthy diet such as the Mediterranean-DASH diet. Higher point totals meant you lived a healthier lifestyle. At multiple times during the 25-year observation period, participants underwent neuropsychological testing.

The results showed that those with the healthiest lifestyle had the best cognitive function as they aged and at death. Patients could have similar appearing brains with classical pathological findings of dementia and similar loads of beta amyloid and Tau tangles but the individuals with the healthier lifestyle reasoned, remembered and performed better.

The moral of study is the lifestyle you live is extraordinarily important in determining how independent you will be as you age.

Continuity of Care Threatened by Deteriorated Communication Between Hospital-Based & Community-Based Physicians

Medicine in my area of the country has morphed into physicians who care for patients while they are in the hospital  as “in patients” or “ observational status” and outpatients.  Very few primary care physicians admit their patients to a hospital and then care for them while hospitalized. There are numerous reasons for this, mostly economic and initiated by hospital administrations and insurers, but that will be the topic of a future discussion.

In today’s healthcare environment, most hospitalized patients are cared for by hospitalists. These are physicians, nurse practitioners and physician assistants either employed directly by the hospital or employed by a group practice that is contracted to provide services at that facility.

My role as a primary care physician is to present the hospitalists with the reason why the patient is at the emergency department with past records and to provide them with the perspective needed to provide continuity of care. If I know my patient is going to the Emergency Department, I phone the ER charge nurse , review the patient’s case and ask to speak to the physician who will be evaluating them. After I have completed those two calls I send over the records via fax. 

Sadly, the ER physician I have spoken to is often not the ER physician who sees the patient. Also, the records I fax to the ER frequently are not added to the patient’s chart nor are they provided to the ER physician even though I have received electronic confirmation that they were received.

I have arranged to have one coverage team of hospitalists see my patients requiring hospital admission. I text or call that physician to alert them that a patient is on the way.  Unfortunately, the Emergency Department doesn’t always call that doctor to see the patient. In those instances, they admit the patient to the hospitalists resident team instead. I have had numerous phone calls and meetings with the hospital CEO, hospital chief medical officer, the physician leader of the emergency medicine group employed by the hospital and the head nurse in the ER regarding these issues.  My name and the covering physician’s name are clearly listed in their computers and they discuss it at staff meetings but somehow patients frequently end up on the wrong team.

As part of the hospital admission process, the patient’s primary care doctor in the community, and specialists, are usually mentioned in the information obtained upon arrival. That information is certainly included in the documents I send over to the facility. Despite this, it is rare to see a patient admitted to the resident program hospitalists program actually notify those specialists or ask them to see their patient. I call those specialists to make them aware of our mutual patient’s hospital admission so they know to stop by and check on the progress of our patients. 

I use the computer portal daily to follow the evaluation and treatment of these patients. If I have questions or concerns, I speak to the hospitalist physician about it. Upon a patient’s discharge from the hospital, I receive a fax notification from hospital administration notifying me that the patient has been sent home.  I access the discharge summary, print it out and place it in the patient’s office chart and update the medication list if changes have been made in the hospital. For this to be thorough and complete the process requires the hospitalist dictating the summary to be thorough and complete. Sometimes this occurs.

Take the case of Kathy, a 63-year-old woman born with cerebral palsy and suffering seizures.  Since her parents died, she is living with a caregiver supervised by a family member who makes all the medical, legal and financial decisions with the patient supported by funds set aside by her late parents. For unknown reasons, she tragically has had a series of uncontrolled seizures and is taken to a hospital not in my service area. To control her seizures required sedating her, intubating her and putting her on a ventilator to breathe while sedated. While unconscious from sedation she had an arrhythmia requiring starting a new medication to control the rhythm and an anticoagulant to prevent a clot from forming in her heart and traveling to her brain causing a stroke.  Her neurologist and heart specialist were never notified by that facility’s hospitalists even though they had partners who routinely visited that facility. 

Upon discharge, the hospitalist prescribed two days of the amiodarone for the new rhythm and two days of the anticoagulant Eliquis.  They suggested seeing the cardiologist for follow up but the soonest his office could see her was five weeks away.  The discharge summary made no mention of the arrhythmia. The discharge summary did not list the amiodarone or Eliquis.   

