Thursday, December 12, 2013

Unorthodoxy Is Not Criminality

     I have a philosophy about practicing medicine.  It's simple.
     When a patient sees me, I believe I should find out what's wrong.  I should even try to find out what might be wrong--or might go wrong--before the patient suffers.  The patient may have no conscious knowledge that a serious problem is lurking;  nevertheless there are clues.  It takes a third ear to hear them, and it takes time.
     Non-invasive, in-office tests can be a big help with those little symptoms.  Family doctors should use them on a regular basis:  labs, ultrasound, x-ray, cardiac testing, vestibular testing, biopsies, nasopharyngoscopy.  It's better to spend a little money up front in order to save a lot down the road.  Is anyone counting the dollars not spent, down that road?
     For all the hype about preventive medicine these days, I don't think family doctors take time to do preventive medicine.  If they did, they'd have hour-long visits with patients.  There are too many guidelines to follow and too many bad habits to challenge.  Because family doctors treat the whole body, patients have a lot to say, most of it prognostic--and on top of that, they want a real doctor-patient relationship.
     And they don't want blandishments.  They want doctors to do tests to find out why they have symptoms.  But we can't practice like this any more.  There are no more Marcus Welbys:  they've been winnowed out by megamedicine, a conglomerate of ruthless medical groups with MBAs and investors at the top and no affection for bedside manner.  The capitalists who are now in charge (including the U.S.  government, which has discovered it, too, can get rich on doctors) demand that doctors churn out patients like chickens on assembly lines, and charge for doing almost nothing.
     The most common complaint I used to hear from new patients in my practice was:   My last doctor didn't do anything.
     It's because I did so much and took a lot of time in the exam room that I had so many patients.
     And it's because I did so much that the federal government has decided that, as an outlier, I must be a criminal.
     Before I took up solo doctoring I was privy to the many strategies used by doctors for getting patients to be quiet so their visits would be brief.  Bring a stopwatch into the room.  Point to the clock at the start of a visit and tell patients they have exactly five minutes.  Refuse to listen to more than one or two complaints per visit.  Never sit down--it conveys to the patient that you have time.  Hurry out to avoid those "by-the-way" questions patients pose when your hand is on the doorknob ("Doctor, what's this chest pain I've been having?").  And never ask about anything that matters:  alcohol, drug use, loneliness, relationships, insomnia, incontinence, depression, fatigue, domestic abuse.  At least, don't ask about anything for which there isn't a pill you can prescribe in a minute.
     By now everyone has heard of the 1984 Beckman and Frankel study which reported that physicians allow patients about 18 seconds to talk before interrupting them (Ann Intern Med 1984:101:692-6).  In the 30 years since that study, HMOs dreamed up the 7-minute visit, so patients now have even less time to say what's on their minds.
     Doctors decide what diagnosis they're going to render and what treatment they'll proffer in the first few minutes of a visit.  After that, the patient becomes an annoyance.
     Terrible, isn't it?  And yet, this way of practicing medicine has become orthodox.
     Taking time to listen, encouraging patients to report symptoms, and doing old-fashioned physical exams augmented by modern tests--all right in the office with results in minutes:  that's unorthodoxy.
     When I converse with a patient for thirty or forty minutes I learn a lot.  Combined with careful attention to that patient's body I can ferret out little problems before they become colossal.  I don't invent the little problems, they're there.  A strange mole, a tremor, a nodule, a twitch, a shuffle, a murmur, too much hair, too little reflex, incongruous exuberance, pitted nails, broken skin, bleeding gums, an odd smell, a tender organ, a rubbery lump, a telltale discharge, funny-looking urine, sadness, confusion, confabulation.  These things are hiding out, but they signify a lot, and we overlook them at our peril.
    Patients don't go to doctors because it's fun.  When they show up, something is stirring.  They may be vague about what it is, and they may even hope we don't ask, yet they want us to find it, or they wouldn't be there. They're anxious:  they need our help, not our haste.
     The cost to patients and society of hurried office visits probably could be quantified, but who's doing that?  In my practice I saw a decline to almost zero of fractures, heart attacks, and advanced cancers, all because of early intervention.
     Listening to patients as though they matter, performing real physical exams at every visit, and offering many tests right in the office happens to be unorthodox these days.
     But unorthodoxy is not criminality.  It might even be the wave of the future.  


