Letters

Group inefficiency

To the Editor:

In "Implementing a New Plan to Compensate Physicians" [September 2000, page 29], the "simple" Rube Goldberg scheme (which produces quarterly bonuses by dividing 10 percent of the group's net income according to eight criteria) predictably resulted in a rebellion. So, what's the point? Amazingly, the plan penalized partners who used a nurse to return phone calls. I have two nurses who do almost nothing but that. How is talking on the phone boosting productivity?

As I pointed out in my article, "Solo Practice: The Way of the Future" [February 1998, page 16], "Groups have a bias for argument, posturing, ego gratification, procrastination, blame shifting -- anything except action. Even if committee meetings are your idea of recreation, do not confuse them with organizational effectiveness."

Come on, guys. You're making practice more difficult than it has to be. If you must be a "groupie," set up your group as an association of solos, share the space and avoid the headaches.

Douglas Iliff, MD
Topeka, Kan.

Author's response:

Dr. Iliff is a strong proponent of solo practice, and I wish him well in his lone pursuit. However, many of us enjoy the benefits of group practice.

Dr. Iliff misses the point of the compensation plan. It is a method to reward achievement above the mean and to assign costs greater than the mean to the physicians responsible for them. The telephone is a good example. Some of the doctors in our group also feel that they are more productive not returning calls, but by using this plan, they pay for that privilege -- as do solo physicians who pay nurses to return calls.

I do not agree that groups do not take action. Developing this plan was an action undertaken by the group -- as is our current search for an electronic medical record system. We don't make instant decisions, but most of the time the input from four heads is beneficial to us all.

Charles S. Colodny, MD
Libertyville, Ill.

Are same-day visits the answer?

To the Editor:

The authors of "Same-Day Appointments: Exploding the Access Paradigm" [September 2000, page 45] illustrated the problem of patients obtaining an appointment in a reasonable amount of time in large primary care clinics. Reducing a 55-day wait in large clinics is commendable. However, in most smaller practices, the wait for acute-care visits is no longer than 24 to 48 hours, and this short, reasonable wait is often vital for the following reasons.

In primary care, many patients present to the physician with nonspecific symptoms early in the course of an illness. The majority of these patients prove to have self-limited illnesses that will improve with time and minimal symptomatic treatment. However, many serious illnesses also begin with nonspecific symptoms initially thought to be of viral origin. Often the passage of a couple days will separate the majority of self-limited illnesses from the occasional serious one. Seeing more patients on a same-day basis will only increase the following: the chance of physicians incorrectly diagnosing a viral illness, the use of diagnostic studies to find the occasional serious illness and the need for return visits because of the difficulty inherent in making an accurate diagnosis at the onset of symptoms.

The same-day appointment may look attractive to managed care marketing departments and some patients, but it may not always be the best way to practice medicine.

Lawrence M. Markman, MD
Wilmington, Del.

To the Editor:

I just finished reading the article about same-day appointments and was dismayed to say the least. The authors make several assumptions that may hold true where they practice but definitely do not hold true in my two-physician family practice or my community:

• If we opened our schedules to every patient in our rapidly growing suburban community who wanted an appointment, we could easily work 24 hours a day, seven days a week -- with each of us seeing 40 or 50 patients per day.

• If we decreased the number of routine appointments and increased the number of same-day appointments as the authors suggest, the waits for health maintenance appointments would worsen from the current 30 days to something astronomical.

• The authors say that physicians can reduce backlog by taking care of more patient complaints "today." In my practice, almost every patient has a laundry list of "oh, by the way" complaints that I used to try to evaluate. However, this brought me close to burnout and regularly kept me 90 to 120 minutes behind schedule. I've now learned the survival skill of saying "no" when a patient wants me to care for a plethora of chronic problems in one visit, and I'm much closer to being on schedule.

• The authors say demand isn't insatiable, but after 12 years of practice in various environments, I heartily disagree. Demand can be insatiable, particularly when other physicians in the community are not good listeners. As soon as patients find out who will listen to them and hear all their complaints, they'll flock to that physician in droves, quickly overwhelming him or her.

I'm not sure what the solution is, but it is surely not the type of schedule the authors suggest!

Michael W. Costello, MD
Eldersburg, Md.

