Monday, October 15, 2012

The Nitty-Gritty of Testing

     A good family doctor puts a stethoscope on every patient's heart and lungs.  No one argues with this testing, despite report after report about the low yield of physical exams when it comes to finding serious pathology.  In addition to the stethoscope exam, I also look at or palpate every patient's eyes, ears, scalp, nose, throat, skin, abdomen, back and legs.  Research doesn't show that this uncovers disease, either, at least not directly.
     I do real exams, anyway.  First, they're quick and easy.  Second, I never know what I might find.  Third, it's a laying on of hands, a way to connect with the patient, proof that I'm not afraid of what I might find.  Fourth, the more often I do a physical exam, the more sensitive I become to the small findings that point to sleeping wolves.  Fifth, they are proof that I care.
     Consider my new pond.  The first ten times I walked around it, I didn't see much:  deer tracks, eagles in the sky, water.  The next ten times I saw more:  raccoon spoor, phlox blooming under the brush, mole trails, tiny white flowers on the tufts of the long grass.  By the hundredth go-round, I was attending to the stick bugs underwater, and paw prints belonging to a coyote.  Now I notice new anthills, the slime-paths left by slugs, gelatinous clusters of frog-eggs, a sandhill crane's nest.
     Doing the same thing day after day turns doctors into highly sensitive seers.  We may not "find something" directly, any more than I have found the actual raccoon when I see its five-toed print in the sand, but little discrepancies make us say, "Something's up, here--your thyroid isn't supposed to feel like that, your belly shouldn't have a little fluid wave, your heart has a new don't look right."  Cancer has a certain look.  Strep has a smell.  Liver problems make the skin look devitalized.  An ailing heart or narrow carotids come across as a certain lassitude of speech.
     Are we supposed to write this stuff down?  Are we supposed to make it intelligible to a coding clerk who's following orders to downcode, reduce payments, deny coverage?  Does anyone really believe that what a specialist in any field is doing can be quantified, item by item, in a linear way?
     There are certain tests doctors are expected to do, whether there's a symptom or not.  Mammograms and colonoscopies fall into this category, and so do "vital signs" like blood pressure, body-mass index, temperature.  Pap tests used to be de rigeur, until lately when the rules changed again, and got too complicated to remember.  Official guidelines make it bad medicine for us not to obtain screening tests on certain populations.
     Other tests require a symptom, or an abnormality found during an exam.  There's a lot of  latitude here--and that's the gray area insurance companies (and the federal government) are banking on, when they take back money.  They inform me, for instance, I shouldn't have done an EKG on a patient, and I won't get paid--because the reason for the test ("patient has palpitations") is written on the EKG paper, next to my interpretation ("PVC's" or "bundle branch block")--proof that I made a diagnosis after the fact.  That's their phrase--what are they talking about?   I didn't write in the chart note that the patient had a symptom--therefore, I didn't have a reason to do the test.  I'm told, in so many words, that I "made up a reason" to do an EKG.  I've stopped fretting and arguing about such stupidity, and order  EKG's whether they'll be paid or not.
     Maybe this is the reason the government raided my office:  I must be doing tests that aren't necessary.  That EKG "wasn't necessary" because the patient's complaint was elicited by me through questioning, rather than volunteered at the outset.  Never mind that it may reveal a problem.  Similarly, when I order ultrasounds because of subtle findings during a physical exam, or because of things patients tell me when I explore the vague territory of a symptom, the government may also consider them unnecessary.  
     Since when did the government get in the business of medicine?  Is this really what Obama was bragging about when he said how much money has been "recovered" in anti-Medicare-fraud efforts?
     The tests I order are an extension of my eyes and ears, confirmation and documentation of what I think I perceive.  It's the proper use of this equipment:  diagnostic detective work.
     I could send patients to the hospital for these tests--a needless inconvenience and postponement of results.  But insurance companies would save, since half the patients probably wouldn't show up.   I could skip the tests, guessing about the diagnosis, instead.  Or I could simply bank on the odds--most patients don't have serious problems.  Why bother thinking about them?
     Now, that's a game plan that could save everyone money this week.  Do as little as possible.  Try not to think.  Keep my eyes and hands off patients.  Don't order tests.
     Come to think of it, that's exactly what my billing specialist told me last week.  He processes the payments--I mean, non-payments--for the clinic.
     "Don't do any tests on Medicare patients," he commanded me.  "Don't do anything--just the visit."
     And then, to prove his point, he flashed a Medicare EOB with zeros all the way down:  "You're not getting paid for them, anyway."  
     It's true.  The government's agents at Medicare have been sanctioning me through non-payments for being too thorough.  It's a waste of money, they say.  Until, I bet, they're the ones with a medical problem.

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