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Archive for Thursday, April 22, 2010

Longtime doctor offers perspective on changes in health care

April 22, 2010

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Dr. Charles Yockey, hospitalist at Lawrence Memorial Hospital, makes his rounds. He plans to leave the hospitalist group in January to become a full-time pulmonologist who provides intensive care.

Dr. Charles Yockey, hospitalist at Lawrence Memorial Hospital, makes his rounds. He plans to leave the hospitalist group in January to become a full-time pulmonologist who provides intensive care.

Dr. Charles Yockey visits with Emilie Stauffer-Sikes, a certified nursing assistant at Lawrence Memorial Hospital in this 2010 file photo. Yockey left the hospitalist group at LMH in January to become a full-time pulmonologist as the need for such services continues to grow.

Dr. Charles Yockey visits with Emilie Stauffer-Sikes, a certified nursing assistant at Lawrence Memorial Hospital in this 2010 file photo. Yockey left the hospitalist group at LMH in January to become a full-time pulmonologist as the need for such services continues to grow.

When Dr. Charles Yockey graduated from Kansas University Medical School in 1972, hospital stays averaged more than two weeks, many physicals lasted three days, and his current position would not be created for 25 years.

Now, Yockey, medical director of the hospitalist program at Lawrence Memorial Hospital, said hospital stays at LMH average about two days and physicals last closer to an hour because of technology and diagnostic advances in the health care industry.

While CT scans and MRIs were uncommon in the 1970s and ’80s, Yockey said nearly every patient with questionable symptoms in the hospital receives CT scans even as a protective measure.

“In 1986 when I left Wichita, there was a huge argument about how many MRI machines you can have in one town,” he said. “There was a huge debate if they could have two — now they have 10 and probably are getting another two this year.”

Also, hospital stays have shrunk dramatically because of advancements in diagnosis and surgical procedures, which often take place at outpatient clinics, where nurse practitioners and physician’s assistants can perform similar procedures to a doctor.

“All the things we used to do in a hospital 30 years ago, most of them are now done as an outpatient,” he said. “When I had my gallbladder procedure in 1977, I had a long incision and I was in the hospital a week. Now, you can do that as an outpatient and have three small incisions and be back to work in three days.”

Meanwhile, advances in antibiotics and other pharmaceutical drugs have reduced the required stay at a hospital.

When he started as a physician, Yockey said he had three prescription choices for high blood pressure — all of which caused uncomfortable side effects.

Outpatient services increase

Yockey said when he was in medical school in the 1960s and early ’70s, doctors would run 24-hour urine collections and a plethora of other meaningful tests because they had little else to help them determine a difficult diagnosis.

The rise of outpatient clinics, as well as hospitalists, who specialize in hospital medicine and attend to medical needs of patients during their stays, have freed up other physicians to specialize and have more family time.

“Twelve years ago there would be 35 doctors taking care of the 70 patients we have today,” he said. “Now there is four. It allows the doctors that used to come to the hospitals to see one or two patients to stay at the office all day.”

Still, physicians are spending only 14 percent of their jobs with patients compared to 95 percent 30 years ago. The rest of the time — 86 percent — is mostly spent filling out paperwork or electronic records.

“The challenge is to take care of the patient that 14 percent of time and make sure they are getting the care they deserve and need,” Yockey said.

With every advancement in the health care industry, Yockey said the costs have also risen dramatically. For example, a pill to fend off staph infections costs $150 a pill and $2,100 over a two-week regimen. CT scanners and other medical machinery often cost millions of dollars, and malpractice coverage has risen from a few hundred dollars to several thousand a year.

The art of medicine

Yockey said when insurance companies started paying for more routine medical procedures and visits a couple of decades ago, people took less care of themselves, causing insurance costs to go up along with the increase in expensive equipment.

“All this costs money,” he said. “In 1350, the most common diagnosis was overheated blood and the treatment was blood letting. We’ve come a long way since then, but the reality is that 90 percent of the money that you will spend on health care is spent in the last year of life when it probably can do the least amount of good.”

While the industry has experienced dramatic changes over the past 50 to 60 years, Yockey said the art of medicine has not changed. Patients still need people to care for them and to provide hope and confidence.

Yockey said people today seek the same three qualities in their physician that they did 40 years ago: a knowledgeable and competent doctor, a doctor who cares and a doctor always there when they need help.

