Musings of a Dinosaur

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Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, April 21, 2010 I've Moved

I've taken the plunge: come visit at my new WordPress site:

Musings of a Dinosaur

(For those who are cut-and-paste-challenged, all you have to do is change "blogspot" to "wordpress" in the URL.)

Same rants; same writing; different look (but still no ads).

posted by #1 Dinosaur @ 4:02 PM 2 comments

Tuesday, April 20, 2010 Buggy Blogger

Breaking one of my rules here ("Blogging about blogging is boring,") to apologize for buggy Blogger hiding posts. Looking into migrating to another platform, and hope to be up and running my mouth off again real soon.

posted by #1 Dinosaur @ 6:03 AM 0 comments

Tuesday, April 13, 2010 More on Palliative Care: Be Careful What You Wish For

My previous post has generated a gratifyingly large response that has been remarkably civil, for the blogosphere. I half-anticipated commentary along the lines of, "Dino, you ignorant slut," which is par for the course on the internet, and frankly, half the fun, given that none of it (for the most part) is intended or taken personally. In fact, it can be quite amusing to watch the fur fly publicly while exchanging warmly professional emails behind the scenes.

The major thrust of several comments was along the lines of, "Sure, it would be nice if all Primary Care docs could do palliative care, but with the current payment system, they just can't manage it." That's straight out of the 10th Law of the Dinosaur, "A bad idea held by many people for a long time is still a bad idea." The system is stacked against us, so we shouldn't even try? Sorry; I refuse to give up that easily.

Medicare and other payment systems have a provision for time-based billing. When more than half of the face-to-face time is spent counseling the patient, reviewing treatment options, etc. then the total time spent in the encounter can be used as the determining factor for payment. News flash: the topics discussed are NOT REGULATED. "Death panels" (ie, the proposed payment once every five years to discuss end of life issues) aside, I can and do (and always have) bill specifically for those visits.

The point was also made that although Family physicians could provide these services, too many of them don't. Point made; shame on them.

The whole "team" concept is also a red herring. I utilize all kinds of other professionals to care for my patients. I regularly call upon psychologists, visiting nurses, social workers, chaplains, and others for their help and expertise. Calling us a "team" is nothing but a semantic boost to the morale of professionals insecure in their role in patient care. Perhaps in the highly hierarchical hospital setting where contemptuous physician attitudes may be more on display, enforcement of the Team concept, complete with meetings and name tags, may seem useful. But out here in the real world, I able to communicate extensively with my non-physician colleagues -- including how much I value their expertise --without wasting their valuable time with "team meetings."

The real issue is the "Specialist" label. While not denying that the increasing body of knowledge about the relief of symptoms and management of patient care at the end of life may warrant specialty status, what are the actual advantages to patients of this further fragmentation of medical care? In fact, a recent article in the New York Times (discussed here and here) seems to point out the enormous disadvantage of palliative care physicians' proud assertion that they love to care for dying patients: if that's what they do, then a referral must mean the patient is dying!

Added to this is the American obsession with "the best;" the newest, the shiniest, the most expensive must be somehow "better." Better than what? Why is the concept of "good enough" so difficult to grasp? Although the fellow who places last in medical school is still called "Doctor," there are hundreds of fully qualified students for every spot. I firmly believe that grading medical students (and residents, for that matter) on any basis other than pass-fail is meaningless for that very reason.

Once you set Palliative Care up as a "Specialty," complete with board certification and all its administrative falderal, you are presenting to the public that you are the only ones qualified to provide this care. After all, if you're Board Certified in Palliative Care, the care you provide must by definition be "better" than that provided by someone not so accredited. It's similar to the unfortunate perception that only a cardiologist can manage high blood pressure, you need a pulmonologist to care for asthma, and you must be getting suboptimal care for diabetes if you don't see an endocrinologist.

How much more compassionate might care be at the end of life if, instead of being seen as yet another distinct specialty, palliative care were viewed as a vital, integral part of primary care. There would be no shifting of emphasis from "curative" to "just" comfort care, because symptom relief would be part and parcel of all phases of treatment. And who best to care for people at the end of their lives than those who have cared for them through the rest of it?

I do believe that self-designated Palliative Care Specialists should have important roles in academic and consultant capacities. Rather than a knee-jerk "referral to palliative care" when the going gets tough and the end may be approaching, I'd love to see primary care physicians in the forefront of caring for these patients, with consultant backup from our Palliative Care colleagues. Recently having dived into the archives at Pallimed, I've developed a new appreciation for the academic study of death and dying. But I still don't think Palliative Care needs to be an independent specialty.

posted by #1 Dinosaur @ 2:44 PM 5 comments

About MeName: #1 Dinosaur Location: Malpractice Crisis State

View my complete profile

About this Blog

They say the solo Family Doctor is extinct; gone the way of the dinosaur.

Well, I've been in private practice for twenty years and I'm still kicking, so here's my blog.

Until they drag my cold, dead body off into the tar pit, read about my trials and tribulations -- and the joys and triumphs, which are what keep me going.

I'm also embarking on a new career as an author. You can read my first book by ordering it below. If anyone worries that I may become so successful with my writing that I will give up my medical practice, rest assured: writing is something I do; doctoring is who I am.

My Book and
How to Buy It


Choose your site: Amazon Barnes ve Moved Buggy Blogger More on Palliative Care: Be Careful What You Wish For Answers to Questions No One Asked Stating the Obvious It Happened Again, Dammit! Waiting and Seeing 100 Days Here, 100 Days There Never Saw That Before Message From my Father Archives August 2006 September 2006 October 2006 November 2006 December 2006 January 2007 February 2007 March 2007 April 2007 May 2007 June 2007 July 2007 August 2007 September 2007 October 2007 November 2007 December 2007 January 2008 February 2008 March 2008 April 2008 May 2008 June 2008 July 2008 August 2008 September 2008 October 2008 November 2008 December 2008 January 2009 February 2009 March 2009 April 2009 May 2009 June 2009 July 2009 August 2009 September 2009 October 2009 November 2009 December 2009 January 2010 February 2010 March 2010 April 2010 Family Posts Thirty Years: Then and Now Road Trip Ultimate Sunday Baking Football Adventures of the Mighty Hunter The Party That Wasn't Gardasil Posts Argument Against Killer Salmonella Boiling Blood Chronic Lyme Posts The Insult Growing a Thicker Skin One More Time CAM The Real issue with CAM More on "CAM" Complimentary Medicine Be Careful What You Wish For NOT ME! (Spring 2006)

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