The Danger of Our Assumptions

“Doctor, I am short of breath,” the patient said to the medical student, “I feel that it is harder for me to breathe.”

A look of concern came over the medical student’s face. I could tell he was worried. I could almost see the wheels of his brain turning as he internally reviewed the causes of dyspnea (doctor speak for short of breath.) With a tone of deep seriousness he began to review the symptoms of heart disease and lung disease. He asked about swollen legs, chest pain, chest pressure, and irregular heartbeat, about high blood pressure, high cholesterol and a smoking history. He questioned the patient about asthma, chronic cough, wheezing and cough. All of the answers were negative.

After about 5 minutes I interrupted the student. “Let me see if I can clarify things,” I said, turning to the patient. “Tell me what you mean when you say you are short of breath. Do you mean how you feel if you tried to sprint a mile, or do you just feel as if you have to think about a breath? Some people say they are short of breath but they can still exercise, they just feel different in their chest. What do you feel?”

The patient quickly answered that it was the latter. There was no true shortness of breath, no lack of air, which meant the symptoms were not due to heart or lung disease. The symptoms were not due to any significant illness at all. The medical student’s questions had been unnecessary. He assumed he knew what the patient meant by “shortness of breath” and based all of his decisions on that assumption. In the case of the student the error was harmless. Doctors are not always so lucky. I have seen many patients harmed over the years by false assumptions.

The harm of incorrect assumptions is not limited to the medical profession. It can be especially harmful in relationships. There have been far too many times in my life when I made a judgment that later, when more information was available, was proved to be false. If I had slowed down and listened much harm would have been avoided.

Our natural tendency to assume is a part of the brokenness of our thinking. It is something we all need to work on. It is also the subject of the second part of the series of talks I gave on brokenness. The talk can be found on my vimeo site, www.vimeo.com/bartbarrett.

-          Bart

I often speak to church groups on a variety of topics, from relationships to Bible teachings. Many of these messages are available on my vimeo site. If you are interested in having me come and speak to your group, please contact me through the website.

An Atheist Asks for Prayer

“Doc, you know I’m an atheist, but I know you are a man of faith and I am going to ask you to pray for me.”

Atheists do not usually ask for prayer but this was a special circumstance. Being diagnosed with cancer causes people to reconsider beliefs they had previously rejected, to look for help in new places. Although my phone call to him delivering the biopsy results was not unexpected the diagnosis still hit him pretty hard. He had cancer and it was serious. He took only a moment to absorb the information before telling me he was not ready to die and he was afraid.

He had been battling a number of health issues for several months. First had come an unusual cancer of the skin and superficial tissue of his back, a cancer so rare that none of the doctors had seen it before. Shortly after the final surgery and radiation treatments for that cancer he developed an irregular heartbeat and was diagnosed with atrial fibrillation. Blood thinners became a part of his life. He had always been strong and healthy and now he was on chronic medications. He was no longer invincible.

While he dealt with the stress of these diseases he began to battle another problem. He developed severe stomach upset that made it difficult for him to eat. Heartburn, indigestion and nausea became his daily companions. He lost 50 pounds. He saw a specialist, but the specialist was concerned about doing an endoscopy and biopsy while he was on the blood thinners so definitive testing was delayed. After several weeks of waiting he called me and asked for a new GI doctor. A few weeks later the new GI doctor called me to let me know that he had done an endoscopy and discovered a cancer in the stomach. That news led to my call to the patient and to his unexpected prayer request.

A few weeks later he scheduled an appointment with me to go over his options and ask my opinion. We discussed what we knew (which was too little for me to give him a decent prognosis) and we discussed several possible outcomes. Although the cancer is serious and life threatening he is determined to survive. He again asked me to pray for him. I told him that I had been praying and would continue to do so.

