CME

Charlie, a friend and businessman, had an interesting take on why some doctors aren't interested in running their own practices. “It requires being highly efficient, not just being a good physician,” he said in an e-mail to me. “I suspect some doctors want to rekindle the days when they could simply cultivate their expertise and a high standard of living was a given.”

Charlie went on to suggest that most doctors are like nonprofits, whereas I was urging them to become more businesslike. “That doesn't happen very often,” he said. “It has to be screened for among applicants and taught as a core competency in medical school. It can't be patched onto someone so easily.”

Then, the businessman in Charlie came to the fore. “Why not create a weekend training seminar? Hold it in a bucolic setting like Mendocino, get it accredited for CME and bring in a bunch of doctors for some golf, some business coaching and a pep talk.”

“Thanks for the feedback,” I wrote back, “but I have a hard enough time just organizing my office, not to mention the logistics of putting together a seminar.”

Charlie was right about one thing: Practice management should be taught in medical school and residency as a core competency. How else will newly minted MDs be prepared for independent practice? “I fear we're turning out cadres of physician employees – homogenized lemmings who are not going to fulfill the vision of family medicine,” I wrote back.

As I continued writing I could see I was warming up to his seminar idea, and things were going to spin out of control if I didn't put the brakes on quickly. “I just remembered that I hate golf and don't much like preaching in front of large groups either,” I said. “Otherwise, it's a great idea.”

Informed consent

“I had a bad day at work last week,” said Terry, my allergy patient. “I nearly killed my patient.”

Terry was a veterinarian who found her career late in life, having started vet school at the age of 40. She was a live wire, which always made for interesting conversation during our visits.

On this particular day, her last patient was a cat with a suspected urinary tract infection. “I was using ultrasound to locate the bladder so I could get a specimen,” she began.

“Wait a minute,” I said. “Why do you need to know where the bladder is before you cath the cat?”

“Oh, we don't cath the animals,” Terry explained. “We insert a needle into their bladder to get the urine.”

“Ouch.” I said. “Why can't they wear a bag? That's less drastic.”

“Yeah, but the specimen would be contaminated,” Terry said, “and we can't wait around all day until they pee. Besides, we charge for the procedure.”

Now I could understand that, although I couldn't imagine any of my insurers allowing it.

“We don't need prior authorization. This is a cash-and-carry business,” she said. “There is no Medicat.”

“Lucky you,” I thought. However, Terry's stab into her patient's bladder was distinctly unlucky; she hit a major vessel and wound up with a syringe full of blood instead of urine. “The damn cat went into shock,” she said. “So I told the owner we had a procedural problem with Fluffy and he had better take her to the animal emergency hospital ASAP.”

I was afraid of the answer but asked anyway, “So how did it turn out?”

“They gave her a transfusion, and she survived. Boy, was that a close call,” Terry said.

The pet's owner returned a few days later, refusing to pay the vet's office and demanding that they pay the hospital bill. Terry's boss rolled over – and made Terry pay half of it. “It cost me 400 bucks!” she lamented. “My colleagues tell me this kind of thing happens because the aortic and venal caval bifurcations all live down there, but usually the bleeding stops. If that had happened my first week on the job, I would have been toast. But they value me as an employee. I just don't think I should have had to pay for that complication, do you?”

“I don't know what would be veterinarily correct,” I mused, “but next time, before you do a procedure, take a lesson from the people doctors. Get informed consent!”

Editor's note: This is the sixty-sixth and final installment of Practice Diary in FPM. Contact Dr. Brown at sbrown@mcn.org or send comments to fpmedit@aafp.org.