As an academic physician, I only spend about 10 hours a week in direct patient care without residents to teach. I have been in Mobile since 1991and so have a number of folks who I have been treating for almost 20 years. On Friday, I saw 13 patients ranging in age from 10 (a person who when I delivered her weighed 500 grams and is now an honors student) to 89 (whom I did not deliver but who still drives herself to her appointments). In the time the patients were in the office we prevented the flu and pertussis (through vaccination), worked towards early detection of breast and colon cancer (through facilitating screening) and treated a number of acute and chronic ailments. What I did not do is have a discussion about end-of-life care. I was glad the subject never came up.

It’s not that I’m averse to having the discussion. In fact, on your porch over a glass of wine or  professionally if I’m caring for you in the hospital I’ll be happy to delve into the intricacies of whether a feeding tube is a heroic measure required by the Catholic faith. But in an office visit, given that I’m spending 15 minutes with a patient and my staff is busy arranging all of the other aspects of his or her care, that discussion is a time killer.

This is why I am following the “death panel” discussion with such bemusement. When Betsy McCaughey and Jon Stewart are having an esoteric discussion about what is in HR3200, I am wondering just how much they are going to pay me to have this discussion and how they expect me to document it. Ms McCaughey was ticking off the required elements and I’m thinking to myself that if I miss one of these, will I be accused of fraud if I try to bill for the discussion. I am all for the discussion and all for being paid a fair rate for having the discussion. In fact, it has been my experience that most people are 1) aware they will eventually die (teenagers and Boomers excluded)and 2) would like to be assured a modicum of dignity as that time approaches. It is my job as a Family Physician to help them with that.

My problem is with the approach. My conversations with patients about this topic do not tend to happen in a rational 90 minute sit down in an exam room. Rather, they tend to be in 15 minute blocks over a number of visits. As patients become more aware of the limitations of modern medicine, the conversations tend to become more focused.

What I would like to see is not an effort to better pay me for piece work (If I give a flu test I get an extra 10 bucks, I wonder what I’ll get if I talk someone out of a ventilator for their COPD?). Instead, what I would like to see is additional reimbursement (and a lot of it) for always or almost always doing the right thing. That would certification of the practice, similar to hospital certification. The Patient Centered Primary Care Collaborative is pushing for this with NCQA as the potential certifying agency. Then I would have to have a policy in place about, say, Advanced Directives requiring that I document elements of the discussion for certain patients and proof when an inspector came that I was actually doing what I said I was doing.  No more tick boxes, no accusations of fraud, nobody like Betsy McCaughey coming between me and my patient. A guy can dream, can’t he?

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