The patient’s legal guardian called me to ask about the lack of medications prescribed and basically to have someone explain to him what had occurred. To clarify the situation, my staff contacted the medical records department of the hospital and faxed them a signed authorized medical release of records . We obtained all the daily progress notes and consultation reports. These documents provided the name of the cardiologist who saw her.  It took several attempts by phone before we reached him and he explained what had occurred and clarified what dosage of amiodarone and what length of treatment he preferred and why.   

This research and clarification took hours of non-compensated time.  It was an absolute necessity to insure safe care for the patient. General internists, family practitioners, pediatricians do this daily attempting to coordinate patient care . The lack of interest by hospital administration and overworked employed hospital physicians and staff make being successful increasingly difficult.  The lack of outrage over these incomplete and lazy handoffs is infuriating.

The same families that are furious at the care they receive donate charitable funds to these institutions with few, if any, strings attached about where the money is needed and should go. With for-profit hospital and medical facilities behaving no differently than non-profit facilities and medical groups, and no pressure from the IRS, Center for Medicare Services or insurers, I see no hope for a more professional and thorough handoff of care between the community physicians and hospital-based care.

Nurse To Patient Staffing Ratios are Important for Safety and Outcomes

There is a battle ongoing between nursing associations and hospital leadership. The main issue is that experienced nurses believe there are only so many patients one nurse can care for in a hospital inpatient location before the health and safety of the patients are put at risk.

When I started practicing medicine in a large public hospital in Dade County, Florida the ratio of nurses to patients on the medical floors was 1:4.  Illness and emergency situations often led to a ratio of 1:5 or even 1:6 patients but the additional patients were usually relatively healthy individuals requiring far less attention.

At that time, the ratio of nurses to patients in the critical care areas such as the intensive care unit, cardiac care unit or surgical intensive care unit was usually 1:1.  Staff illness and emergencies rarely led to a ratio of 1:2 but that second patient usually was well enough to require less attention. Only the more experienced critical care nurses were assigned to that second patient. 

There were times when nursing shortages led to the unit’s charge nurse closing beds in critical care areas rather than bringing in patients who could not receive the attention they required. As a clinician and physician let me make this perfectly clear, the quality of the care was directly proportional to the quality and skill of the nursing staff. Good hospitals with good outcomes had great nurses.  In those days the head nurse or charge nurse on a particular floor or ward was usually experienced and had overseen that area for years.  As a physician you quickly learned that if you wanted your patients well cared for, you followed the rules that the charge nurse on that ward or floor  established. There were other differences such as the same nurse cared for the same patient on the same shift daily until that patient was discharged.

In today’s hospital world there is a post pandemic shortage of experienced nurses. Continuity of nursing care doesn’t exist in most places. The ratio of nurses to patients has dramatically increased.  Hospital administrators cite cost constraints and new technology permitting nurses to care for more patients as the reason ratios are climbing above 1:5 today.

Linda Aiken, PhD, RN of the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research is a firm believer in keeping the ratios of nurses to patients low.  The best staffed hospitals in her study maintain a 1:4 ratio while some corporate facilities have a 1:11 ratio.  Her research from a 2002 study reveals that there is a 7% patient death rate increase for each additional patient a hospital nurse is assigned.  The State of California is one of the few states that passed legislation limiting the ratio to one licensed nurse per five patients. Other states have tried but they have run into a lobbying roadblock from none other than hospital administrators and corporate owners.

The quality of the care one receives in the hospital is directly related to the quality of the nursing care and the availability of the nurses to assess the patient and respond to their health needs. A ratio of one nurse caring for four patients should be the goal. 

In my community, for the last decade or more, our local community hospital has behaved and billed no different than the for-profit corporate facilities.  The community is affluent and fund-raising campaigns at extraordinarily wealthy country clubs and oceanside and golf course condominiums raise hundreds of thousands of dollars for the local facility. I ask these charitable groups, “Do you know what the money is being used for?”   The answer is always, “No.” When I suggest that they use the charitable funds to sponsor another nurse on each floor to reduce the ratio of patients to nurses they look at me like I am insane. I stand by my suggestion. 

Ask what the ratio of nurses to patients is at your facility. Ask if the same nurse cares for the same patient on the same shift daily.

