Dr. Iconoclast

primary care office work

On the "Duh" front, researchers have determined that primary care physicians manage several patient problems during a single office visit.
Researchers analyzing conversations between physicians and patients more than 65 years old found that on average, six topics were discussed during the visit, as the patient and physician each brought up items of concern.
This actually seems like a low number to me. Primary care physicians are asked to do what is literally impossible. To keep an office open, based on the low reimbursement rates, you need to see something like 25 patients a day, which means 15 minute office visits.
The average patient over 65 probably has at least three chronic conditions to manage, plus preventive stuff, plus acute problems like knee pain or dizziness.  Just to do the required preventive care takes something like 10 hours a day - there's research on that.
Primary physicians need to be paid more per office visit, so they can see fewer patients and take good care of the ones they see.
If this doesn't happen, we won't have any primary physicians left because they'll all quit or have heart attacks from the stress.

How doctors think

Emerson said that in works of genius, we recognize our own rejected thoughts. This came to mind the other day as I picked up Dr. Jerome Groopman's new book, How Doctors Think, which explores the cognitive processes behind medicine. It's designed for the public, but certainly would be useful for medical professionals also.
I have to admit that for a doctor, this guy writes OK.
I spend a lot of time personally trying to install the medical thinking engine into my medical students.  It's nothing that's easy to write down, and that's why I like to book so much. 
For my students, I describe the diagnostic process, for example, as an intuitive manipulation of probabilities. We teach using case examples, by walking students through a history-taking and a physical examination, asking questions, provoking hypotheses, helping them think through the potential consequences of any action. The whole art of it mostly seems to be passed down person-to-person over the ages.
And it's not easy. That's why I hate the word "misdiagnosis." A diagnosis should be just a temporary concept that we use to make patients better. For example, sometimes when you receive a diagnosis, it's not entirely certain, and we just proceed as if it was in an effort to help allay symptoms and prolong life. Diagnoses in some situations can be picked up and cast away rapidly, and that's how we work. Is the first discarded diagnosis then a misdiagnosis?