Is outpatient really that bad?

[Splenda88]

I have trained and worked as a rheumatologist in 4 different states at this point. Everywhere that I’ve worked, there’s always been a “30/day” rheumatology practice nearby - and they have always been horrible.

This is a specialty which requires fairly extensive and detailed H&Ps, with patients who are often complex - and even “stable” rheum patients have a way of having random things happen that complicate visits and make them take longer. In fact, one of the things that I (and most good rheumatologists) like about the specialty is that you can take the time to really listen to the patient and try to figure out what the hell is going on.

You can try to cut corners and speed it up, but much beyond 25/day and I promise that you’re not cutting fat anymore. It’s muscle. The 30/day rheums rarely have their patients under control and doing well. Plus, who do you want to send your mother to? The doctor who’s going to sit down and take the time to make sure everything gets sorted out, or the guy with his foot on the gas nonstop who’s going to hurry out of the room?

And I don’t think PCPs should be doing this either. I’ve posted at length around here about PCPs not getting the job done because they’re packing in 40/day and doing a crap job of it.

I dont know that much about outpatient medicine beyond my horrible experience with it in residency.

I am just guessing that some might have an efficient system that allows them to see more patients than the average.

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[Osteoth]

I dont know that much about outpatient medicine beyond my horrible experience with it in residency.

I am just guessing that some might have an efficient system that allows them to see more patients than the average.

Even if you maximize the time you take, you have a finite cognitive load. The more pts you see the smaller the differentials, the more consults, the worse medicine.

 

[PikminOC]

I've seen many hospitals that decrease the amount a doctor makes per rvu after the guarantee is up

 

[PikminOC]

Even if you maximize the time you take, you have a finite cognitive load. The more pts you see the smaller the differentials, the more consults, the worse medicine.

This is why they want ai to replace us.

 

[VA Hopeful Dr]

I've seen many hospitals that decrease the amount a doctor makes per rvu after the guarantee is up

That's why you should always be distrustful of a high starting salary.

When I started my current job the starting pay was a bit below median starting for FM, but the RVU and bonus structure was very competitive once you got busy.

 

[NewYorkDoctors]

Even if you maximize the time you take, you have a finite cognitive load. The more pts you see the smaller the differentials, the more consults, the worse medicine.

true.

though to be fair PMDs do get hit with the laundry list of garbage complains that have already been addressed before but the patient figures "heck let me try my luck at the slot machine again and play dumb with this doctor."

careful documentation and keeping a note that keeps track of historical clinical events helps me shut the garbage down.
"you already had scan/tests recently that showed you have no cancer. I know you think that you might have cancer because of the pain in your back which you do not want to do PT / analgesics /exercise for is persisting, but I am telling you otherwise. This does not mean you do not have pain. This means I wish to reassure you against anything bad. But I understand you might feel some therapeutic effect by talking about this to get it off your chest. But we are done with this issue now. If you repeat this in a circle on loop mode, I am not going to listen as I have already listened an explained in detail. Doing things in circles will not change what is going on now."

i routinely pull this line out with patients after i did the whole empathy, fake smiling, talk about your kids or pets opening line thing.


addendum: I do make a genuine attempt to "be nice / kind / hold the patient's hands figuratively" because I find most patients respond to this and they will become more adherent or open to recommendations. It's a form of "framing the conversation" and "selling a bill of goods."

But some patients are just stubborn and set in their ways and will just find ways to try to "mold the situation to fit their world views." If I ever bust out the more confrontational (though still somewhat helpful) lines, I make sure I document like a sternographer in my note. This is not for any lawsuits (as being mean is not a lawsuit as long) but for the PMD. As I do PMD, "unhappy patients" come to me all the time to complain (i.e. slander) a subspecialist they felt did not instant-heal insta-cure like the Pokemon Center the patient.

"how dare that specialist tell me to do lifestyle modifications I don't want to do! slander! Libel! 1 star angry review bomb!"

 

[dgdg]

Even if we do not consider a patient complaint as medically concerning to us, it is concerning to them and that's why they come to us. If they repeat their complaint, then they remain uncertain or worried for some reason. Those reasons are valid.
Sometimes more frequent visits can help with this. Sometimes psychologist counseling or antidepressants can help. Other times we just have to navigate the balance of things that concern us vs. what solely concerns them and provide the best care we can.

If we see some complaints as 'garbage' and feel like we are 'faking' our empathy, physician burnout may need addressing as well.

 

[Splenda88]

US healthcare system is a mess. You are somewhat forced to treat grown ups like children

 

[gutonc]

US healthcare system is a mess. You are somewhat forced to treat grown ups like children

You're talking about surgeons, right?

 

[PikminOC]

US healthcare system is a mess. You are somewhat forced to treat grown ups like children

And in socialized medicine how is it? "Wait your turn Billy for your knee replacement in one year '

 

[Splenda88]

And in socialized medicine how is it? "Wait your turn Billy for your knee replacement in one year '

I really don't know because the US system is the only one that I am familiar with.

 

[NewYorkDoctors]

US healthcare system is a mess. You are somewhat forced to treat grown ups like children

tell me about it.