If you are generous enough to donate and raise funds for your local hospital, sponsor an extra nurse per shift per floor! It could save your life or someone you love!

Walking Leads to Decreased Cardiovascular Events & Mortality Risk

I have often extolled the benefits of continuing to move. The arbitrary goal of 10,000 steps per day seems to resonate throughout the community but peer-reviewed published studies show that with far less walking you receive a strong positive benefit. Timothy Overton, MD MPH and associates published a study in the Journal of the American College of Cardiology that showed as little as 2,600 – 2,800 steps per day reduced your risk of a cardiovascular event and mortality risk. In their study, participants achieved additional benefits when walking up to 8,800 steps per day. Above that level, there was continued improvement in reducing cardiovascular events and reducing the risk of mortality, but the improvement numbers were not considered statistically significant.

Dr. Overton’s study examined the data of 111,309 people from 12 different published studies examining the relationship between step counts and cardiovascular event rates. With 2517 steps per day there was an 8% reduction in all-cause mortality. This increased to an 11% reduction in all-cause mortality with 2,735 steps per day, an addition of just 200-300 steps.  The reduction in mortality and cardiovascular events continued with increasing step counts to 7,126 steps.

Any additional benefit was not considered statistically significant. This did not necessarily mean more steps didn’t help. It may very well have to do with the number of individuals in the study walking that far. That subject needs additional study. 

The study did not define whether there was a benefit to accumulating your steps over the course of the day or all at once in one exercise period. Those studies will need to be done.

What is clear is that you don’t have to hit 10K steps a day to benefit and walking just 2,600 steps per day reduces cardiovascular events and mortality risk. As the weather cools down, find a safe course to walk and get your steps in.  It could save your life and certainly improve its quality.

Shared Decision Making or Covering Your Liability?

Much has been written about patient / physician relationships and sharing decision making responsibility with your patients and their health care surrogates. My concept of shared decision making involves explaining to the patient exactly what the conditions are you are dealing with and trying to remedy.  It involves outlining the choices and options to both evaluate the problem and treat it. That outline should include the physician’s preference for evaluation and treatment and why these suggestions are made. The patient then has the information to ask questions and make their decision.

In reality, that is not occurring especially the part that requires the physician to explain what options they prefer and why. What’s worse is when the patient declines the best option. The physician then documents it on the chart as “ Patient declined suggestion” to lower their medico-legal risk.

This past week’s experiences provide examples.  An 80+ year old patient of mine with dizziness for several days decided to self-refer himself to the emergency department in the middle of the night.  He had no vertigo or loss of consciousness or slurred speech or motor or sensory changes. The patient had not discussed any of these multi day symptoms with me or with his  very responsive cardiologist or neurologist.  He did call me at 3:00 a.m. Saturday morning to let me know he was in the ER. I awoke, logged into the hospital computer electronic health record system and reviewed the very appropriate and complete and thorough evaluation planned by the ER physician and staff.  

Two hours later a physician assistant observed him walking and reviewed the tests and felt he was well enough to go home. An EKG had been read as revealing changes which could be associated with acute poor blood supply to the heart muscle or ischemia.  The Emergency Room physician’s official note says he offered the patient admission to the hospital to stay and evaluate this and the patient declined.

I called the patient at a reasonable hour and, while feeling better but tired, he insisted that no one had ever suggested he stay or that there might be a cardiac problem. I have no idea if the physician actually said, “I think you should stay because your EKG has changed and that may be related to your dizziness.” I suspect that message was never delivered. Instead, the patient received the message, ”Your neurological symptoms have disappeared and the brain CT scan is normal. What do you want to do?”

A similar situation occurred the next evening when at midnight I received a phone call from a family member whose spouse had tripped and fallen in her bathroom putting her head through their dry wall.  There was a cut on her scalp bleeding profusely but she seemed to be neurologically intact.  The patient was 69 years old and had been taking aspirin for aches and pains and occasional ibuprofen. There was no loss of consciousness.

The fall was not related to alcohol ingestion or recreational drug use but probably was related to a foot and ankle orthopedic issue and knee issue that should have been addressed after previous falls. I suggested they go to the local ER and be examined.  They followed my advice and at the ER she was examined and treated. The ER doctor told her she had no neurological abnormal findings and inquired whether she wanted a brain CT scan to look for brain bleeding or injury.  The patient declined. In the official record it is stated that the physician suggested a CT brain scan and the patient declined. At no time did the ER physician say , “I think a CT brain scan without contrast would be a good idea based on your use of aspirin, your age and the trauma involved.”  

