LETTERS to the Editor - patients with multiple problems in family practice - Letter to the Editor

Journal of Family Practice, June, 2001

MULTIPLE-PROBLEM PATIENT VISITS

TO THE EDITOR:

Flocke and colleagues[1] presented some important findings about the nature of family practice that are applicable to primary care in general. Because primary care physicians do not have the procedural approach that many other specialists have, it has always been difficult for health insurers to understand the scope and the value of their work. The misguided environment created by managed care has only made it worse. Some physicians are so preoccupied with having charts that will pass muster in case of an insurance audit that a "clean" chart has undermined their approach to treating patients. Maintaining a humane perspective and a compassionate outlook under today's working conditions has become an increasingly difficult task.

I have been a family practitioner for more than 25 years, and it is common for patients to come in with one or more problems. Sometimes the add-on problem is more important than the scheduled visit for that patient. Most of us in general practice (family practitioners and general internists) are familiar with patients who come in for a sore throat and as they are leaving mention incidentally that they noticed blood in their stools or that they have been having funny chest pains when they work in the garden; there are also patients who come in with a family member and ask if we would mind just looking him or her over. These added demands consume physicians' time and energy. Unfortunately, there is no billing code that rewards physicians for responding to these requests. In fact, those physicians who make themselves most available to their patients in situations like these are the ones who are least compensated for their efforts by the health care system.

But getting compensated for seeing multiple problems in the office does not only have to do with the misperceptions of health insurers. Because most patients get to see their physicians for only a small copay, they have become silent partners in the process of turning physicians into commodities. Perhaps primary care physicians need a different system of compensation that does not depend on the inappropriate concept of productivity. For example, why not have patients assume responsibility for all of their primary care office visits with the exception of expensive tests and procedures? This would make patients more aware of the valuable time that their physicians are spending with them. If they do not think that they are getting their money's worth, they could shop around for another physician. The present system of billing is no longer adequate. It makes all primary care physicians interchangeable and rewards them all equally. It is time to look for different ways to reimburse primary care physicians.

Edward J. Volpintesta, MD Bethel, Connecticut

REFERENCE

[1.] Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in the family practice office visit. J Fam Pract 2001; 50:211-16.

Editor's note: Dr Flocke and colleagues declined the opportunity to respond to this letter.

A NEW SUICIDE

TO THE EDITOR:

A colleague in family medicine recently described the case of an elderly patient with angina who presented to the emergency department secondary to an anginal attack. The angina was treated with nitroglycerin and resulted in the patient succumbing to a coronary event. During the aftermath, it became clear to the family physician that this patient committed suicide and may have feigned an anginal attack. Unbeknownst to the emergency physician, the patient had obtained sildenafil citrate from another family physician and was made aware of the adverse cardiac events related to concomitantly taking nitroglycerin and sildenafil citrate.[1] As verified by collateral sources, this patient planned to commit suicide using this method. The same family physician reported that he was following up another elderly man with depression who requested a similar option for committing suicide. Hopefully this letter can make physicians aware of a new way to commit suicide--sildenafil citrate and nitroglycerin.

Shree Bhalerao, MD St. Michael's Hospital Toronto, Ontario, Canada

REFERENCE

[1.] Feldman R and the Sildenafil Study Group. Sildenafil (Viagra) in the treatment of erectile dysfunction: efficacy in patients taking concomitant antihypertensive therapy. Am J Hypertens 1998; 11:10A. Abstract.

THE SILVER LINING

TO THE EDITOR:

Last evening after several days of exhausting suspense and subsequent match day activities (otherwise known as Black Tuesday) and after a 1-hour power nap, I picked up my March 2001 issue of JFP and foraged for useful information that I can implement in practice. I was overwhelmed and inspired by the abundance of good research relevant to practice presented in a way that makes it useful and easy to implement in my day-to-day work. This issue, especially, demonstrated reflective practice in action, from the provocative editorial on rigor or relevance to the always-useful POEMs to the Art of Medicine narratives at the end of the journal. I say to you and your editorial board: very nicely done.