I was fully prepared to start full-time private practice in 2013 when the trend was, yet again, for the private practices to seek shelter under the roofs of the bigger hospitals. And I did start the practice. My only regret is that I should have done that a few years prior to 2013. It has provided me with the greatest satisfaction as a physician. I am my boss, not dealing with the inane corporate bureaucracy, and hence devoting my time 100 percent to what I like to do in a way I want to do it.
Good and bad coexist. The bad (and the ugly at times) for me is to learn firsthand how medicine is often being practiced in the community setting. I can confidently state that the practice of medicine has deteriorated at many levels even as medical science has advanced.
How so? The economic pressures on private practitioners – diminishing reimbursements, increasing overheads due to a plethora of rules and regulations, a general increase in the cost of doing business – have forced them to squeeze in more patients into their schedule. This is hardly a revelation. What is not talked about is the impact of this one factor on the quality of patient care. A physician is unable to spend adequate time with a patient, not even long enough to obtain a basic history at times. He/she is quick to order tests. Despite the medical advances, basic history taking remains the most powerful diagnostic weapon in a physician’s hand. An MRI, a genetic test, or a PET scan will never replace the comprehensive clinical examination as the cornerstone of a competent and caring clinical practice.
I often see patients who have become the victims of incorrect diagnosis, lack of diagnosis, inappropriate medication prescribing, and unnecessary surgery. These are the side-effects of today’s drive through medical care. A nice gentleman in his late 40s walked into my office a year ago, with a history of multiple strokes within a year. He was admitted to a hospital where a “million-dollar” work up was done. He was told that there was no apparent reason for his strokes. He lamented that he hadn’t spoke at length with his doctor. Having been discharged from the hospital without an answer, he remained quite afraid that he will get another stroke any time.
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After spending about an hour with him, I could gather adequate history. I had reviewed his prior medical records. We finally determined to order a genetic test that can pinpoint a condition that is often responsible for such unusual presentation. And we found the perpetrator. Similar intellectual curiosity, if exercised by his previous providers, would have delivered him an answer he was looking for some time ago.
Inquisitiveness, persistence, persuasiveness, combined with astute clinical skills will resolve most problems. Alas, only if we had enough time. How sad. Or, to be honest, how offensive.
A Big Mac pickup via a drive through is a quick fix for our hunger. However, frequent such visits will contribute to many diseases down the road. Similarly, many medical quick fixes have contributed to several public health problems. The current opioid abuse and dependence epidemic is an egregious example of a medical crisis induced inadvertently by a physician or surgeon or by medical treatment.
The push to treat the chronic pain by academic researchers (who were mainly funded by the pharmaceutical companies) and patient advocacy groups (whose emotional reasoning took over a more balanced cerebral approach), and quasi-legalization of pain management by the interference of the accreditation body called The Joint Commission, all contributed greatly to this crisis. Management of chronic pain is not as simple as prescribing an opioid. It requires significant behavioral management of pain as well as treatment of any associated psychological issues. And all that requires time. A physician must also say “no” to a patient when clinically indicated. They must not be shamed into prescribing something by name calling or threatening a lawsuit.
We all must do the necessary homework to find a physician who is willing to listen to us and engage in conversation with us. The regulatory bodies, the government, and the insurance companies must do all they can to create an environment for the doctors to deliver quality care to their patients. No technological advance can strengthen the physician-patient sacred bond.
Dr. Manish Fozdar is a neuropsychiatrist and a behavioral neurologist in private practice in Raleigh. He has teaching appointments at Duke University Medical Center and Campbell University School of Osteopathic Medicine.