Step 1) Greet patient.
Step 2) While chatting, check all boxes in electronic medical record for a complete review of systems and physical exam. Copy and paste parts of previous chart note while looking at patient every once in a while. Smile if possible.
Step 3) Tell patient to do yoga.
Step 4) Bill insurance company for complete physical exam.
Welcome to big-box assembly-line medicine.
Ever wonder what happens when a doctor goes to the doctor? Same shit.
A physician friend recently told me: “My last trip to my PCP was shorter than the time it takes to brush my teeth! If I hear one more suggestion to drink chamomile tea and do yoga . . . I just don’t need the 3-minute bullshit session.”
The truth is health care can’t happen in 3-minute increments. Assembly-line medicine doesn’t work for patients or doctors. Here’s why: doctors aren’t factory workers and patients aren’t widgets.
I shared my physician friend’s experience on Facebook and turns out it’s the norm for many Americans.
EB Sheffield writes, “Lol…this made me laugh…the last time I went to see a doctor for a yearly lab and all check…he didn’t touch me….the stethoscope never left his neck and he kept talking about Suzanne Somers??..but he is board certified ..sigh”
“I’ve had the ‘no-hands’ PE [physical exam] before, which is always really, really, weird to me. I’m a veterinarian and our PEs [exams] are totally hands-on, all over and everywhere…” claims Margaret Brosnahan.
Dr. William Halstead shares, “I thought this only happened to me. Haven’t had a complete physical exam since I finished residency.”
Amina Moghul reports, “Yup, recently developed a tremor, went to a neurologist who didn’t even examine me and shooed me out the door telling me to do yoga because I must be stressed out.”
“My internal med doc spends about 5-7 minutes with me,” claims Theresa Stier Brown, “He never listens to my heart/lungs or lays a hand on me. He only asks about my diabetes meds even though I take meds for 7 other health problems—so no medication review.”
“I’ve had fraudulent physical exams where no hands on, no listening to heart or lungs but he dictated lungs clear to auscultation and heart rate regular, etc etc. such B. S.” confirms Louann Harrack, “That’s why my primary care is a nurse practitioner. (No offense to the good doctors out there).”
So what’s a patient to do?
- Boycott big-box assembly-line medicine.
- Find a good doctor or nurse practitioner.
- Can’t find one? Go see a veterinarian.
Pamela Wible, M.D., is a family physician and founder of the Ideal Medical Care Movement. She loves helping docs, PAs, and NPs get back to being healers, not factory workers. If you need help, contact me or come to our retreat.
Veterinary medicine, amen. Actually, see a D.O. who actually practices osteopathic medicine, and it better be hands on!
Yes! After a bad car accident and subsequent concussion, I went to a neurologist for headaches, memory loss and concentration issues. He cut off the nurse: hehe middle of me falling a mini mental status exam (he never even looked at the results), shined a light in my eyes, and said “okay here’s some topamax for the headaches” and left.
I think we should ask for a printout of the form they submit to the insurance company. And maybe someone should be sued for fraud – the insurance companies who demand so many patients get seen daily! I haven’t been to a doctor in over 8 years because I’m uninsured, but even when insured, I rarely go. Learned a long time ago they really don’t do much…one told me to meditate…I wouldn’t be at the doctor if it wasn’t more serious than that…pitiful situation. Hope your ideas catch on Pam!
You know, Pamela, I love what you do and the way you do it, but it’s becoming a bit of an echo chamber in here. It’s simply not true that all doctors don’t do hands-on physicals anymore (or that DOs or NPs are better.) Obviously the people who write to you are the ones who have had bad experiences. I don’t doubt that they’ve been poorly cared for, and I deplore what they’ve been through and I’m ashamed to call their doctors my colleagues. But that still doesn’t make it the norm.
There are also plenty of happy, solo doctors running the equivalent of an “Ideal Medical Practice” without actually calling it that and without paying to join the website or going on your retreat, lovely as it sounds.
I will keep discussing these human rights abuses until we stop losing so many colleagues to despair and suicide. You can depend on me to continue. I commend all docs like yourself who have given up being victimized by big-box assembly-line medicine.
If you think this little website is an echo chamber then Presbyterian must be the Grand Canyon.
My question is what do they say when the patient already has a daily yoga practice?
Then you move on to chamomile tea.
SO true.
I saw my old physician (now fired after this visit). I had hip pain that I later self diagnosed as ilio-tibial band syndrome. At the time I wasn’t sure about it and wanted some additional feedback.
