För sjuk för hälsokontroll?
24:e december
Too Sick for a Physical?
Today my first available ?physical? appointment is in January and some patients are appalled: ?January? I?ll be dead by then!?
My answer, through the nurses, is: ?If you?re not feeling well, you?re too sick for a physical in January ? let?s get you in right away for a sick visit!?
This seems to confuse some people.
Over the years that I have been in practice, the well person ?Health Maintenance Visit? has grown more complex and comprehensive, while the time allotted for it has shrunk, and the number of sick people calling each day for appointments has increased.
Someone has figured out that the ?Health Maintenance? and preventive health needed for the average primary care doctor?s ?panel? of 1500 patients would take about 40 hours per week if done right, which means there would be no time left to see sick people.
Here is today?s reality of a middle aged well person visit, which takes 30 minutes in our clinic and is reimbursed at the same, fixed, rate as a quick visit for a sore throat:
1) Immunization review/education/update including tetanus, diphtheria, whooping cough, pneumonia, flu and shingles.
2) Heart attack risk screening and intervention, with attention to family history, lipid status, inflammatory markers, blood pressure, smoking status and cessation counseling, diabetes screening and aspirin use.
3) Breast cancer screening for women.
4) Skin cancer screening.
5) Prostate cancer screening and review of testicular self-examination for men.
6) Cervical and ovarian cancer screening for women.
7) Colon cancer screening.
8) Depression screening for people with chronic illnesses.
9) Alcoholism screening.
10) Osteoporosis screening and prevention for women.
11) Screening for domestic abuse.
12) Screening for abdominal aneurysm and peripheral vascular disease.
13) Other things, depending on personal and family history as well as personal habits.
In addition to this agenda, which is what I have to address, patients invariably have a few things of their own to bring up; many actually bring a long list. Some people even say: ?I just want this in my record in case something comes of it later?, almost as if they have a warranty that is about to run out soon.
Needless to say, today?s primary care physician has to limit the number and length of routine physicals in order to also serve sick people. Many of us also find it difficult to switch gears between sick visits and the extensive counseling involved with today?s physical.
With a looming worsening of the primary care physician shortage, the tension between sick care and preventive medicine is likely to grow, and doctors will have to ration preventive care more and more due to the ever-increasing demand for sick-care.
The ?routine physical? may soon go the way of the house call and the penicillin shot; it may be something most people won?t expect anymore, because it doesn?t seem practical or cost effective.
2008-12-26 20:36
Om man skulle hinna med hälften av alla era profylaktiska undersökningarn i svensk primärvård skulle man bli överlycklig. Även om det talas mycket om profylaktisk medicin i den svenska primärvården går nästan all tid åt till sjuka människor.
2009-01-17 06:00
Vi hinner inte heller med allt....