Cast & Curious

Tag: business of medicine

  • Do you charge professional fees for additional procedures done to address complications or morbidity?

    This question was thrown on me recently by a newbie colleague who was agonizing on whether or not to charge patients for an additional procedure he did to address a complication. I instantly went blank thinking what to say.

    when surgery goes wrong…will you charge mr. bean?

    In the field of medicine or at least here in the Philippines, there’s really no hard and fast rules on charging professional fees for services rendered to patients. This service for fee setup of our healthcare system is somewhat messy and often embarrassing to patients and doctors alike. The price haggling is totally unnerving. Sadly, this is what plague the professional practice of most physicians here in the Philippines.

    Such charging “grey” is even more embarrassing in cases where patients entailed additional services outside of their routine or planned operative procedure. While explaining and appraising procedure risks and complications to patients is a requisite of any informed consent, most patients still think that additional procedures,  should be an additional work for the physician and the healthcare providers alone. Patients or their financiers are not obliged to pay the healthcare providers for the services rendered for these additional procedures. Wherever, that notion came from, the stress on the attending physician(aside from that of managing the complication) is enormous, working on a very limited logistics to address complications. Besides, Docs have mouths to feed too.

    This situation is akin to the “heroic” services rendered by physicians to dying patients. Just because the patient dies (despite the doctors valiant efforts to revive the patient), the fees for the physician’s services (resuscitation)  does not “die” with the patient too. Services rendered have to be paid even if the service given did not achieve its original goal (that of reviving the patient). Can this situation be applied to procedures done to address morbidities?

    What do you think??

  • Lesser Surgeons?

    I’m amazed at how surgeons in provinces surpass the seemingly insurmountable odds besetting their practice. I’ve heard of horrifying stories regarding provincial practice during my training, that I sometimes wince at the thought that me too shall join their ranks soon when I get back to my hometown.  Then I got the first hand “feel” of what its to be like a surgeon from the provinces.

    In my first year of practice I remember managing one patient who sustained multiple closed fractures of the ankle and that of the leg. On treatment appraisal I found out the guy can afford an operative procedure for the (bimalleolar) ankle fracture but not that of the leg fracture. I was in a dilemma at that time since current evidence only supports good overall functional results if both fractures will be treated operatively at the same time. Treating the two fractures differently or separately will result to a less than good outcome the review further noted. I racked my brains out for a middle ground solution. I can find none more than speculative statistics. I presented this dilemma to the patient and let him decide based on the ‘literature” and statistics I was explaining. I was dumbfounded with what he told me after my lengthy explanation. “Do what you think is best doc”.

    Not only that.  I  told the patient that because we don’t have intra-op x-rays in that institution, it’s either we risk infection bringing out the patient to the x-ray room during operation to check for fracture reduction or just feel out reduction and accept whatever comes out after surgery. His only answer was “do what you think is best doc”.

    Inside OR, there were so many other things that are less than ideal and often “damning’ to surgeons. I’m pushed to use a manual drill because we don’t have a sterilizer fit for my power drill. No pneumatic torniquets. No reduction clamps nor suitable retractors. And did I say before we don’t have a c-arm or an intra-operative xray machine? None of the nurse assists is comfortable with my orthopedic instruments. If this surgery turned horribly wrong, I wouldn’t be surprised. So I made sure the patient knew exactly what are our risk and he too wouldn’t be surprised if this surgery go bonkers.

    I don’t know how the patient’s surgery went well despite these never ending list of “have nots. He went through the surgery knowing all of these and it went well, save for the surgeons’ anxiety and stress. I couldn’t sleep before and after the surgery knowing the odds we’re getting through. Frankly, I’m scared more than the patient but choice is something limited for us during those times. The need outweighs the risk.

    Nowadays, I stil encounter a few of these have nots in most of my ORs, and I’m just as scared as before. I always talk these oddities to my patients and secure their approval before performing any surgery on them under these situations. This doesn’t lessen my anxiety and stress level though. It just pushes me beyond my comfort zone trying out new things “unorthodox”  that are anchored on a logical framework I’m taught during training. Ultimately, need is such an impetus for innovation.