Dr- You go by Ann, don’t you? (Instead of my first name, Martha.)
Me- Yes. (I give a brief summary of my hip symptoms.)
Dr- Well, Martha, the nurse says you’re walking OK. It doesn’t seem to be anything serious. (Looking at chart.) Have you had your cholesterol checked recently? Here is a lab slip, Martha. Go get your cholesterol checked and these other labs and we will be in touch with you. (Quickly leaves the room without ever actually examining me.)
I am pretty sure that that office was working on some metric that would analyze how many patients of each physician were up to date on cholesterol testing and the doctor was wanting to get a good score on compliance. Still no excuse for ignoring my primary concern.
I had another physician who I was seeing to adjust some oral medications who spent most of the visit asking about possible osteoporosis and trying to get me to agree to come in for testing. (I was at very low risk at the time.) After I left I found out they had just purchased a new testing machine.
Not only have I refused to return to these places, I have also steered my patients away from them as well. I am wondering if medicine will ever get the message that good patient care pays off.
Boycotts still work!
I am one of those annoying, insurance company NPs that do a full assessment at the member’s home. It is great to hear that their regular doctor is just as thorough at the office. More often I hear about how much more thorough my exam is compared to the regular doctor. In all instances, I hear how no one ever educated the member in a manner they could comprehend regarding their health issues and why their medications work for them.
I long to practice in a state that allows NPs the right to open their own clinic and to practice without a doctors involvement. I also long to practice in an independent office where no one dictates to me how many clients I need to see per hour to provide for the unnecessary overhead which is what hospital network employed providers are subject to.
I thought I would share my thought as a nurse of 36 years who has witnessed a lot of changes in healthcare.
I have watched residents and nurses come out of school with knowledge but limited skills. Physical examinations and clinical diagnosis is a thing of the past. Fragmentation of healthcare is rampant. Patients have become organ systems. Surgeons say they don’t feel comfortable writing a complete medication list at discharge because they don’t know about medications. I have experienced “on call” physicians be unavailable when nurses call to report changes is their patients. I have observed nurses and physicians acting out because they are working holidays and off shift forgetting that the patient does not want to be in the hospital either. I have watched healthcare become so regulated that we can’t give care and unfortunately it is because people take short cuts and don’t remember why they became doctors or nurses. In my mind nursing/medicine is not a job- it is a special career for people that care. I see so many nurses and physicians that insulate their own feelings of not being able to provide good care because fear of litigation and having their hands tied by insurance policies. So many colleagues have become jaded- they have “drunk the koolaid” to make it easier to survive. It is an honor to have another human being put their trust in your knowledge and skill. It is wonderful to live (or die) understanding their disease. It is difficult but necessary to be able to know there are limits to our knowledge and share that with patients– We don’t have all the answers but we keeping trying to hear the patient and understand and respect them as human beings.
Linda
I’m a Physician Assistant. I traveled over an hour to see a specialist about some chronic left hip pain. My appointment was at 3:30. He walked in at 3:30 on the dot. He shook my hand and introduced himself…taking a seat across the room from me. He asked me 4 questions, then told me I had sciatica. I asked..”really?” Then he said that it was spinal stenosis so we’d get an MRI and go from there. He opened the door for me to leave, I checked out, and was on the road for my 1 hr drive home by 3:45. This cost me a $50 co-pay and GOD only knows what Cigna shelled out. Turns out, it was NOT sciatica or spinal stenosis. I went to a physical therapist, got a THOROUGH exam, and was cured with dry-needling and a stretching regimine.
OMG. Horrible. 85% of all diagnoses can be made just by listening to the patient. We need to get back to it!
You got that right, Pamela! I am so sick of it. I see what corporate medicine has done to my patients, to me, and to my family; and it is an absolute atrocity! My wife and my children are absolutely sick of it, as am I. There is just no way to properly care for patients in this environment, and this is no way for any professional or any family to live. I am now in my 40’s and this last run of big-box assembly line medicine has nearly done me in. It is hard for me to look back on my career and realize that my documented high quality of care and over-the-top patient satisfaction rates mean nothing to the corporate medicine bean counters, who are hell bent on moving meat and turning as much of a profit as possible at any cost.
