letters

Playing by the E/M rules

I have a question regarding "A Multiple-Service Rule for E/M Services" [Opinion, June 2008] by Nancy Ness, MD: When can we start?

Sarah Robertson, MD
Texarkana, Ark.

Dr. Ness' brilliant idea addresses many of the questions and problems associated with the great inequity in medical reimbursement in one fell swoop.

Why do we allow gross underrepresentation of primary care specialties on the committee that determines relative value units? Why are multiple procedures reimbursed while multiple problems are not? Why are procedures reimbursed at a much higher rate than cognitive work? Why are cardiologists, ENTs, etc., paid three to five times more than we are? Why are medical students abandoning primary care and going into higher-paying specialities? Why is there projected to be a massive shortage of primary care physicians to care for our elderly?

The AAFP needs to champion this idea with all its might.

Keith Millette, MD
Grand Forks, N.D

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I have just one word for Dr. Ness' article ... brilliant!

Kathleen J. Shrine, RN
Ashland, Ohio

Learning about the RUC

While I enjoyed reading about the inner workings of why physicians get stiffed ("What Every Physician Should Know About the RUC," February 2008), I cannot help but wonder who agreed to this scheme and why. What's worse, no one recognizes that physicians as a whole are being duped by a time-tested strategy of "divide and conquer."

The article quotes Tom Scully, former administrator of the Centers for Medicare & Medicaid Services, who captures the essence of the process: "Essentially, we sit down with [RUC] every year and say, 'Here's $43 billion and growing, how do you want to [divide it]? What's the relative value of weights between anesthesiologists, gastroenterologists, surgeons?' and set the relative values at what the physician community thinks the relative payment should be."

What do we expect is to happen? Our altruistic nature has really gotten the better of us when it comes to business sense. It's no wonder that subspecialists are laughing at us all the way to the bank while our patients are screaming at us about their $15 co-pays and droves of potential residents are flocking to the subspecialities.

Ajoy Kumar, MD
St. Petersburg, Fla.

Another approach to clinical decision making

Donald (Raj) Woolever, MD, shows his usual profound understanding of medical heuristic thinking in "The Art and Science of Clinical Decision Making" [May 2008]. I would like to take his probabilistic thinking one step further.

The real issue isn't the probability of a disease being present but the probability of significant harm from a disease. For example, a middle-aged male with chest pain may be at low risk (say, 5 percent to 10 percent pretest probability) for ischemic heart disease, but the consequences of missing ischemia are severe, thus the pretest probability of harm from ischemic heart disease is significant. The likelihood of costochondritis and reflux may both be moderate (say, 40 percent), but the consequences of initially missing these are minimal. We subconsciously integrate the probability of the disease being present with the probability of harm if we misdiagnose.

This process guides us as we sort through our individualized evaluation strategy, appropriately excluding some low-probability diagnoses while leaving the more likely diagnosis on the "back-burner." If we fail to incorporate this probabilistic thinking, we will either jump to conclusions with potentially devastating results or risk causing harm and wasting resources by chasing every rabbit trail in the differential.

The final element is recursively reevaluating after the diagnosis is made. Do the treatments work? Is the patient following the expected pattern of recovery or deterioration? If not, we get to modify our probabilities and start over. Is it a failure of treatment or a failure of diagnosis? This is the power of follow up that we as family doctors excel at. We don't have to exclude every low-probability item on the differential because the final and most powerful test we run is the test of time.

I challenge clinicians to start thinking in terms of probabilities - high, medium, low and very low - and apply the probability of harm when making diagnostic decisions. Try it for a week; it may help sharpen your intuition as a diagnostician and help to get out of the trap of knee-jerk responses to presenting symptoms.

Dave Chakoian, MD
Viroqua, Wis.

Closing the divide

"Closing the Physician-Staff Divide: A Step Toward Creating the Medical Home" [April 2008] left me with two questions: First, the authors refer to "our research program." I notice, though, that the authors come from several different institutions. Could they clarify whose research they are referring to? Second, the article talks at some length about the importance of "boundary spanning." This sounds like little more than good communication. Is the fancy term really justified?

Earl Martin, MD
Blackshear, Ga.

Authors' response:

The AAFP funded a multisite research center more than 10 years ago that included Robert Wood Johnson Medical School (Benjamin F. Crabtree, PhD), Lehigh Valley Hospital (William L. Miller, MD, MA), Case Western Reserve University (Kurt C. Stange, MD, PhD), University of Colorado (Paul A. Nutting, MD, MSPH) and University of Texas Health Sciences Center at San Antonio (Carlos Jaén, MD, PhD). This collaboration has been enriched by consultations that Reuben R. McDaniel, EdD, of the University of Texas, Austin, an expert in the study of complex systems, has conducted across projects. This investigative team forms the Center for Research in Family Practice and Primary Care, which has been studying primary care practices for more than 10 years with a series of eight grants from the National Institutes of Health and other related funding. Each project is headed up by a specific team from one of these institutions and carefully builds on the growing experience and insight from the previous studies. This collaborative program of research has resulted in more than 100 peer-reviewed publications.

The term "boundary spanning" comes from the organizational literature and seeks to distinguish other forms of organizational communication and connecting, such as gatekeeping. "Bridge building" might convey a similar idea, but boundary spanning includes more than just communication. You can think of a boundary spanner as someone who pays attention to multiple organizational functions and creates and maintains connections across potentially disparate organizational components. Certainly this includes communication but also other activities such as creating opportunities for sharing ideas and experiences and enhancing working relationships.

Benjamin F. Crabtree, PhD
Reuben R. McDaniel, EdD
Paul A. Nutting, MD, MSPH
Holly J. Lanham, MBA
J. Anna Looney, PhD
William L. Miller, MD, MA