    So I wonder, does these insurmountable odds make us- the”provincial” cutters, less of a surgeon?

     

  • Chief’s Notes:Life and death tasks and physician’s perception to change

    Amongst professionals around, physicians are slow in adopting to change. By change I mean adapting  innovative ideas to handle cases, concerns and issues. In our aim to effect innovative administrative policies and changes, I’m trying to understand the behavioral reason behind this “reluctance” to adapt among physicians.

    Many physicians are not inclined on taking risks, especially when the issue on hand concerns them, their patients or their practice. An admirable trait perhaps that evolved primarily to safeguard patient’s safety and is ingrained in the professions’ dictum- “Primum non nocere“. First do no harm.

    When taking to the extreme, and coupled with an obsession towards handling ALL (medical or otherwise)  tasks as a matter of life and death, breakthroughs for innovations rarely push beyond the research stage. A physician will stick to whatever will sustain life from his or her experience. Thus, whenever an innovative solution for improvement quality of care is implemented, changing perceptions and attitudes will be a bloody issue to tackle.

    One other reason is the lack of  (new) knowledge and skills needed to adapt to change. For whatever reason we have, without the necessary new knowledge and skills, no physician will dare venture into any “unfamiliar” tasks. A seemingly slow adaptation is seen among physicians.

    It’s quite obvious then that to effect a change in perception or hasten adaptation of any new policies, innovations, or new ways of treating a particular disease, knowledge, attitude, values and skills (KAVS) should be initiated first. That way adaptation to  innovations and policy changes will be a bit faster than what we usually observe today.

  • Reviving the physician’s administrative function

    Right. I almost forgot. The medical staff do have “dual” functions.

    The medical staff has a dual and overlapping management system- the administrative which involves the activities of a medico-administrative character, and professional, which concerns of the clinical aspects of its functions.

    The physician is typically absorbed with the clinical aspects of his profession and rarely bother with administrative functions unless he or she is managing a large group practice or a hospital. Private, solo practice large reduces the physician’s administrative function to bare minimum.

    This may not be necessarily true in a practice that involves a tertiary institution.

    This realization struck me as I was tasked an administrative position of setting up clinical services for a tertiary level health care facility. While defining clinical functions is not a “breeze”, setting up additional administrative functions for the involved physician is like “walking into a storm”. Again, this is seemingly related to physician’s preference to clinical functions rather than the administrative part. In reality, most physicians shy away from ANY administrative functions at all.  I now understood why physician administrators grow (or lose) gray hairs by the hundreds each day.

    physician as administrator
    physician as an administrator, what gives?

    The reason?  My personal observation is this: As a physician, we were trained mainly on the clinical aspects of our profession. The few that got some training on the administrative skills probably got stuck in such functions. This compartmentalization of functions seem to enhance productivity on either of such functions but not on both. We were trained to specialize. Even solo, private practice seem to support this observation. The other reason is that physicians are generally slow to adapt to any change. Our comfort zone is just to comfortable to let go suddenly.  Thus, physicians tiptoes and are slow to adapt to administrative changes intended to improved  health care delivery.

    This is where I am looking for ways to get viral and enthusiastic response from the medical staff. This dual function of hospital based physicians are intertwined and complementary. Defining such functions is necessary for providing top notch health care service and the smooth operations of the health care institution. I’m not just saying this because I’m now part of a hospital administration. As I’ve said before,  have I recognized administrative functions before in a solo practice, my practice would have been smoother and productive.

    In your practice, do you really care about administrative functions at all?