The ER physician next asked if the patient wanted her to suture the wound with staples or not. No explanation of the options and reasoning behind choosing one option or the other was advanced. The patient chose no suturing and chart was documented as a suturing offered but declined.

At the very least, patients have to ask “What choice do you think I should make and why?” It would also be acceptable to ask, “If I was your mom, what would you suggest and why?”

Has the Business of Medicine Ruined Health Care?

Early in my career if I had an elderly patient recovering from an illness or surgical procedure and their condition required an extra inpatient hospital day, I just looked at the chart and found some chronic condition still not “normal” . I wrote a note in the chart documenting it and the patient stayed put. Most of the time the reason was medical. Sometimes it was logistical, such as a family member flying in to be the caregiver and unexpectedly delayed. Sometimes it was about a hospital bed or wheelchair or nebulizer unavailable until the next day. I deferred to caring and compassion.

As we moved into the 1980’s and 1990’s, and managed care evolved, a new hospital employee position replaced the “social worker” called a “ case manager”. They would discuss “ Length of Stay or LOS” and tell us reckless spenders how much we were costing the hospital. This didn’t jive ever with the annual financial report card I received from that facility  in the first quarter of each year on patients I cared for while hospitalized. There was not a year where I had not made the facility at least $250,000 in profit and that was only from the inpatient data. I kept a copy of that report with me when I made rounds and, as an independent practitioner not employed by the institution, I had the ability to put my patient first and remind administration each time they complained.

I bring this up because I read an article in the New England Journal of Medicine this week written by a young physician complaining about how the hospital employed physicians discharged patients routinely before their evaluations were complete. He cited examples of how this practice delayed the diagnosis and life span of the patients. The author felt great compassion for the patient and the hospital based employed  physicians who are under tremendous contractual pressure to discharge quickly and keep the admission profitable. This is occurring in for-profit hospitals as well as in  not-for-profit hospitals.

At the same reading session, I read an article discussing the problems that occur when an older adult is admitted to the hospital for an illness which the authors, in retrospect, believe could have been handled while the patient stayed at home. In 40 years of practice, I know of no situation where a patient who could safely stay at home was hospitalized for physician profit.

Do you have any idea how inconvenient, inefficient and cost ineffective it is  for a physician with an office-based practice to care for a hospitalized patient ? You have to get there before daily office hours, return after office hours and handle dozens of phone calls from nurses, aides, pharmacy staff and physical therapists – not to mention family members.

“The suits”, business investors, insurers and employers, plus CMS and our elected Congressional officials, have cut the heart and caring out of medicine. I stopped going to the hospital at the  start of the pandemic when hospital officials limited who could see patients as a means to slow the spread of infection. When it was considered safe to return to the hospital, the control of administrators over care decisions had expanded so much that it was clearly uncomfortable to work there.

My physician partner, who covered my practice when I was out of town or ill, refused to  return to hospital care for just this reason. It left me without backup.  I explored returning but the care and concern by hospital staff were so different and so robotic I felt that if I returned I would end up in a shouting match trying to advocate for my patients and lose my credentials anyway.            

My local hospital was built because emergency care was not available for two youngsters who died enroute to a distant hospital in the early 1960’s. The facility was built by the community and recently sold to a major not-for-profit chain. Just prior to the sale, they  closed its pediatric unit because it  was not  profitable. However, they continue to have a profitable labor and delivery program and continue to deliver babies. If those newborns become ill they are sent to hospitals 35 – 40 minutes away. If a child is brought to the Emergency Room and requires admission to the hospital, they too are transferred to a pediatric unit in Broward County or the one in Palm Beach. This is what occurs when financial people run healthcare.

The influence of ‘ business” on medicine has even infiltrated into medical schools where students are encouraged to become employees and work shifts for balance of life reasons rather than enter their own private practice and develop lifelong professional relationships with patients.

An article from Canada talked about the importance of primary care in treating chronic illnesses. With an aging population of baby boomers, preventing and controlling chronic problems is essential to the health of the citizens and the financial health of the country. 