  1. I was a patient at the Colasante clinic and I was very impressed with the way I was treated. The staff was courteous and conscientious. Of course the best part was Dr. C herself. I had some sun spots on my face that were bugging me. She removed them free of charge! It only took her a few minutes and it hardly hurt at all. She must have used a local anesthetic, can't recall. Anyway, what impressed me about this place was the range of services they provided right there. My regular primary care doctor is always sending me somewhere else for treatment. Second thing that impressed me was the professionalism and competence of everyone I met there.

  2. Right or wrong, Medicare and Medicaid have rules to prevent patient visits from becoming all-you-can-eat buffets. The bottom line is you don't think the rules apply to you. You either ignore the law or reject any interpretation that you don't agree with. It looks like you were willing to bet your freedom, everything you own, and the guardianship of your retarded son on your ability to justify medical necessity in a way that no other doctor dared. Don't play the saint, there are people that worked beside you that understood that your exhaustive level of care was self-serving. There is nothing noble about keeping an elderly patient seeking relief from flu symptoms at a clinic for 4-6 hours so you could establish whether she was at risk for osteoporosis. You did this every day, for years. Has your attorney acquired a witness list yet? Twenty-three former employees have agreed to appear as witnesses for the prosecution.

    1. Somebody with the flu does not wait around 4 hours for an osteoporosis test, they go home. People have free will. Or are you saying the 23 employees locked the elderly flu patients up and force them to have osteoporosis tests?

    2. The depth of ignorance represented by calling an autistic young man retarded is difficult to fathom. It sparks wisps of violence in the heart of true humans. Liars, cheats and thiefs speak in these terms and have made a run at controlling reality. I know this young man and he is the most peaceful and kind person that I have met. He also has an extensive body of artwork that rivals even the best museums. His use of color and shape is beyond my ability to describe. I will not engage in ranting dialog with liars and thieves because they truly only bow down to violence and that rarely solves anything. The only criminal in this tragic play is the whistleblower. Our government will always be a step behind the highest level criminals due to the fact that it has institutional charactersitics and evolves slowy. The whistleblower has found a way to steal gobs of cash and the lie to cover their tracks, thus gaining much needed immunity. This is a new shell game and plays on our governments desire to protect its people fully. When the actual truth becomes apparent, many good Americans will have lost excellent health care and probably will die musch younger. But, the whistleblower wil remain insulated under the guise of being helpful. I only wish that my soul would allow me to operate in such a heinous capacity. No, I could never sink that low. Maybe I'm just retarded.

    3. You are the retarded one, in and of your implications. It really is sorry that people seem to feel sorry for those who cry the loudest, for nothing, as in point the finger to someone else in order to be obscure of scrutiny. Years are lost in this insanity, law, so all you idiots who think you know secrets may want to reassess what you think you know versus what is reality.

  3. Is there some reason you require anonymity in your comments? Could you be the self-serving one, hoping for a whistleblower bonus? The laws are in your favor!

    1. Brilliance is usually found in the future, after the fact so to speak. You, Ona, may perhaps be the most brilliant person I have ever had the honor of knowing, and it truly baffles me how our so called system of Democracy and or Republic can be so ignorant in chasing BS. As to the idiots who think you are fraudulent, it is the sign of the times, just dumb down everything and or everyone and there you have it. For the record Americans' must smarten up and stand up for the Freedom our Forefathers wrote for us in the Constitution of the United States of America. Ona, you are loved more than you know, always.

  4. Hey Doc, I think it's the one and only Pat who you introduced us to in the beginning. Didn't she start all this?

  5. The accusatory and acrimonious tone in the 7:15 comment above belies the writer's self-interest, probably monetary, which is threatened by the facts, now that this case is opening up. If the accuser is the person who "bought" my Hawthorne practice, it makes sense that she would wish to misrepresent the whistle blowing motives underlying her supposed interest in buying a rural medical practice as a hyper-ethical desire to save the government from "thieves" like me. If in fact she had actually spent 16 hours a day running the clinic, seeing patients, addressing their multitudinous complaints, and caring about their health as well as about the healthcare crisis in this country (instead of disappearing for long holidays, weeks at a time, to the detriment of the clinic, immediately after taking over) (why bother to run a clinic when a living can be made trumping up a whistleblower case for a gullible government) her viewpoint would be very different.