  • Balancing Act: Community and tertiary care orthopedic practice

    Barely five years into a private medical-surgical practice, some people got interested how I’m “doing” with my “kind” of orthopedic practice.  Orthopedic practice refers to an orthopedic surgeon’s working environment, the plethora of patients or cases he handles, the time, effort and money he or she invests on it as well the returns (monetary or otherwise) he gets from this professional career. This is rather a simplistic definition, one that is based on a business model, but roughly what approximates a “medical-surgical practice” in the real Philippine health care settings. This definition is further muddled by “subtypes” of an orthopedic practice as well as the mix and match attitude by most orthopedic surgeons practicing in this country.

    Before I’d shed light on my kind of orthopedics, let me describe what I think is the two extremes in orthopedic practice- the community type, generalist orthopedic practice  and the super specialist tertiary level academic orthopedics.

    A community type of orthopedic practice usually caters to patients with general orthopedics (osteomyelitis) and extremity trauma (fractures) problems and usually the first line of orthopedic care in the provinces. These patients are commonly admitted to a non specialist, primary to secondary level, health care institutions found within the surgeon’s community or area of practice. Academic orthopedics on the other hand,  is basically a tertiary, level I trauma care practice that deals with, specialized or complicated orthopedic problems (e.g. arthroplasty or spine cases) that requires super specialist institutions with supporting facilities (ICUs) . Such specialist type of orthopedic practice is usually coupled with training residents in the orthopedic specialty. Some hospitals add admitting and/or administrative privileges to the surgeon.

    The contrast between these two types of orthopedic practice is probably  apparent in the  amount of time and effort an orthopedic surgeon “invest” on each cases .  A super specialist academic orthopedics is generally thought to be more time, effort and learning  intensive, compared to a community type of orthopedics.  It is also perceived that specialist care are more lucrative, pay and prestige wise.  Of course there will be exceptions to this observation, as the delineation between “learning” in the country side versus the urban centers is gradually grayed by the advent of fast information and the internet. But for our purposes here, let me just simplify definitions to differentiate between the two.

    Why am I differentiating between these two types of practices?  Theoretically speaking, somewhere between these two practices is the middle ground which is for me, the logically desirable type of practice –time, effort and income wise.  Thus, a balanced orthopedic practice (in my opinion) is one that  involves continuous learning and at the same time, offers a “relaxed” environment that caters more to delivering quality orthopedic care in a community setting.

    Many surgeons believe such “balanced orthopedic practice” is not easy “find” , difficult to live with, or is unsustainable. The inherent affinity of the orthopedic practice to orthopedic implants and gadgetry as well as to a tertiary level health care institutions is believed to be the primary reason for such negative perception . While many many orthopedic surgeons still conglomerate on urbanized cities and tertiary level care institutions because of  this logistics necessity, a trend towards community type of orthopedic practice is picking up pace because of improved information technology and delivery of much needed orthopedic implants.

    One former mentor asked me if I’m happy with this dual type of orthopedic practice. I answered ” yes” although I qualified it immediately by saying “.. with some necessary lifestyle and living adjustments” . Personally, I find it natural that this two sub types of practice  complement each other. A community practice without continuous learning is boring. Likewise, teaching orthopedics without actually doing what you teach is too good to be true. Somewhere between these two “extreme” sphere of practices lies a compromise that I felt, will produce the balancing act.

    “But what about lifestyle modifications as you said?” I for one, chose this balancing act, because it fits my lifestyle. Compared to an urban, high volume, city practice, I certainly preferred the relatively relaxed working environment of a community practice. On the other hand, I cannot let go of the many opportunities for learning that these big academic institutions could give. Besides, I love teaching. Teaching could have  been my career if not for the ‘healer” awakening I got in college. Like one mentor said ,  “there’s no better way of learning than to help others learn“.

    Well, a community type of practice will rarely make you rich, but I’m pretty sure you’d be able to put food (or a house and a car perhaps along with some other perks) in your family’s table. A simple living will surely come handy in surviving this dual type of orthopedic practice. But it does pay well in the amount and quality of time you spent with your love ones! I guess it all boils down to what fits your lifestyle and your priorities. Mine just happened to be where I wanted to be years before I became a doctor.

    So which one do you prefer then, the community type of practice? the academe?or both?