Friday, March 6, 2009


The problem with first-year medical students is that they haven’t yet learned which questions not to ask.

Two weeks ago, I had a student spending the afternoon with me at my office. We met a patient and his wife, and talked with them about the results of a CT scan he had done earlier in the day. After the visit, the student asked me "Why did he have to come to your office today?" Her concern was that the man had difficulty walking and had recently moved into a care home an hour away from Saskatoon. It was a significant effort for them to travel, both to get to Saskatoon and then within the city.

My staff is diligent about scheduling CT scans (and other tests) on the same day as an office visit, so I can review the results with the patient. I pointed out to my student that this saves people an extra trip into town.

Then she got really impudent.

"But he still had to wait between the morning CT and afternoon office, then had to find a place to park near your office and walk here on icy streets. I know he had to come to town for the CT, but couldn’t he get the results by letter or over the phone?"

You know, once they get their teeth into something, you sort of have to humor them. So we broke down the reasons for an office visit:
  • Need for physical examination
  • Establishing rapport and trust, especially on initial consultation
  • Emotional support when discussing bad news
  • Complex discussions that involve dialogue (not suitable for the one-way communication of a letter), or the opportunity to pick up emotional cues (not suitable for a phone call)

None of these applied to this man. He’d just had a CT scan so, in this case, there was nothing that a physical exam would add. I’ve known him for over 10 years, and we have a good rapport. The test results were good, so no bad news to break. The results were straightforward, so a letter or phone call may have sufficed. What were we missing?

  • I get paid fee-for-service.

Awkward moment.

I don’t make patient care decisions based on how much money I’ll receive. (Or, I’d like to believe I don’t…) But, it’s inescapable that incentive drives performance. This is my job – how I support my family. I work in a partnership in which I’m expected to generate my share of revenue. Under the province’s medical insurance system, I’m not allowed to bill the government for letters or phone calls to patients. That means any time I spend on those activities is for free. I could send a bill to the patient, but that means some messy bookkeeping for my staff, and might upset my patients.

Although, come to think of it, I’ve never asked my patients what they would prefer: Paying me directly to receive their results by letter or phone? Or spending their money on gas, meals, and lodging to travel to Saskatoon to visit me in person? That might be an interesting survey to conduct.

And, if anyone is going to do that survey, can they please ask patients this broader question: What do you want from specialists? The iconic “specialist referral” is often necessary, but maybe it’s not always the right tool for the job.

At Saskatoon Health Region’s Quality and Safety Summit this week, the Deputy Minister of Health pointed out that people don’t really want to consume health care. They’d rather be healthy. If you’re in the ER with a heart attack, you’re probably grateful for the expert treatment you’ll receive, but you’d rather be walking the dog. Perhaps you’d give higher value to a health care system that was designed to maintain your health, by promoting exercise, proper diet, and a healthy lifestyle. But, we’re sort of used to doling out high-tech acute care, so that’s what you’re going to get.

In the same vein, we’ve built a specialist referral system that mandates a physical visit with the specialist. Patients don’t want to see a specialist; what they want is resolution of a health concern. That may be best done with a specialist visit, but there may be other approaches.

I’ve been thinking about this a lot over the last few weeks, as there’s been a glut of men wanting vasectomy reversals. Actually, they don’t want vasectomy reversals – they want information about the procedure, success rates, and costs (it’s one of the few uninsured procedures for which we directly bill patients). As often as not, men decide not to go ahead with vasectomy reversal. They could have saved a trip to see me if I had sent them an information pamphlet explaining the procedure, and inviting them to make an appointment to see me if they were convinced they wished to have the operation done. The same goes for many other common conditions that aren’t serious, but are still valid health concerns.

But, what’s my incentive to do that? Why should I put effort into developing the information pamphlets and sending them out or posting them on our website? Sure, it gives people the information they want, saves them the nuisance of a visit with me, and opens up the appointment time they would have taken so I can see someone else sooner, but I’d be cutting my own fiscal throat. As long as I’m paid fee-for-service, that’s what you’re going to get from me: Lots of services that I’m paid for.