As often happens during life and death conversations the discussion drifted to other areas of his life. He talked being estranged from his son and how difficult that had been for him. He shared about a recent school reunion that was bittersweet, as the joy of renewing old friendships was tempered by the gravity of his diagnosis. He told me about his journey away from faith many years ago, how travels to Europe and Africa had included visits to concentration camps and  areas of mass genocide. Faced with such evidence of evil he had rejected the idea of God's existence.  

Time and circumstances made deeper conversation inappropriate but it seemed to me that there was much he wanted to discuss, many more issues of the heart he desired to explore. It seemed that my years of caring for him had resulted in me being someone he felt he could trust. I wrote down my cell phone number and handed it to him.

“Anytime you want to talk, I’ll buy the food or the coffee. Not as your doctor, but as your friend.”

He promised he would take me up on the offer. I pray I will be an encouragement to him if and when he calls.

When he left I was again reminded of how important it is to not only care for my patients but to care about them. Sometimes the greatest therapeutic tool available is our ears. We just need to listen.

- Bart

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Celebrating Freedom on the 4th of July

Freedom. It is a universal value but an American foundation. While all people may desire it, Americans have fought and died for it. Our constitution is devoted to it. The First Amendment specifically delineates those freedoms we hold most valuable- The free exercise of religion, freedom to speak, the freedom of the press, and the freedom to assemble. The pursuit of these freedoms is what led to the existence of the United States. We celebrate these freedoms on the 4th of July.

While we joyfully celebrate these freedoms, there are some who seem to have forgotten the source from which these freedoms spring. Our Founders were clearly aware as they made it clear in the Declaration of Independence, “men are endowed by their Creator, with certain inalienable rights, among them life, liberty and the pursuit of happiness.”

Our rights come from our Creator. It is He who gives us minds to reason, hearts to love and hands to work. It is He who gives value in meaning to life and a purpose for living. It is He who gives us the freedom to not only do what we want but an even greater freedom, the ability to do what we should.

-          Bart

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Doctor! My Brain is Broken!

Doctors are supposed to get things right. We interview patients, perform an exam, analyze and process data and reach a conclusion. Patients depend on us to make good decisions and reach accurate diagnoses. For the most part most of us do a pretty good job. We get things right most of the time, more because most common diagnoses are straightforward and most patients have common conditions than because of any brilliance on our part, but we are trained to figure things out. It is what we do.

In spite of all of our training we still make mistakes in thinking. This may be rare in our professional lives but it is common in our personal lives. We can be as selfish and short-sighted as anyone and we are more stubborn and arrogant than most. We have grown so accustomed to trusting in our intellect and ability to figure things out that we are blind to errors in our thoughts and conclusions in the rest of our lives. We forget that no amount of education and experience can change the fact that we are human and humans make mistakes.

We make mistakes because we are broken people. Selfishness, judgment, pride and anger are a part of who we are. If we are going to become loving, kind, giving and understanding people we are going to have to change. This change cannot come from within us. Relying on our broken thinking to solve our problems will result not in healing but instead in different ways of expressing our brokenness. So what do we do?

We need to quit trusting ourselves. We need to question and challenge out emotions and conclusions and be willing to change. Most of all, we need to ask God to help transform us into the people we need to be.

Understanding our universal brokenness and need for change is the topic of a series of lessons I have uploaded to my vimeo page, www.vimeo.com/bartbarrett. The first lesson has been uploaded and more will be available in the coming weeks. The series is intensely personal. I share some areas of personal brokenness I have dealt with over the years and how God has helped me overcome. I pray that my struggles will be a source of encouragement for others.

-          Bart

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The Future of Primary Care Under ObamaCare

“I won’t be able to see you anymore.” When these words are a spoken in a Nicolas Sparks’ romance movie they are to be expected. When a physician hears them from a patient it is a surprise. Well, it used to be a surprise. More and more patients are being forced to find a new physician due to a change in their insurance plan.

