Letters

An apostle of "big ideas"

To the Editor:

I just read the new issue of FPM on "Big Ideas to Help Your Practice Thrive" [September 2004]. It's a great issue. I love that you are capturing and disseminating big ideas. These articles give me grist for the trainee mill and provide hope that you can have fun and a good life as a practicing family physician. I am an apostle of these ideas, and your articles provide the real-life examples I need to do the myth-busting required in this day and age.

George C. Xakellis, MD, MBA
Sacramento, Calif.

Including deaf patients in the conversation

To the Editor:

Dr. Emily Herndon and Linda Joyce wrote an excellent article regarding "Getting the Most From Language Interpreters" [June 2004, page 37], but not all patients can hear the spoken language. Deaf and hard-of-hearing patients have been notably excluded from their article. Much of the advice in this important article will help to enhance physicians' interactions with deaf patients, but two of the authors' guidelines need to be revised for use when communicating with deaf patients:

• When addressing the patient, the interpreter should be next to the physician and across from the patient. This facilitates interactions of facial expressions, which is integral to American Sign Language.
• Phone interpreting services will not work with deaf patients. Offices with high-speed computer connections, a video camera and monitor can use video relay servicing to speak to a sign language interpreter, who then signs to the patient. This may be the wave of the future for communicating with this population. Certified sign language interpreters, especially those with medical training, currently are the ideal solution for helping the deaf patient and the nonsigning physician to communicate.

Rick Hudson, DO
Atlanta

Authors' response:

Dr. Hudson makes very good points about how to best work with a sign language interpreter. The scope of our article did not include sign language interpreting, and we should have noted that. Sign language interpreting is just as important and vital for patients as spoken language interpreting. Our health system has successfully used video conferencing for several years and has recently expanded its use.

Rational world a better environment for physicians

To the Editor:

My thanks to Robert Edsall for calling attention to the inmates climbing the walls of the asylum in which we ply our trade ["Exploring the Limits of an Insane System," July/August 2004, page 11]. In a rational world, physicians would charge for their time, just as lawyers and accountants do. It wouldn't matter whether the 20 minutes were spent counseling the fearful, excising a mole, performing a physical exam or answering a question by e-mail. The nuttiness of insurance reimbursement, which was designed to prevent financial ruin from surgery or catastrophic illness, comes from covering services for which it is ill-adapted.

In a rational world, physicians who deal with difficult patients over the long haul -- family doctors and general internists - would find themselves at the top of their profession in prestige and reimbursement. Merely technical pursuits such as interpreting EKGs, performing colonoscopies or reading mammograms would devolve to lower-paid technicians. And presto! Primary care residencies would be overrun with applicants and the hinterlands would no longer go begging for coverage.

In a rational world, patients would scream bloody murder when a podiatrist charges $450 for a biopsy of a mycotic toenail, a general surgeon bills for an extensive consultation after a two-minute interview or a neurosurgeon claims to have performed bilateral carpal tunnel releases when only one wrist bears a scar. These are but a few of the outrages to which my patients have submitted like sheep, because a third party pays the freight.

In a rational world, patients who habitually make bad lifestyle choices would bear large financial consequences for their behavior; and when I offered them help or direction, I would have their full attention. Instead, obesity is about to be named a disease and therefore worthy of my sympathy and (through insurance payments) financial support.

What disturbs me most is not so much the present insanity as the failure of the AAFP leaders to put an ax to the root of the tree. Whatever their skills, lobbying for fair reimbursement is not among them. America desperately needs an insurance system that puts cash and decision-making back in the hands of patients who are, after all, wise, tight-fisted and steely-eyed when purchasing barbecue grills or salad dressing. Instead, it seems our physician-politicians are desperately trying to shoulder their way to the front of the trough, when the trough is the fount of these problems.

Douglas Iliff, MD
Topeka, Kan.

Accentuating the positive in family medicine

To the Editor:

OK, now I've had it! Another "ain't it awful" editorial, "Exploring the Limits of an Insane System." How are we to recruit young physicians to the specialty if all we do is shame and blame? Yes, the system needs fixing, and understanding managed care and third-party payers is next to impossible. But isn't practicing family medicine fun? Aren't the possibilities for the future exciting?

The Future of Family Medicine report didn't say that family medicine was threatened by "the insane asylum in which family physicians practice today." It said to get an electronic health record system, practice patient-centered care, do practice-based research and offer comprehensive services. Basically, it said to treat each other and your patients as a professional would and you will insure the survival of the specialty.

So how about we do away with negativism and finger-pointing and proudly offer up our residencies and practices to medical students as delightful places to do scientific work, take quality care of nice people and make a decent living (without having to charge people to return their phone calls)?

Brenda O'Hara, MD,
Fort Wayne, Ind.