Expect something different? Then I suggest you read On the folly of rewarding A, while hoping for B.

The beauty of first-year medical students is that they haven’t yet learned which questions not to ask.


  1. Originally posted by Jill 03/06/09 1:45 PM

    I've been reading and enjoying your Adventures in Improving Access since Day One but have never felt the need to respond. And now twice in a month. Setting aside the whole FFS thing, there is another challenge in communicating test results. We have urologists who follow prostate cancer patients across the province - probably in a fashion similiar to your practice. The urologists gets the follow up PSA results. Do you make an elderly man drive in from whereever for the 5 minute visit to find out his PSA is normal, or do you call and say "your PSA is normal". Everyone can agree that ideally, you call and say "your PSA is normal." But what happens when the PSA is NOT normal? Well, then you get into the points in your blog "breaking bad news and complex discussion", which are better done face to face.In this scenario, the urologist's office calls the patient to make an appointment. So in effect, you have just told the patient that his PSA is not normal and causing him and his family distress and uncertainty until he can get in for his appointment. Therefore, the lesser evil seems to be to bring everyone in so that we don't cause distress for the minority for whom the news is bad. What we need is some out of the box thinking for how to minimize harm for those patients while reducing "unnecessary" visits for the majority.

  2. Originally posted by Dorothy 03/06/09 1:50 PM

    I have read your posts and have really enjoyed them as well as the comments from others. I am, however, very puzzled by your latest post. My understanding is that you entered Clinical Practice Redesign (CPR) in part because you were too busy. Your wait times were far too long, you were providing services that could be provided by family physicians and you were attempting to eliminate ‘muda’. Yet when your medical student made a very valid point about the need for an office visit following a CT scan, you raised the issue of fee-for-service. Considering your abundance of patients, is it really your bottom line that is concerning you? Might it possibly be a wavering faith in CPR? Is the old way of thinking just too comfortable? I am not a physician, nor am I a resident of your province so I have no knowledge of how your remuneration system works. However, I do know that if you want to learn to swim, you have to let go of the pool wall.

  3. Originally posted by S. Smith 03/09/09 10:30 AM

    We (the tired-of-these-shenanigans) health consumer learned several years ago what the game was, and found that all the answers we needed to help us get to health, rather than to the specialist, were online. It's true. Your vasectomy example needn't come to you for his information package. Google has it. Oh maybe not in a convenient industry-authored package, but it's there, with pros and cons, and non-industry opinion too. We've known for some time what you've been doing and had less respect for you (universal you) because we knew you knew too, but did not have to change it. So you didn't. The internet library is amazing. Some of you would like to think we're reading those garish neon websites that promise us virility, fertility and one simple cure all, but no really, we're consulting Swedish and Finnish physicians by e-mail, sending our lab results to American pathologists, filling out questionnaires about statin side effects which our own physicians have apparently never heard of, to the one researcher looking into that, reading Healthy Skepticism, PloS and Therapeutics Initiative, subscribing to CSPINET, Pharmalot (now defunct but archived), reading Marcia Angell, Cassels, Moynihan, Abramson, Shannon Brownlee, got the conflict of interest and hidden data information on Zyprexa, Vioxx and Paxil before you did (most of it's on an untouchable off-shore registered server) and are linked with thousands like us through Yahoo Groups, consumer websites, advocacy blogs, list servs and twitter. Fascinating column though. Welcome onboard.

  4. Originally posted by F.A. 03/11/09 8:30 AM

    Indeed, fee-for-service is a barrier to the efficient delivery of medical news and results to the patient. Given that you, your colleagues, and the public know this - would it not be possible to lobby provincial governments to allow for physicians to charge for either the phone consultation or the letter? Or is there no desire on the part of provincial Medical Associations to lobby for such an adjustment because at the end of the day the mandatory visit is more profitable?