Minding the Gap

Sharon is one of my sixty year old patients. She came in for a general check up and has been doing well. As I sit down with her and go over her chronic medical conditions, I remind her that it’s time for her to get her mammogram. “I don’t want one,” she says. “I’ve had them before and they always hurt. I don’t want another one.” Fair enough, I think. Then I go on to remind her that she is due for a colonoscopy. “No thanks,” she retorts. Flu shot? “I’d rather not. I don’t believe in them.” Sharon is also a diabetic, but fortunately for me, she is controlled and has a relative contraindication to statin therapy. While I like Sharon as a person, she is the worst kind of patient. Sharon represents one giant “gap.”

If you’ve ever been to London and took a ride in the “tube,” then you know that the expression “mind the gap” refers to the space between the train and the platform. It’s the most polite way of telling a riding passenger to be aware of the space, otherwise, you’ll trip and fall and potentially have a disaster to deal with. This reminds me of the most irritating thing about medicine these days: HEDIS.

HEDIS stands for Healthcare Effectiveness and Data Information Set. Most patients don’t know what HEDIS is so to briefly summarize, it is essentially the mandate set forth by the government on how medicine should be practiced. In other words, we, as your doctors, are required to fulfill certain “quality measures” in order to be fully compensated for the work that we do. These days, you can’t just go to your doctor for a cold and expect to be treated and sent on your way. Now, you need to get your vital signs taken, go over your entire medical history, and make sure that all of the preventative measures, like mammograms and vaccines, are offered. What should be a ten minute doctor’s visit turns into a twenty to thirty minute visit depending on the complexity of a patient’s medical history.

The problem with HEDIS is that the “quality measures” are constantly changing. At first, it was just a matter of getting a blood pressure under control and making sure patients got their pap smears and mammograms. Now, it’s about making sure that the heart failure patient is taking an ACE inhibitor. Now, it’s making sure that all diabetic patients are on a medication for their cholesterol (regardless of how good it is). It’s about making sure that a diabetic patient has an HbA1C for less than 8. While these “quality measures” are inherently a good idea, unfortunately, they are unrealistic in certain cases. For patients that have an intolerance to certain medications as in the case with the rheumatoid arthritis patient that can’t stand methotrexate because of stomach upset or the diabetic that gets fatigued with statin therapy, these measures can make their lives more difficult.

In addition to constantly changing the target, patients are becoming ever more reluctant to being compliant with the measures. From the anti-vaxxers to the Dr. Google-ers, patients are feeling their most empowered these days, but not in the good way. These days, there is a distrust in the medical field. I’m not quite sure how that happened, but I think that, perhaps, patients see medicine as “the establishment” instead of the doc that’s around the corner that they’ve come to know and love. Perhaps, it’s the stereotype of the rich doctor driving around in his Ferrari that has patients thinking that they, themselves, are cash cows. Perhaps, it’s true that a little bit of knowledge that can be gathered from the internet is a very dangerous thing. By the way, I can attest that as a primary care doctor, I do not drive a Ferrari, I drive a Nissan.

What’s the result of all this? Your doctor has been reduced to becoming a salesman, pitching a product to you, the customer. And while these products are in your best interest to take, sometimes, there is no convincing you. When you decline or outright refuse a test or medication, this creates a gap in the quality measure that we, your doctors, are trying to fill. Again, these quality measures are inherently a good idea for 95% of patients, so when you refuse it, you are essentially stating that you acknowledge you are doing something that is counterproductive to your health. If a doctor fails to meet the quality measure by year’s end, he or she doesn’t just fail to get paid by the insurance company. He or she is usually terminated from the insurance plan, resulting in you, the patient, needing to find a new doctor.

So please, the next time you’re at your doctor’s office, please mind the gap. Believe me when I tell you that I want what’s best for your health, but I also want to keep my job. For Sharon, I have the rest of the year to try and convince her about that mammogram.

Post by: Dr. Juan Borja
Original Post Here

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