Author's response:

While we appreciate Dr. Markman's comments regarding same-day appointments, we now know that this approach has as great if not a greater effect in pure fee-for-service environments. Building a system that reduces waits for all patients actually reduces demand. We have two concerns about the division of patients into urgent and routine queues:

• Despite the fact that some patients with self-limited illnesses do clinically improve, all patients asked to wait are less than satisfied and some do find other ways to enter the system (be it through other providers, urgent care or the emergency department).

• Segmenting the "really ill" from the "not-so ill" and the "they can wait" categories takes work, rework, triage, inclusion/exclusion criteria and creates three waiting lines. It's next to impossible to manage three lines of wait without extending the "they can wait" line. So patients who have long relationships with us must wait even longer.

  Pulling the work into today, in a sense, has nothing to do with clinical issues. It's operational: If we create two queues -- the urgent and the routine, we have to create a carve-out method to distinguish the two. When we do that, we have built a system that simply won't work.

We would also like to address a few of Dr. Costello's points:

• If there are more patients than a practice can handle, pushing the work to the future won't make it go away. Instead, it will disappoint lots of patients. Measure the demand, calculate the supply and determine if there is a mismatch. If the demand and supply are in equilibrium, a wait is not necessary.

• We don't suggest decreasing the number of routine appointments or increasing the wait time for routine appointments. In fact, we suggest quite the opposite: Offer an appointment for any problem on the day the patient calls.

• While saying "no" to patients' needs may seem like a survival strategy, in reality it assures nonsurvival. Reducing the work of each visit increases the total visits, which increases the rework: a second parking space, receptionist, nurse, set of physician questions, etc. The marginal time spent handling more problems is far less than the work of repeated visits. In health care today, we push demand work to tomorrow in order to protect today, but what we need to do is pull the work into today in order to protect tomorrow's capacity.

• Reducing demand by not pleasing patients is actually the opposite of what we recommend, which is to listen to patients in the office and before they get there. Our studies have shown that patients want dignity, respect, a quality experience in the office and easy access to their chosen physician even before the visit. If we attract new patients because of these activities, we can rationally grow the practice.

We're confident that the changes we advocate lead to improved satisfaction for patients, staff and physicians, improved clinical outcomes and enhanced revenues. In addition, responding to our patients' needs and desires for better continuity and reduction in waiting time speaks to the heart of what family medicine is all about.

Mark M. Murray, MD, MPA
Catherine Tantau, BSN, MPA
Chicago Park, Calif.

Questionable terminology

To the Editor:

The article "Strategies for Expanding Your Patient Base in Diverse Communities" [May 2000, page 31] was excellent overall, but I was disturbed by the authors' decision to follow the current fad and refer to people of European ancestry as people of "white Anglo backgrounds."

"White" is a value-laden word connoting purity (the only "white" patients I've seen have either been severely anemic or dead). Moreover, I'm sure that many people of Irish or German-European descent, as I am, would not care to be referred to as "Anglo." I would think either "Caucasian" or "people of European descent" would be more accurate terms.

Neal Devitt, MD
Santa Fe, N.M.

Author's response:

Dr. Devitt raises important questions and reinforces a point Dr. Strothers and I tried to make in the article, which is that no one likes to be lumped into broad ethnic categories. We used the term "Anglo" not to represent British ancestry, but rather to describe people whose first language is English and whose culture is non-Hispanic.

I could be described in Dr. Devitt's terms as Caucasian or European-American. I'm clearly not white (actually I'm pale-orange and kind of freckly). People of my skin color have the luxury of pretending for months or years at a time that we live in a color-blind society. If I'm to become one with people of color in my community, I must break through my own personal denial and own the fact that I'm unlikely to be pulled over by police in certain neighborhoods because of how I look and I'm more likely to be referred for a cardiac catheterization due to chest pain because I'm perceived in the health care encounter as "not a person of color."

Dr. Strothers and I agree that in skin color we're all just different shades of human, but describing myself as a "white Anglo" is one imperfect way to acknowledge that the experience of people of color is different and that I am willing to be part of a diverse community that works to change these dynamics.

George Rust, MD, MPH
Harry Strothers, MD
Atlanta

We want to hear from you. Letters is an open forum for our readers. Write to Letters Editor, Family Practice Management, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-6272. If you prefer, fax your letter to 913-906-6010. You may also contact FPM by e-mail at fpmedit@aafp.org. Include your address, daytime phone number and fax number, if any. Letters may be edited for length and style. All letters sent to the editors of FPM are presumed to be intended for publication unless otherwise specified in the text of the letter. Submission of a letter constitutes transfer of the copyright to the AAFP.

Copyright © 2001 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.