Comments

Christine Anderson 4 years, 4 months ago

Dr. Yockey is an outstanding physician. I do have some sincere questions about how the hospitalist program works. For example, if a patient comes thru E.R. and it is determined they've had an M.I.-is their cardiologist part of the orders that will be written to take care of that patient? Will they see their cardio at all during the hospital stay? Suppose someone comes in with multiple pulmonary emboli-will a pulmonologist such as Lida Osbern( for ex.) be called in? What about O/B hospital stays? Do we still have the same dr, who has followed the mother and baby for nine months taking care of them in the hospital or not? At least the ob dr.'s covering partner? I haven't been in the hospital for a long time. I would be scared if I had to go now. The rest of these docs are great at what they do, I'm sure, but to be admitted and then find out you're not going to see the dr. who has treated you for many, many years? Yikes! It just seems like the hospitalist is a general practitioner. Is this truly best for patients who present with a wide variety of problems which DO require a specialist's care? Or at least their primary care dr. who knows them?

Ah, Dr. Jim, wish you were still here so we could benefit from your input.

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lori 4 years, 4 months ago

Most docs now turn their ill pts over to hospitalists. Hospitalists are specialists in the acutely ill patient. If a patient has had an MI, absolutely you will see a cardiologist. If you are having a baby, you will see your doc (or whomever is on call for your doc) for your labor, birth, and post-partum. Otherwise, most likely you will see a hospitalist. If your pulmonologist has privileges and still see patients in the hospital (ie, Dr. Osbern), then yes you will see her. But if not, you'll see a hospitalist. FYI, Dr. Yockey used to be the other pulmonary specialist in town, if you can remember way back when, about 15 years ago.

I am a nurse at LMH, and let me tell you why we love our hospitalists. They are accessible. There is a hospitalist in the hospital 24 hours a day. If you are in the hospital and take a turn for the worse, I can call the hospitalist and he or she can be at the bedside in minutes. Your primary care doc has office hours all day; by the nature of their busy office day, they are more difficult to get a hold of to pass on patient status changes and for orders; it is even more difficult and therefore unlikely for them to leave their offices and come in to see a patient during the day.

Hospitalist specialize in acutely ill patients. It is very difficult for a primary care physician to keep up on EVERYTHING. Acutely ill hospitalized patient care, management of chronic conditions, primary care prevention: it is very difficult for them to stay on top of the latest recommendations and research for everything. Turning their patients over to a hospitalist allows them to have their patients receive up-to-date, specialized care, and allows the primary physicians more time in their offices, specializing in managing patients outside of the hospital.

It reduces time spent in the hospital. Primary care physicians make rounds once a day typically. After all, they have a full day of office hours ahead of them. A hospitalist can monitor a patient throughout the day, and decide if they can go home later, after tests have come back, or if their condition improves over the course of the day. Primary care docs can do this, too, but it often is remotely, from their office, when they have a free moment to talk to the patient's nurse. In my experience, hospitalists have reduced the time patients spend in the hospital. This reduces their risk of hospital acquired infections, their risks of complications due to the inactivity of being hospitalized, and it reduces costs, for patients (particularly those with a high deductible or with no insurance) and for insurance companies and the government.

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lori 4 years, 4 months ago

Part two...

It standardizes medical care. Each primary care physician has his own way of treating pneumonia, for example, and that may or may not be according to national guidelines. The hospitalists, because they specialize in the care of acutely ill, hospitalized patients, are up to date in the latest standards for treating patients for such problems as pneumonia, heart attack, stroke, etc. Of course your primary physician may be up to date on these things as well; but because he or she has to stay on top of so many other thing, such as how to care for these patients long term, outside of the hospital, it is more difficult for them to stay abreast of the latest treatment recommendations. There just isn't enough time in the day for them.

Hospitalists do communicate with the patient's primary physician. Primary physicians receive care summaries, detailing treatments, medications, tests and consults the patient received during their time in the hospital, and what their discharge instructions and medications were. Hospitalists can and do contact the primary physician, particularly during a lengthy and/or complex stay, or during the patient's stay in the ED (though often the ED doc does this there).

Overall, I feel hospitalists have greatly improved the quality of care to the hospitalized patients, and they have freed up time and energy for the primary care physicians to care for their patients outside of the hospital. There are still a few primary care physicians who do admit their own patients, and they do a fine job, although I'm sure it is sometimes a strain for them.