In Canada, with a national health system, less than 1% of the caregivers are nurse practitioners or physician assistants. You are evaluated by and treated by a physician. Hospitalists( hospital-based and employed physicians) were the creation of a bunch of residents at University of California San Francisco who, upon completing their training, had no idea what to do with their careers. Their mentors in academia detested their time away from their research while out on the wards supervising the care and training of internal medicine physicians. They hired these doctors to perform their clinical duties and responsibilities so they could continue to teach and conduct research. Hospital administrators loved the concept because by employing them and making it difficult for community based independent physicians to come to the hospital, they had a mechanism to control costs and length of stay. Insurers and employers loved them for the same reason. Nurse practitioners and physician assistants were adored for the same reason.

Hiring a “mid-level” provider is far less expensive than hiring a physician. The original wave of NPs and PAs came from experienced nurses with years of  experience in the field. Bringing them back to school for training and then supervising their postgraduate clinical experiences produced some outstanding clinicians. The new breed of mid-level providers come from students with two years of experience only. While a physician in training is supervised for a minimum of 144,000 hours, the oversight on mid-level providers is far less. Asking them to be the chronic care supervisors in the USA may help the bottom line of insurers, employers and hospital systems but it does little for senior citizens.

My advice to patients is simple.  Find yourself a well-trained independent physician who actually sees patients. Stay away from HMO plans unless it is a superior product like Kaiser Permanente. Stay away from Medicare Advantage plans. They are not the same as traditional Medicare. They cost less for patients but the price you pay if you get ill in terms of choice of physicians to care for you and facilities can be very limited.

If you can afford a concierge physician or direct pay physician with a small practice it is well worth it.  If you get hospitalized you need a savvy advocate who knows health care to be there with you.  Write your Congressman and advocate  against Medicare Advantage plans which actually cost more per patient now than traditional Medicare. If your care is switched to a mid-level provider, ask that provider how much clinical experience they had in nursing prior to entering NP or PA programs. Scrutinize them the same way you would view the credentials of a perspective physician. Lastly, ignore their online reviews. In general, online reviews are written by patients who are dissatisfied and don’t necessarily represent the overall sentiment the majority have of the provider.

The Death of Private Practice: Who Will Take Care of Me????

I was trying to reach a colleague to discuss a mutual patient who was seeing this surgical specialist on my recommendation and referral for years. The call went to an automated attendant answering system during normal business hours. The answering system did not give me the option to identify myself as a physician who was calling about a clinical issue of importance. My staff had made several calls about this matter to this office earlier and had left messages with no response. The specialty physician was supposed to have returned to the office to see patients two weeks ago but still was not back or seeing or scheduling patients.

I noticed subtle changes in this family-owned practice over the last few months. The front office staff had completely turned over. The previous staff greeted you by name with a smile when you walked in. During the pandemic you saw the smile and felt the warmth right through their surgical masks which none of the current staff were wearing. I decided that my colleague might be ill and not seeing patients due to the recovery process and I felt terrible about not reaching out, so I texted her on her cell phone. The story I heard gave me chills and goose bumps of fear and concern.

This well-established respectable family run practice with the physicians nearing retirement age and needing extra cash to cover the medical expenses of a relative. They had sold the practice to an investment firm. The contract called for the staff to remain the same. Management made the lives of these experienced workers so miserable that they left within 90 days. The new staff answered only to management. The volume of patients increased. The time allotted for patient visits was diminished. It became increasingly clear that the physician owners had little or no control.

A technician in the office who is well respected and experienced received a phone call from Human Resources at the investment firm claiming that they believed the physicians were sexually harassing the new staff and creating a “hostile work environment”. They told him that if he expected to keep his job they wanted a phone call within two weeks documenting the sexual harassment he was experiencing. Having worked at this practice for two decades, the employee had never experienced hostility or sexual harassment. Two weeks later he received a similar call and he told them the climate was professional and pleasant. The technician brought these baseless claims to the physicians who were being bombarded with calls from physician colleagues saying no one was answering their phone calls or returning them.

The now employed doctors called the staff together and demanded that they start answering the phone calls and giving them messages. The new office manager told them that they were busy and they answered only to management.