Creating the lifestyle you want

To the Editor:

Dr. Eugene Guazzo truly lives his life by his principles and values ["Making a Living and a Life," September 2004, page 70]. In 1977, while I was a resident at the University of Maryland, I was lucky to work in his office, the Chaptico Infirmary, and our family lived with his family on his farm. The experience was the highlight of my training. Dr. Guazzo's lifestyle - moving from overalls in the tobacco barn in the morning to tails at a function in Washington, D.C., in the evening - is the envy of anyone whose life is not exactly as he had planned.

Dr. Guazzo's passion for the people, land and water of tidewater Maryland, was inspiring. I recall meeting him at the office in the morning as he arrived in full riding habit, having galloped his horse over the miles of fields between his farm and office.

None of this was an accident. I had never seen anyone else speak so openly and frankly with his colleagues and have them love him for it. Patients, too, received the same honesty and were grateful. For me, hours spent away from the office, in the kitchen talking about life, were as valuable as the lessons with patients.

Anthony Valdini, MD
Lawrence, Mass.

Put yourself in patients' shoes

To the Editor:

After reading the article "Sticking the Landing: How to Create a Clean End to a Medical Visit" [July/August 2004, page 51], I feel the seven points offered are an excellent way to end a visit satisfactorily with a patient. Another way to look at the situation is to consider how you would like to be treated by your doctor. Would you like him or her to rush you, to ask few questions or to leave the room without saying what comes next?

Most of us know what we want from a medical service; no one is ever free from the need to see a doctor. If we put ourselves in our patients' shoes, knowing what to do comes naturally.

Michael D. White, MD
Hermosillo, Sonora, Mexico.

Crunching the numbers

To the Editor:

I read with interest Dr. James Dykes' article "Making Time to Listen" [September 2004, page 45]. Working the numbers - 10 patients a day, 4 days a week and gross income of $350,000, and assuming 48 working weeks per year and a 100-percent collection rate - I determined this would be an average charge of $182 per patient. Perhaps I'm missing something, but this appears to be a very steep fee for a family physician. Few family physicians have a 95-percent collection rate, let alone so many patients who are able to pay that amount for an office visit. Does Dr. Dykes care for any indigent patients? Most inner-city practices, mine included, require some sort of subsidization because of patients' inability to afford medical care. Is Durham, N.C., a particularly affluent city, or can such an ideal practice be imitated elsewhere? I ask these questions because the article painted a very attractive picture that was far different from my experience in private practice.

Jack O'Handley, MD
Columbus, Ohio

Author's response:
Compared to specialists' fees in my area ($400 for initial consultation), my fees are a bargain. I do not consider my care to be of any lesser value than that of my more expensive colleagues.

I charge $250 for a one-hour physical and $187 for a highly complex, 45-minute visit. I charge $125 for a 30-minute, semi-complex follow-up visit and $75 for a 15-minute, single-problem visit. Lab fees are charged on top of this.

There is no incentive for patients to return if they do not value the service they receive and feel comfortable with my charges. In Durham, N.C., the home of Duke Medical Center, physicians practice on every corner. Yet many of my patients have stuck with me for more than 15 years.

By way of comparison, I took my tractor in for its 200-hour maintenance the other day. My bill was $695. Are we worth any less?

I do pro bono work and consider it a privilege. But I do not accept insurance contracts that devalue my time and my profession.

It takes time to counsel patients in distress, to conduct a careful and competent physical exam, and to educate patients effectively to prevent illness. I value my time and believe my high collection ratio indicates my patients value me.

"Listen" article inspires med student

To the Editor:

WE WANT TO HEAR FROM YOU

Send your comments to FPM Letters Editor by e-mail, fpmedit@aafp.org; by mail, Family Practice Management, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; or by fax, 913-906-6010. Include your address, daytime phone number and fax number. Submission of a letter will be construed as granting AAFP permission to publish the letter in any of its publications in any form. We cannot respond to all letters we receive. Those chosen for publication will be edited for length and style.

I just read Dr. James Dykes' article "Making Time to Listen." I'm a second-year medical student at the University of Maryland in Baltimore, where I recently became secretary of the family medicine interest group.

I came to medical school focused on my personal belief that I am always going to spend quality time with my future patients, regardless of the specialty I choose. Now that I'm beginning to get out into the wards and offices, I hear of doctors' worries about overhead costs, escalating malpractice insurance costs and lack of patient insurance. I hear physicians complain that they are required to see a certain number of patients a day. I am starting to feel concerned about how I will ever manage to spend the time with my patients that I would like.

Dr. Dykes' article gave me hope that I can someday be the type of doctor I wish to be. He made a risky choice, but I am sure it is an amazing feeling to know that his patients value him and his time, and that he can give his patients the type of care they deserve. Thanks for publishing an article that helps this second-year med student know that all this book time and memorization are worth it.

Kathryn Winslow
Baltimore

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