Letters to the Editor

Whither rural medicine?

Your article “Is the generational gap a growth opportunity” [ACP Internist, April 2008], states some well-founded concerns. The younger generations of physicians are justified in demanding predictable and humane work hours and this is one reason for “hospitalists,” “surgical hospitalists” and “laborists.”

However, in rural communities, these may be a long time coming. Physicians in my generation (“boomer”) who work in rural communities are wanting the same humane lifestyle, particularly as we enter our mid or late years in practice. It is disconcerting that most likely we will never have the opportunity for a practice without frequent on-call weekends (sandwiched between full weeks) and unpredictable night work. The reason is that practices or hospitals have to be fairly large in order to have the patient volume for hospitalists.

Some rural docs simply leave for the city (see those recruiting letters with “practices with no call”) or do locum tenems work. The rest of us have to just accept these disadvantages of rural medicine in order to enjoy other advantages of living in rural areas.

How will the rural areas get doctors, especially skilled internists in the future? Already, most internal medicine residents go for subspecialties and many of the rest become hospitalists. As a general internist in a rural area, I sometimes feel like a dinosaur about to become extinct. Physician assistants and nurse practitioners can be helpful but they cannot manage many of our patients with multiple diseases and complex treatments. Medical communities in rural areas will have to deal with these issues soon in order to attract hard working and skilled young physicians.

Bobby W. Marek, ACP Member
Brenham, Texas

Feedback on PBMs

PBMs are behind the effort to require e-prescribing as a condition for Medicare participation. One cannot begin to estimate the cost savings for the PBMs as physicians will become the data entry clerks for them at no cost. PBMs will no longer need to employ all those people who presently perform those duties, and will physicians do it for free. Physicians will have to bear the cost for software, hardware and support for e-prescribing which is certainly not minimal.

Caremark provided me with a “free” three-year trial of iScribe and related equipment, with monthly charges to start after the free period. No estimate was available as to the exact cost. It was certainly not helpful for my solo practice. After multiple hours of staff time to get the software working, I would have to scroll down the list of patients, scroll down the list of meds, then scroll down the list of pharmacies, just for one patient. It was far more time consuming than simply writing the prescription the old fashioned way.

Patient safety, you might ask? In 22 years of practice, I have had one or two calls from pharmacies unclear about what was written.

It should be a policy of the ACP that PBMs who would benefit from e-prescribing the most pay physicians for the time and effort. A fee should be paid for each prescription electronically provided by physicians. Whether the fee would be twenty five cents per, or a monthly fee based on volume, physicians should require that fee in order to compensate for the time, and expense necessary to comply. Before the e-prescribing mandate train leaves the station and leaves physicians on the platform, this should be an ACP policy.

Paul Sovran, ACP Member
Kissimmee, Fla.

Gap or growth?

I read with great interest your recent article “Is the generation gap a growth opportunity?” [ACP Internist, April 2008]. I tend to align myself with the boomer generation and agree that professionalism (especially bedside manners) and the sense of duty and responsibility to the patient seem less prevalent these days. I don't necessarily believe the 80-hour work week itself is a bad thing, but the Accreditation Council for Graduate Medical Education's letter-of-the-law interpretation and enforcement of the rules has contributed to the problem. Now, hours seem to be the focus, not patient care.

I also found Ms. Maya Babu's statements telling of the modern generation—less intense work for an easier residency. She suggests a night float to avoid overnight calls or allowing postcall teams to leave in the morning at the end of call. While our current system surely has flaws, these ideas are no better. The result would be more fragmented care leading to more handoffs and more errors. The handoff error may be as subtle or simple as repeating a test or a scan that was already done. While this seems innocent, in today's business of healthcare, inappropriate tests add up to wasted dollars, not to mention more harm to the patient. This is one of many examples of handoff errors.

We do need balance between errors caused by fatigue and errors caused by fragmented and inefficient care. Unfortunately, I think the former has gotten most of the press but as a former hospitalist, I can attest to the fact that the latter plays as large of a role in medical errors but gets far less attention.

As an aside, although I align myself more with the boomers, in fact I am a Gen X’er! I think balance is the key. There is more to life than a career but conversely, we must also not forget our unique and high calling as physicians.

Tanna Lim, ACP Member
Atlanta, Ga.

More on the medical home

I read Dr. Hornbake's letter [“Advocate for primary care,” ACP Internist, May 2008] and I take issue him and the ACP regarding a few points. First of all the “patient-centered medical home” sounds like possibly it has some merit for rural practices. However, let's not forget that many patients still do not use computers. In addition I think it would lead to too many evaluations and treatments without actually seeing the patient.

I think if we can cut down on the waste and abuse, we might save a great deal of money. Does every sonogram have to recommend a CT scan? Why does a specialist visit cost $500 but a primary visit $40 or $50? Yet, the primary care doctor is still expected to be addressing all aspects of patient care and is overburdened with the paperwork and liability.

If the government wants to install a plan that would have me act as a primary-care physician and pay me a salary with benefits and retirement, then my response would be “Give me the pen, NOW! There will continue to be a growing shortage of primary care doctors until the problem is appropriately addressed.

William DeStefano, ACP Member
Brooklyn, N.Y.