I feel the effects of what corporate medicine has done to me (and continues to do to me). I mean I really feel it physically, not just psychologically. I have literally come home and cried on my wife’s shoulder due to some of the atrocities I have witnessed. So, of course, my family sees these extremely damaging effects as well. It is causing me a slow death by means of unnecessary stress. Stress kills. It is directly linked to many severe, life threatening illesses such as hypertension and coronary artery disease. We all know that. I have already had emergent open heart surgery once. I do not think I would be able to survive going through that again. If I were ever told in the future that they wanted to crack my chest open again, I believe I would just make myself a strict DNR and enter hospice care.
I have put so much into my career as a physician, and I have been continually shit on and beaten up by heartless managers. I mean I really have put my heart and soul into the job! Most of these “managers” either have no formal medical training at all or, if they do, they have sold themselves out to big box medicine whose primary goals are not at all in line with why I became a doctor in the first place. And EVERY SINGLE TIME something like this has happened it has simply been due to the fact that I truly care about the lives of the people who trust me to take care of them! Usually it has been because I just had the guts to speak up about certain things that were not only wrong but also very unsafe. These things represented real threats to the lives and physical safety of my patients, literally. Everyone at work knows it, but most are too scared to speak up (and, apparently, this fear is not baseless…look at me!). Furthermore, every time I have spoken up in an attempt to initiate positive change I have been professional and very courteous. No one can say I have been an asshole or otherwise out of line. I simply made myself a target by truly caring for my patients and then actually showing it and doing what all of us should do when our patients’ care is compromised…SPEAK UP! All this has done in the long run is screw things up royally for my family and utterly destroy our financial security, because when a heartless and greedy individual or corporation sees you as a threat to their ill-acquired monetary gains and their power, even one stinking dollar of it, you better watch out! They will make every attempt they can to take you out and they don’t give a damn whose lives they destroy in the process, my sweet children included. This last go-round was just awful. I kindly asked for changes to be made to a really screwed up system, and then I continued to speak up for seven months to no avail. Finally, they found a way to get me out of their hair without firing me (because they had no grounds to take any kind of real disciplinary action), and shortly after that they announced they would be implementing the changes I had been recommending all along! Will they follow through with this? I don’t know, we will see I guess. If they do then I am very thankful for that because the patients in this community will benefit greatly from those changes. But I’m tired of being scapegoated for simply doing what we all should do in the first place. We are physicians for God’s sake, not car salesmen! I am tired of turning the other cheek and just walking away when I have done nothing wrong. My wife and my children are sick of it as well, and they are truly innocent victims in this situation. They did not ask to be put in this situation; and although I have a right to make a personal decision to turn the other cheek in a bad situation, they were never given the opportunity to even make that decision. Big money made the decision to threaten their security without their consent, and that is just plain wrong. It also makes me very angry because I am a human being with real emotions, and I love my family very much. I am not Jesus Christ by a long shot! I am a flawed human who has just about had enough of this, and who feels a very real duty to protect his family. I am tired of turning the other cheek, dammit. And a cuss too!
I work at a very busy hospital that is inundated not only with a much larger than average patient census, but also with a much sicker than average (and much more complicated) patient population. Now that they found a way to give me a final F*** YOU with a big middle finger attached, they are replacing my full time position with two residents! F*** my years of experience and documented quality of care over many years of practice! F*** the fact that I actually have empathy and compassion for my patients! Now they have found two very unfortunate souls to abuse and enslave (yes, enslave…see following comment), and possibly make sick or kill, by virtue of their predatory hiring practices. Yes, they are predators…plain and simple. We all know what happens when a doctor is hired straight out of residency with the promise of student loan forgiveness. If the doctor fails to pay off the commitment with their labor, then they could be found in default of their student loans and the state could take their medical license (thus ruining their careers permanently). This hospital is no place for an inexperienced doctor, plain and simple; and these two poorly informed individuals are going to suffer miserably as a result of this deceitful corporation’s behavior as well as the overall uncaring and heartless, as well as abusive, environment. And while they suffer, they will have to keep their mouths shut. They will have no one to turn to for help once they realize the pickle they have gotten themselves into. I have never met these two doctors because Big Money doesn’t want them to talk to me, that’s for sure!
The Bill of Rights, particularly the First Amendment, apparently has no place in this little fiefdom. And quality of care appears to be a very low priority among the priorities of the “powers that be”. Money is numero uno, and they will not hesitate to cut someone’s throat to get it. As far as I know, these two young doctors have never worked a job outside of their training program (or, if they have, it has been limited to very brief moonlighting gigs). And now they are being thrown out of the frying pan of their medical training programs and directly into the fire of something far, far worse. Yes, my current job is the roughest one I have ever been in bar none; and it makes the worst residency program imaginable look like a freaking cakewalk! No joke. Ask anyone here, and if they are honest they will tell you the same thing. And here, doctors don’t have the inherent built-in protections that exist in a training program. Out here, you are on your own baby!
