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So, who gets the “short straw”? Not the government, not the insurance company, not the doctor, but—you got it—the patient. Patients’ time with their doctors will be decreased, increasing the probability of incomplete evaluations, more errors, more misdiagnoses, more inappropriate treatment, more radiographs and lab tests, and more consultations.

AAOS Now

Published 11/1/2014
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S. Terry Canale, MD

Confessions of an Orthopaedic Surgeon

I recently ran across a concept that I hadn’t realized before—maybe I’m just a slow learner. It goes something like this: As doctors’ incomes per patient are decreased by insurance payers, both commercial and government, doctors’ incomes will stay the same because doctors will see more patients per day. To do that, doctors will decrease the amount of time each patient will be seen.

In addition, there will be less communication, less empathy and understanding for the patient, and less compliance and adherence to the treatment by the patient.

This concept (problem) is not original with me, but was brought to my attention in an editorial in the New York Times by Dr. Sandeep Jauhar, “Busy Doctors, Wasteful Spending.”

I’ve sinned
This really makes me reflect on my office practice. For years, I taught the four Es of patient-physician communication—engagement, empathy, education, and enlistment—preaching the sermon of the Bayer Institute about giving each patient the time he or she “needed,” but it seems all that is changing and the world has become very impersonal. Have our patients come to expect being treated in an impersonal, short, “fastfood manner?

I know that, in an effort to see more patients, my office practice certainly has changed in the past few years—and probably for the worse. I have listed my sins and will confess them so that you can benefit from my mistakes.

  • I spend very little time establishing a rapport with the patient. I get right to the point. My opening question is not “Tell me a little bit about yourself,” but “Show me with one finger where you hurt the most.”
  • I still touch and examine the patient, but I go to radiographs pretty quickly. (I use an iPad—it saves time!) My nurse orders the radiographs before we even see the patient and assumes that the correct body part will be imaged. Many times this is wrong and wasteful—but, again, it saves time when it’s right!
  • I no longer work with a resident, so I quickly move from diagnosis to treatment. I know 600 to 800 orthopaedic diagnoses and, if the patient doesn’t have one of those, then I’m stumped. I tell the patient I don’t know what’s wrong with him or her and I can’t help, but I will refer to a consultant more specialized than I am. Saves time, but you have to leave your ego at the door.
  • Sometimes in the middle of an examination (eg, an acute sports knee injury), I realize that the patient is going to need an MRI, so my examination is less thorough and I ultimately let the MRI give me the diagnosis. This leads to an order for an MRI or expensive lab test that really is not needed. This is called covering my backside or defensive medicine (in this world of litigation and malpractice).
  • When patients come in convinced that they need an MRI, I don’t argue—it saves time! “OK, let’s get an MRI,” I hear myself saying. “Even a negative MRI is good information. It tells us what you don’t have and if it is negative, it means nothing is terribly wrong and it will alleviate your fears.” Sounds pretty good, doesn’t it? Except that the insurer just paid $1,200 and got no positive information and no diagnosis. Who’s kidding whom?

And sinned again
I also must confess that I waste very little time “riding a problem out,” such as waiting a few weeks to see how the patient’s back pain responds to rest and anti-inflammatories. I frequently hear myself saying, “We can try conservative measures or we can order an MRI now. Depends on your personality type. Patients who are type A want an answer now.” Hearing that, most patients will opt for an MRI now, regardless of their deductible! As most orthopaedists know, the MRI is one of the greatest inventions in modern medicine, and it is also a money machine. I must confess that I feed the fuel that drives it.

To cover my backside, I also frequently “overdiagnose” simple fractures. “You have such a lot of swelling; even though your X-rays are negative, I bet you have a hairline fracture, so we’re going to treat it like a fracture—2 to 3 weeks in a long-arm cast, sugar-tong cast, short-leg cast, or 3D walker ($400, $350, $400, $375).”

I don’t waste much time in questionable diagnoses and treatment options. If there is any doubt, I get a consultation from one of my partners in a specialized area. I do this much more frequently and earlier than I used to, partially because of the litigation and malpractice issues, but also because two orthopaedists looking quickly at one patient is better than one.

Finally, I must confess that, especially early in the day, I go out into the reception area and try to move the patients through triage, electronic medical records, and the nuisance of paperwork resulting from the Affordable Care Act. I even try to talk to the patients about their chief complaints (saves time), only to be swatted away by the witches of the appointment desk with the brooms they came to work on, while they yell at me about HIPAA violations.

If you have never been in your waiting room, you should try it. It’s an eye opener—patients sitting there in pain, misery, boredom, irritation. I once saw “Dancin’ Jimmy,” a local homeless guy, drop in to get out of the cold, drink a cup of complimentary coffee, watch a little television, and ask who ate all of the free donuts!

For my penance
Forgive me for my sins, but I hope this mea culpa will help other orthopaedists confess to theirs. Now that I’ve confessed, I feel better, but as any good dysfunctional person knows, “if I am the problem, what is the solution?”

Is it physician extenders, such as nurse practitioners or physician assistants (PAs)? I’m not sure this is the answer. It would save me time, but I would still be seeing the patients less (if the PA were seeing them). This may be where we are going in the world of government medicine. I only hope we don’t create an inferior level of care and lose control of who is seeing the patient, as we have done with physical therapy, and of who is in charge at the hospital, as has occurred with hospital administrators.

Maybe it’s more ancillary services. Besides MRI, outpatient surgery, physical therapy, soft goods, and pharmacy, I could possibly perform laser surgery on varicose veins or maybe liposuction—gluteus area, thighs, knees, arms. After all, these are extremities and obesity is in an “epidemic stage”!

Scribes, kiosks, email medicine, concierge medicine? All in the future, but maybe too “futuristic” for me. Hard to believe my shenanigans in the reception room will be replaced by a kiosk.

About 10 years ago, I did an office time-flow study and found that the average time spent in the room with a patient was 6 minutes and 24 seconds. Ten years ago that seemed like a really short time; today it seems about right. I wonder what the average is today—4 minutes? Maybe 5?

The obvious solution to the “Busy Doctor” problem is to take longer with each patient, see fewer patients, make less income, and feel less liable, less stressed, and more fulfilled. But this isn’t going to happen; it would be like I was standing in the “miracle line.” So I don’t have the solution, but I do feel better now that I’ve confessed. Maybe you would like to email me your office sins. I’m so old and near retirement that I have heard it all, but I could hear your confession, forgive you for your sins, and give you absolution, and you too would feel better. Mea culpa, mea culpa.

S. Terry Canale, MD, is editor-in-chief of AAOS Now. He can be reached at aaoscomm@aaos.org