letters

Chronic disease management

I would like to thank Dr. Roger Shenkel for his insightful input in "1-800-Chronic Disease Management" [November/December 2005].

Even when insurance companies employ disease-specific, outside case management, physicians end up footing part of the bill. These third-party "services" require physicians and their staff to spend significant nonreimbursable time completing paperwork and responding to various issues. While I am busily switching patients from one angiotensin receptor blocker to another, I do not get the sense that quality of care is improving. Because of the extra work that patients with chronic conditions require and the lack of reimbursement for this work, many primary care physicians are screening these patients out of their practices. It is much more profitable to see two level-III patients in 30 minutes than one level-IV patient in 35 to 45 minutes.

In the name of case management, we are chasing doctors away from patients with chronic conditions, and we are avoiding funding services that could really help patients as well as save money. Meanwhile, we are placating the insurance oversight commissions by providing something we call case management. It's time for a change.

William L. Blanchet, MD
Boulder, Colo.

Where's the fire?

In response to Dr. William Hueston's editorial "Rekindling the Fire of Family Medicine" [January 2006], I'm afraid the fire cannot be rekindled. It is too much to ask medical students to value a nice relationship with their patients more than the satisfactions of high-tech, subspecialty care. In fact, the proposition is a bit of a con job. How can today's doctors have the kind of relationships that family physicians of my era valued and enjoyed so much when they are not there to deliver the babies, insert the pacemaker for the acute MI patient, fix the fracture in the ER, do the follow-up and final care for the patient with cancer, remove the inflamed appendix, assist the orthopedist when he pins a hip, answer the phone during the wee hours of the night, and generally be available for all things at all times? The family physicians who are still in a position to do some of these things have the relationships we prize, but a full scope of practice is not always possible because of the increasing availability of specialists, subspecialists, hospitalists and midlevel practitioners.

We must realize that we are witnessing the final years of family medicine. The only bright point I see is that we are probably not much better at predicting the future of American medicine than our predecessors have been.

James W. Crichton, MD
Helena, Mont.

I read with interest Dr. Hueston's editorial regarding the status of happiness among family physicians. I understand his concerns and have witnessed some of them among my colleagues. However, I am very happy in my chosen career as a family physician and am proud to be a member of what I consider the most valuable medical specialty in our great nation. True family medicine embraces continuity and attracts like-minded, relationship-seeking patients. Many of my patients have been with me through multiple practice settings, and they are the main reasons I enjoy going to the hospital and office every day.

Stephen F. Staten, MD
St. Louis

A thought on Dr. Hueston's commentary: Patients don't value continuity and their physician's independence as much as their own convenience and cost. Those who do tend to be more emotionally needy and not as well insured.

Paul Hunter, MD
Milwaukee

As a third-year resident, I am very encouraged by Dr. Hueston's commentary. My decision to go into family medicine was based on the values and ideals Dr. Hueston mentioned. Nevertheless, going into family medicine was a hard decision to make because the "better life" is in the high-tech specialties. I'll admit I have grown somewhat cynical of my profession because of the disheartening statements and actions of some of my colleagues. It is discouraging to hear the frustrations and opinions of veteran family doctors, and it makes me concerned about the future. It was a pleasure to read an editorial by a seasoned physician with the same desires to improve this atmosphere and possibly rekindle the fire for family medicine in me and many others like me.

Joshua Dawalt, DO
Indianapolis

Make notes better with macros

We read Dr. Melvin J. Knight's article "Make Medical Notes Better and Faster With Macros" [September 2005] with interest. We would like to propose an alternative software called Allchars. It offers the ability to create macros among other functionalities. A few advantages of Allchars: It's freeware, it's easy to customize, and it can be used with any Windows-based software. It allows macros to be activated not just with single key combinations but with multiple keys - even whole words - and it doesn't interfere with other programs' utilities because it does not use combinations of keys. Allchars is available at http://allchars.zwolnet.com/.

Ernesto Barrera Linares, MD
Raúl Sánchez González, MD
Madrid, Spain

Dr. Knight's article on macros was very interesting. Another way to do the same thing is by using the AutoCorrect feature in Microsoft Word. You can find it if you choose Tools and then AutoCorrect. It converts abbreviated words, like "amox," directly into a sentence or formatted paragraph, such as "amoxicillin 250 mg/5 cc 1 tsp tid for 10 days." You can also export these AutoCorrect entries to other computers.

The advantage of using AutoCorrect is that you will not be limited by available key combinations.

K. Al-Maghaslah, MD, CCFP
Qatif, Saudi Arabia

Group visits for chronic illness care

I have read your articles on group visits, most recently "Group Visits for Chronic Illness Care: Models, Benefits and Challenges" [January 2006] as well as the past article "Planning Group Visits for High-Risk Patients" [June 2000]. It seems that group visits would be the ideal format to address weight management. Could the group visit concept be applied to weight management, in addition to the other chronic diseases mentioned in the article? We have developed a weight management program that includes all of the group visit elements described in the article, but up to this point, we have been conducting our program off site and requiring patients to pay out-of-pocket to avoid reimbursement problems. Most patients are happy to pay fee-for-service, but I am concerned that this limits access to those unable to pay.

Michelle May, MD
Phoenix

Author's response:

If an insurance carrier allows payment for individual medical visits related to obesity, then it should also cover a group visit related to obesity. A group visit performed properly is no different from an individual visit from a billing perspective. Unfortunately, many insurance carriers don't cover this diagnosis, thus complicating recruitment and billing for weight management group visits. Clearly, having patients pay out-of-pocket simplifies things, and many patients are willing to do so if your fee is reasonable.

For more information on how to conduct group visits, see "Planning Group Visits for High-Risk Patients," FPM, June 2000.

Steven Masley, MD, FAAFP, CNS
St. Petersburg, Fla.

How are you doing?

I identify with Dr. Richard Waltman's experience in his article "So How Are You Doing?" [November/December 2005]. I was surprised to be diagnosed with colon cancer almost five years ago and continue on treatment today. Like Dr. Waltman, I like it when people want to know how I'm doing. Depending on our relationship, I may share details of my treatment and recent test results with them. Many respond by saying, "I'm praying for you" or "I'm thinking of you." It keeps me going with hope and the sense that I am surrounded by hundreds of supporters, and that feels good.

Perry Klaassen, MD, MPH
Oklahoma City