I have to call my Captain later today (as you already know, I am still actively employed in law enforcement as well) and discuss the possibility of working a protective detail tomorrow. I would much rather go to work and risk catching a bullet for those who trust me with their personal safety and security than go back to that hospital where my life will just continue being sucked out of me until there is nothing left. Hell, it’s safer being a cop in the long run! A lot safer! I can say that because I used to be a full-time police officer. It was my job. I went to work every day wearing a badge and a gun; and I did what I had to do to make a living, fully aware of the inherent risks involved. I can now tell you in no uncertain terms that the slow, methodical, and life-sucking stress most corporate medicine-employed physicians in our country have to deal with on a day to day basis makes it worth no amount of money to do the job. The only reason I have stuck in there this long is because I truly care for my patients, and if I leave the job then those who depend on me will very likey be thrown to the wolves and processed like potted meat on an assembly line by physicians who have either already sold-out or who have been abused beyond the point of being capable of caring anymore.
Something’s got to give dammit. I can’t keep doing this. I have applied to work at a couple of facilities that seem to be very nice; and they appear to be very patient care-oriented, which is what I want. We will see. If this doesn’t work out then I am going to have to retire from medical practice go back to doing what I used to do. Like I said, no amount of money is worth this. And what good is the money if the job I have to do to get it ends up taking my life? My wife and my kids are absolutely fine with me not being a doctor anymore if that ends up being what I have to do to avoid prematurely kicking the bucket, and I am sure that any other reasonable person would agree with that. I have seen some real horror stories here, like the sweet little old lady who lost her life due to a medication error that was totally preventable. There was just inadequate oversight of the worn out and burned out employees who were involved in the incident. This shit has got to stop…now!
When my MD retired, I switched to a naturopath that had helped my kids with some chronic issues over 20 years prior. I am an RN, and I switched because she spends time with me and does a good physical exam. These days, you can’t see your PCP when you’re sick because they’re overbooked. I’m a healthy middle aged woman who rarely gets sick, but see others struggle to be seen or get the in depth help they need, hence the need for so many urgent care clinics…where no one knows your history. Doctors here are telling patients they can only discuss one problem, and if they have another problem they need to make a different appointment!
When working in FQHCs I am constantly harassed by managers for “being too slow” and “not seeing enough patients”. I examine every patient. When working in medical cannabis clinics in California you risk losing your medical license if you don’t do a “focused physical examination” of every patient. Patients in all clinics complain if you don’t get to them “fast enough” yet complain if you don’t examine them or appear to not “listen” to them. Office staff frequently fail to inform patients that I am giving every patient the attention that they themselves want. Patients complain because I am black, I am not giving them the controlled drugs they desire and in the amounts they desire, or take too much time with the patients before them; but if I do rush patients through like fast food orders they then enter the exam room with at least three complaints and want multiple drug refills or new medications. As a locums doc I often have to do all paper charting and prescribing. 22 patient at 15 minutes each (no matter the nature of the visit or condition of patient) equals 5.5 hours of work. That gives you six additional minutes per patient to do all paperwork (prescriptions, checking DOJ controlled drug website, referrals, reading chart, calling insurance, calling referral desk, filling out lab slips, filling out forms, writing work/school notes, calling pharmacies, reading consult notes, etc…). If you go to the bathroom, eat, or take a break you deduct time from patient care. Now you have completed eight hours of work – giving 21 minutes to each patient. If you have been successful doing this you have generated over $2,200 to the facility that day (Medicaid generally pays about $104 per visit for their PCP visits). You have yet to sign off on incoming record, labs, notes, and forms. You have not responded to any tasks or phone calls. You have not gone to the bathroom or eaten. There is no guarantee that you will be paid for any work you perform beyond eight hours. You have perhaps generated about $700 of income for yourself in eight hours. Is $700 worth holding your bladder and bowel functions, being stressed out, not eating properly, and turning over control of your career to business people? Many people I know who make $8-$10/hour think that it is okay and that we doctors are whining. They feel we are “rich” and “spoiled” and should stop complaining.
You deserve to be happy and to live your dream in medicine. I’ll email you some resources. <3