In the early 1980s, I made almost all my decisions in conjunction with my patient, together with the specialists we deemed appropriate in a given case. It wasn’t but a few years before modern medical “oversight” or “management” began to assert itself. This started first with government programs, soon followed by big business. Docs were forced to learn a new set of skills to overcome these obstacles to the delivery of care.
Early on, it was a benign process. Every once in a while I’d get a call from old Doc Smith who’d ask about a case. I knew him from State Medical Society meetings. Retired, he’d never made all that much when he was in practice, so I understood his need to supplement his income. I’d even taken over some of his patients, so Doc Smith knew me well. He wasn’t going to scoop me on much over the phone. I had the advantage of being the doc who saw the patient, and we both knew he wasn’t in a position to compete with that. Doc had to call every so often. I understood. He’d call and ask a few questions, and I’d tell him in doctor terms about where to go, and we’d laugh.
By the mideighties the minor nuisance grew to a downright disruption of patient care. I remember a fellow I had followed since I started my practice. I inherited him when a local doc retired. The patient was elderly and had multiple medical problems: several heart attacks, a pacemaker revised several times, bad kidneys, bad lungs, but he was a heck of a nice guy.
My first hospital admission for the patient was for an episode of syncope (they call it “falling out” around here) and the situation was complex, so an extensive workup was undertaken. Both carotid arteries had partial blockage, but the surgeon said that the literature showed that only the worst side of a 70 percent blockage warranted intervention. (Here is a country doc tip for you: if a surgeon doesn’t want to operate, I would take that advice very seriously.) I talked it over with the local cardiologist, we ran everything by the big boys at the Medical Center, and everyone agreed to a treatment plan. With some adjustments in medication, we sent the patient home. Surgery, at least at that time, was not indicated. A week later, he had an unanticipated TIA (near ministroke), which thankfully resolved. Due to the change in circumstances, the surgeons changed their minds and proceeded with surgery to correct his right carotid artery blockage.
The patient did well, and he went home satisfied with the outcome. For him, it was the end of that chapter of his story. For me it was the beginning. Six weeks later, I got a letter from one of the Medicare review boys, who determined the first admission to be unnecessary. I knew my patient could get stuck with the tab, so I began to compose a letter of explanation. Before I could complete it, I had a second letter on my desk from a different review bureaucrat (I call them chart jockeys). This jockey determined the second hospital stay was due to a premature discharge from the first admission. I have a fair amount of education, but I was confused. How can one be discharged too early from an unnecessary admission?
I found it a silly demonstration of the lack of medical sophistication on the part of the reviewers, but I did not anticipate the intense effort required to win this battle. However, I lost the war. Years later I noticed reviewer number one had his name on a government medical complex, and I assure you I will labor in obscurity until the end. I’ll consider myself lucky if I just stay out of trouble. I was the doc for my patient until the end, when he died of plain old, very old, age. Every so often we delighted in laughing at the incompetence of those chart jockeys.
(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)
Dr. B talks about the chart jockeys. Today they come in many forms. If the clinic is part of a health system, the chart jockey may be the quality review folks who review patient charts for each clinician looking for patients who are lost to follow up or are out of compliance with recommended treatment. They can be helpful. Thanks to electronic health records (EMR or EHR), we can pull up lists of patients based on diagnosis codes (ICD-9, soon to be ICD-10). As a result, I can look at all of my diabetics and know who has been in the clinic in the last 6 months and what their lab values are. With diabetics we aim to keep their HGBA1C under 8. (Glycosolated hemoglobin-the measure of sugar molecules on a red blood cell gives us an idea of how well a patient’s diabetes is under control over three months, the life of a red blood cell.) Then the nurse and I can figure out which patients we need to contact and ask them to come into the clinic. In the old days, we waited for patients to come to us. Today we make more efforts to reach out to patients, especially patients with chronic health problems. With diabetes we know that certain medications and checks actually keep patients healthier and prevent or delay kidney failure, loss of vision and amputations.
The chart jockeys can be a nuisance when I have to jump through hoops before I can order a treatment or medication–often call a prior authroization, especially if it is what I know I need to do for my patient. On your rotations you will hear lots of clinicians complain about the paperwork or phone calls that accompany this. It is all an effort to avoid unnecessary treatments, identify fraud and to manage cost. Often it consumes time and energy for staff that interferes with caring for patients.