Two hours later a senior partner in the firm arrived with an attorney and fired the doctor for creating a hostile work environment and sexually harassing staff. Her restrictive covenant prevents her from practicing medicine in this area for a defined period of time. In a flash, an investment firm had destroyed a successful practice for the purpose of quickly offering their shareholders a better dividend and return.

This is not an isolated story. I see the same story repeated with firms affiliated with all the local health care systems and hospital systems buying up practices, changing over the staffs, driving out the experienced physicians and replacing them with mid-level providers who are cheaper to employ and retain.

A physician shortage coupled with young doctors being indoctrinated in medical school and residency to become employees coupled with the extraordinary educational debt they carry make for very few physicians willing to take a risk on practicing independently. Balance of life is a big subject among young physicians so many prefer to work a shift and go home with no off-duty professional responsibilities. The problem for patients is no one is there to be their advocate, coordinator of care and physician when they become ill. If they can get a human being to answer the phone when they are ill and call, the response is usually, “If you are sick please go to our urgent care center. We don’t see sick people.”

When a practice gets bought by an investment firm or large health care system, the first thing I notice is the institution of the automated attendant phone answering system. Next comes the staff changes. Familiar faces disappear and less expensive, less customer service-oriented personnel arrive. Next comes balance billing. In the past, these practices billed Medicare and the patients’ secondary insurance for payment. Now if there is a small balance left after those payments are made, they go after it with a vengeance .

I repeatedly hear the cry, “I want transparency in medicine. I want my office notes and labs immediately available online via a patient portal even if the doctor has not had a chance to see them yet”. How about transparency in who owns the practice and who makes the decisions about scheduling, time spent with patients and which messages will get through to the doctor? If a practice is sold to a private entity, it should be required by law to inform every existing patient and place public notices.

Frustration of a Technologically Challenged Physician

Recently I tried to log onto my hospital system electronic health record to check on the status of a patient. This patient is elderly, severely mentally incapacitated and being cared for by physicians on the neurology service. Her son, a practicing physician at the same facility, had not received a return phone call from any of the inpatient physicians and wanted to know why his mom needed a lumbar puncture (spinal tap). As a member of the staff and her outpatient physician, I attempted to log into the system and answer his questions or at least find the contact information he needed to find a physician to talk to.

My local community hospital has recently signed on to be a member of a large regional not-for-profit hospital system. In the past I would access the hospital website and enter my user ID and password to log in. Now I must first enter the health system data base using several levels of authentication which proves it is me and not some mercenary trying to introduce a virus or kidnap the system. If I enter my information correctly a prompt is sent to an app on my mobile phone. I must access that app and then, if I enter everything correctly, a new sign-in window appears from my local hospital.

On this occasion, I miraculously performed that task flawlessly and suddenly the log in screen appeared. I entered a different User ID and password and clicked on the “log in “ tab. A new window appeared asking if I had downloaded a Citrix receiver. I clicked on the tab that said, “I have already downloaded a Citrix receiver”. It replied that it could not detect the receiver. So, I chose the option to “download Citrix receiver” . A new window appeared. I clicked on it and suddenly I was inside the system.

I used my mouse to click on the patient electronic health record portal I always used and up popped a new question asking what software app I wished to open this system with. It gave me a choice of six different ones. I did not have a clue what to do so I called the local hospital phone line and asked the operator to connect me with “Anna at the hospital Information Technology (IT) help desk.” I was told rather brusquely that she didn’t know each employees’ individual phone extension, but she would connect me to the general number.

The next thing I knew I was told by an automated system that I was connected to the general health system IT help line and number 16 in line. The expected wait time was 90 minutes. I hoped they would give me an option to leave a phone number and they would call me, but none was given. I hung up and went back to the computer screen that had given me a choice of six options. I chose number six and the screen turned into unintelligible numbers and letters. Clearly, I had made the wrong choice.

At that point I quit. I turned off the computer, picked up the phone and dialed the hospital phone number. When the automated attendant answered I pressed zero to speak to a live operator. I was connected with a different message and again pressed zero for an operator. A message came on saying all the operators were busy with calls. Several seconds later (felt like minutes) an operator answered. I identified myself and asked to be connected with the neurology ICU. A human being answered the phone. I again identified myself and asked for the nurse who was caring for that patient. She came to the phone, was pleasant and professional, answered all my questions and promised to ask the patient’s in-hospital attending physician to call the patient’s son who is a doctor.