Thank you, LMH hospitalists, for working so well with the various departments and staff! I appreciate your hard work, your expertise, and your wonderful attitudes, and it is a pleasure to work with you. And thank you, LMH, for supporting and expanding the hospitalist program.

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lori 4 years, 4 months ago

Oh, and misplacedcheesehead, I forgot to address your concern regarding consults. Hospitalists appropriately consult cardiologist, oncologists, nephrologists, urologists, neurologists....the hospitalists would provide you with excellent and compassionate care.

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gconfo 4 years, 4 months ago

I second that Dr. Yockey is an excellent physician. He treated my at Watkins and was then my PCP for years (before he took on his current position). He is one of the best physicians that has ever treated me (next to my current one, Dr. Cordova).

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Ryan Neuhofel 4 years, 4 months ago

Lori, Thanks for your perspective on the "hospitalist" trend. As a family doc-in-training (resident), I have recognized a great deal of public confusion about this terminology. A "hospitalist" is NOT a "specialist" in the traditional meaning - via formalized post-graduate training (residency and/or fellowships). They are defined by their setting of practice (ONLY hospital care), not specialized training. In fact, hospitalists can have a variety of backgrounds - the majority with residencies in primary care/general practice such as Internal Medicine, Family Medicine or Pediatrics. Due to Interal Medicine's focus on 'hosptial-based' care during residency, they tend to be more likely strict "hospitalists", but many Family Medicine physicians restrict their scope of practice to hospitals as well.

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Ryan Neuhofel 4 years, 4 months ago

cont'd.

I believe this fragmented system is primarily reactionary due to over-burdened primary care system and NOT neccessarily best for patient care. Continuity of care is something that is sorely missing from most health care today - an ongiong relationship with a physician in multiple settings (office, hospital, etc) is a romantic notion, but something we should strive for. While "hospitalists" are one fix to this mess, I don't think it's ideal.

The patient load of each 'family doc' has been steadily increasing for the past 30 years - with the average established family doc having a 3000+ patient panel . . . which is nearly double-to-triple the load from 1970. Consequently, family docs have given up more-and-more services (house calls, hospital, etc.). In order to survive, we have been restricted to hamster-wheel practices created by the demands (and dollars) of middlemen (third-party payers).

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lori 4 years, 4 months ago

Thank you for your perspective and your clarification. Absolutely I did not mean to imply that all hospitalists go to medical school and study the specialty of hospital medicine. They currently are specialists by their practice and environment, similar to primary care physicians who gravitate towards providing care for a certain demographic, due to their interests, skills, experience, and environment. We will start to see hospitalists trained in their specialty in a more formal capacity in the future, however; there are many hospitalist fellowships now available or in development.

Good luck in your residency and your future practice.

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Kristine Bailey 4 years, 4 months ago

Remember when Blue Cross and Blue Shield was a NON PROFIT INSURANCE Co? Remember when you did not have an army of people at the insurance co. and the doctor"s office certifying/denying care? That group alone must add a lot of dollars to health care costs on both sides. Remember when you didn't have health insurance auditors on the ward clogging up the nurses station and using patient charts?

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sherbert 4 years, 4 months ago

$150. a pill? That's part of the problem right there.

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acg 4 years, 4 months ago

I'll second that sentiment sherbert. We give medicines away to poorer nations and have for decades. However, this nation is in a world of hurt like we haven't seen since the 20's. Maybe it's time we start doing a little medical charity at home. The cost for health care is ridiculous when you consider what you get. Case in point, I had my last kid in Nov. 08. It costs me/my insurance co. around $5000. This was monthly visits, labor and delivery plus two post delivery visits. Of those 9 months of doc visits I saw the actual Doc maybe twice. Nurse practitioners took care of my appointments. When I went to LMH to have the baby, Nurses did everything (except the epidural of course). They put in my iv lines, did all check ups, checked on the dilation and coached me through pushing. My doc walked in about 5 minutes before I gave actual birth, she put on gloves, caught the baby, my hubby cut the cord, she put him on my chest said good job and left. I didn't see her again, even for my two post pardum visits. I called her office for an annual check up, the receptionist told me I have a three month wait, unless I'd like to see a nurse practitioner. It seems to me the nurse practitioners are doing all the work.

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Christine Anderson 4 years, 4 months ago

Thank you, Lori and Ryan. Your perspectives and info did clear up a lot.

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