ObamaCare has been in effect for over a year now. The public and media focus on insurance coverage and costs to the consumer but they overlook the profound impact on providers and health systems. Methods of care delivery, attitudes to customer service and access to providers are all evolving as the health care system struggles to adapt to a changing marketplace. As primary care providers are the point of access for most care we are seeing these changes directly impact our practices and our livelihoods. Doctor responses to these changes are likely to result in it becoming increasingly difficult for a patient to see a physician, so it is important that patients understand what is happening and what their options are.

As with many things in a capitalistic economy, it all comes down to money. The Affordable Care Act places limits on what insurers can charge for coverage, particularly for the sick and the elderly. In order to continue to make a profit (which is why companies are in business) they must find ways to cut costs. Costs are cut by decreasing payments to providers, both hospitals and doctors.

For primary care doctors in Southern California, ObamaCare plan cuts have been dramatic, 40% or more on already discounted rates. Insurers that once paid $75 for a routine office visit billed at $110 are now offering to pay $45 or less. Many doctors, especially those in private practice, cannot survive at this level of reimbursement.

Understanding the struggles faced by doctors in the current system requires an understanding of the costs of maintaining an office. A typical Family Doctor in private practice has a minimum monthly overhead of over $21,000 a month (for many it is much higher), or $160 per hour of patient care. (a cost breakdown is below.)Typically, a doctor’s day is 6 hours of direct care and 2-3 hours or more of additional work (paperwork, review of lab results, refills, phone calls, emails etc.) If a doctor saw only Obamacare patients at a rate of $45 a visit and saw the standard four patients an hour, he would be making a profit of only $20 per hour of patient care. That works out to $600 a week or $30,000 a year! At the previous level of reimbursement of $75 per visit, doctors would make $140 per hour of patient care, $4200 a week, or about $200,000 a year. A reasonable salary for the years of training and level of responsibility, but it is no longer a given.

Doctors faced with such drastic changes are faced with limited options-

1-      Increase the number of patients seen. At a payment of $45 per visit, doctors would need to see 8 patients an hour to keep pace. It is hard to provide good care in 7.5 minute increments, so the quality of care will drop dramatically. This is the reality for many patients on Medicaid (Medi-Cal in California)

2-      Hire Physician Assistants or Nurse Practitioners. PA’s and NP’s earn about $70 an hour, so the profit on a busy midlevel provider could make up for some of the loss in income. This requires an additional 120 visits a week, (about 2500 patients in the practice), and as it could take years for a practice to double in size this is not a viable option for most providers.

3-      Give up and join a hospital practice. An increasing number of doctors are leaving private practice and becoming employees of hospitals and medical groups. The financial pressures are not removed, they are simply passed on to a larger entity. The need for increased volume and the resultant decrease in quality remain.

4-      Refuse to participate in lower paying plans. This is the current option of choice and explains why there is a fear that it may become increasingly difficult for patients to find a primary care doctor. This is the option I am currently choosing, but it means saying good-bye to many long term patients.

5-      Charging extra fees. This is the wave of the future. Insurance contracts prohibit charging extra on a per visit basis, so doctors are charging “membership fees”, annual fees for access, email communications, and annual fees to cover such things as insurance appeals and form completion. In my community these fees range from a low of $400 to a high of over $3000 for the high-end concierge practices.

Patients are having to make choices as well. Some of my patients are choosing to see me outside of their insurance plans and pay cash for their visit. They view their ObamaCare plan as something to cover emergencies and catastrophic illnesses and injuries. Other patients are leaving my practice for physician employees of large medical groups. Almost all of my patients are wondering what the future will bring. My answer is always the same, “I have no idea.”

Bart

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Monthly Cost Breakdown: (very conservative estimate)

Rent- $3500

Staff Salaries and Benefits: $10,000

Billing Service: $3000

Malpractice: $1200

Phones (office and Cell): $700

Workers Comp & Liability: $500

Utilities: $300

Medical Supplies: $1100

Equipment (computers/Ecg): $100

License and Membership Fees: $100

Miscellaneous expenses: $500

Total                                      $21,000

Patient care hours/ month: 130

Overhead per hour:        $161