What should have been at best a five-minute operation took at least 25 minutes and I am still left with having to reach someone tomorrow to learn how to get rid of the program that did not work and choose the program that will work.

When I used to make hospital rounds prior to the millennium, I would spend 10- 20 minutes with a patient and a few minutes documenting the visit in the chart. I now understand why hospital-based physicians complain that they have no more than five minutes to spend at the bedside while spending 15 – 20 minutes in front of the computer screen trying to document what they did during the five minutes at the bedside. There has to be a better way!

Why I Switched to Concierge Medicine in 2003

I have been practicing in my independent concierge style practice since 2003. When I decided to switch from a traditional practice to a concierge membership practice, I was examining 25 to 35 patients per day in the office plus about five patients spread between three local hospitals.

At that time, managed care , with the blessing of the Center for Medicare Services (CMS), and private insurers, was flourishing . Patients of mine were now being directed by their employers and insurers to switch to doctors who had contracted with them and agreed to see these same patients for seventy-five cents on the dollar. Lab work performed in my in office “certified” lab was being directed away to national chains like Quest and LabCorp.

To make up the difference in lost income, I was advised to be more efficient and see more patients per day. So, on some days I managed to see 45 patients.

I gave it my sincerest effort in the beginning.  However, it quickly became clear that patients like Mrs. Smith, who joined the practice at age 45 and suffered from an occasional ache and pain from doubles tennis, was now 20 years older. She went from taking an oral contraceptive for perimenopausal hot flashes and irregular menstrual bleeding to being on a low dose of three blood pressure medicines, one cholesterol lowering medicine, two eye drops for glaucoma, one weekly pill for osteopenia and an anxiety / depression pill prescribed by a psychiatrist to help her deal with becoming an empty nester. She went from having two physicians, her internist and gynecologist, to having five or six. Coordinating her care in 5 to 10-minute office visits, advised by the administrative experts promoting managed care, as less expensive meant you never comprehensively covered anything. Thus, it quickly become blatantly obvious to me that taking care of fewer patients very well, by investing as much time as needed to do so, was far superior to taking care of 3,000 patients in a rushed, piecemeal fashion.

Concierge medicine in my practice offers you time and availability. New patient visits are allotted 90-120 minutes to allow the patient and me to get to know each other well. Return or follow-up appointments are generally 45 minutes long. Availability to see your physician, plus time spent being proactive with your care rather than reactive, is proven to improve health outcomes and reduce ER visits and hospitalizations.

During regular office hours, my staff answers the phone not an automated attendant. For after office hour emergencies you have the option of calling my cell phone directly.

Patients phone calls are returned the same day. Requests for prescription refills are completed before the office is closed at the end of each business day. If a health concern requires same day attention, I will see you in the office or send you to the emergency room, depending on the type and severity of the concern. 

By having more time to spend than I did in a regular practice, I am able to advocate for my patients.  I doggedly do so whenever the situation requires it.

When your medical condition warrants you be seen quickly by a specialty physician, we call their office and make the arrangements. We are fastidious in making sure what we call an emergency is actually a medical emergency so when we call and ask for a quick appointment, they appreciate the fact that we respect their time as well as our patient’s.

When prospective patients arrange a complimentary “meet and greet “ session with me. we stress availability, time and advocacy. My staff is customer service trained, oriented and compassionate.  My practice is set in a convenient location with a relaxing atmosphere.

There are fewer and fewer primary care doctors coming out of medical school and residency programs. Most of those that do are faced with six-figure student loan debt and lifestyle pressures which makes an  employed position with a for-profit look appealing. However, their contracts have volume and revenue generating parameters which, if not met, result in termination or less compensation offered the next contract period.

A few enlightened ones find concierge medicine or direct pay membership practices and remain independent so that their relationship with the patient has no insurer drug benefit manager or pre procedure authorization company standing in the way of the health care you and your doctor decide you need!

I began providing concierge-level care in 2003 because at the end of every day you have to be able to look yourself in the mirror and say that you did the best job you possibly could!  Making the decision to change to concierge medicine was the right decision for my patients, and myself, and I’m glad I made it when I did!