I do the whole "by the books (fake) smiling and empathy, talk at a 6th grade level with clear terms (unlses the patient is proven highly educated and can talk in bigger medical terms), use lay language, do cultural sensitivity an dunderstand cultural factors when someone does not automatically agree with recommendatinos and plans (I am in NYC after all - im fairly familiar with basic customs of many cultures)" - i do all of that "hand holding stuff" but sometimes patients just want to interrupt and argue with me before I even finish a sentence.

hence if a patient wants to be treated like a child, then will treat them like one.


but my first move is to do all of these (exhausting) by the book proper nuanced approaches that the Family Medicine and Academic GIM doctors always talk about doing (though they have far lower volume than I do) for everyone before I go to a bit more extreme approach. Though I never become paternalistic because the patients will argue back harder like the "teenager" rebels that they are.

 

[Splenda88]

You're talking about surgeons, right?

These guys think you should cater to their needs and they are the only ones with a MD/DO degree. What make things even worst is that the nurses (and sometimes administration) make them feel that way.

 

[NewYorkDoctors]

These guys think you should cater to their needs and they are the only ones with a MD/DO degree. What make things even worst is that the nurses (and sometimes administration) make them feel that way.

well they bring in the hospital the big bucks. shrugs. money money.

Ortho is the top dog though. They can make cardiology get a stat echo for cardiac clearance for a lucrative joint surgery

 

[sloh]

tell me about it.

I do the whole "by the books (fake) smiling and empathy, talk at a 6th grade level with clear terms (unlses the patient is proven highly educated and can talk in bigger medical terms), use lay language, do cultural sensitivity an dunderstand cultural factors when someone does not automatically agree with recommendatinos and plans (I am in NYC after all - im fairly familiar with basic customs of many cultures)" - i do all of that "hand holding stuff" but sometimes patients just want to interrupt and argue with me before I even finish a sentence.

hence if a patient wants to be treated like a child, then will treat them like one.


but my first move is to do all of these (exhausting) by the book proper nuanced approaches that the Family Medicine and Academic GIM doctors always talk about doing (though they have far lower volume than I do) for everyone before I go to a bit more extreme approach. Though I never become paternalistic because the patients will argue back harder like the "teenager" rebels that they are.

The worst patients are those who are too smart for their own good. Dunning Krugers

 

[Splenda88]

The worst patients are those who are too smart for their own good. Dunning Krugers

They will make sure you know they have PhD in something. Lol

 

[sloh]

They will make sure you know they have PhD in something. Lol

“Listen, I’m an engineer.”

“Listen, I’m a lawyer.”

Oh boy…here we go.

 

[NewYorkDoctors]

once someone led with I am a lawyer. I said nice to meet you. I have a great lawyer myself. No i'm kidding, don't worry ill treat you with the utmost standard of care and not deviate from usual practices.

this lawyer was a chemistry patent lawyer and understood the levity right away and we both had good laugh.

 

[Splenda88]

“Listen, I’m an engineer.”

“Listen, I’m a lawyer.”

Oh boy…here we go.

They are telling you I am equally as smart or smarter than you.

Me: Cool

They get angrier because they think I dismiss them.

 

[goldsummer]

I prefer the "bad" parts of outpatient over the "bad" parts of inpatient....but yeah, outpatient is getting pretty bad. Patient's attitudes seem worse in general. Doctors are not respected like we used to be (from what im told), I get treated like a vending machine. We get evaluated on patient satisfaction scores...

I've had some patients get mad when I mention diet & exercise at a visit they made for obesity. They just want wegovy cause, you know, theyve "already tried everything"

I get messages through portal requesting antibiotics cause theyre sick. When I decline and ask them to schedule an office visit for an evaluation first, some get angry cause "i know my body" "you just want to charge insurance!"

I had a recent patient complaint: Patient upset about not hearing about knee xray results. I check the chart... Knee X ray was ordered by a different provider. Results were available 2 weeks after our last visit which was for DM follow up and patient didnt mention the knee. Apparently they think I'm responsible for following up on another doctor's workup in addition to everything i do. Its silly, but they have an avenue to file complaints and therefore leverage.

 

[PikminOC]

tell me about it.

I do the whole "by the books (fake) smiling and empathy, talk at a 6th grade level with clear terms (unlses the patient is proven highly educated and can talk in bigger medical terms), use lay language, do cultural sensitivity an dunderstand cultural factors when someone does not automatically agree with recommendatinos and plans (I am in NYC after all - im fairly familiar with basic customs of many cultures)" - i do all of that "hand holding stuff" but sometimes patients just want to interrupt and argue with me before I even finish a sentence.

hence if a patient wants to be treated like a child, then will treat them like one.


but my first move is to do all of these (exhausting) by the book proper nuanced approaches that the Family Medicine and Academic GIM doctors always talk about doing (though they have far lower volume than I do) for everyone before I go to a bit more extreme approach. Though I never become paternalistic because the patients will argue back harder like the "teenager" rebels that they are.

I'm sure it's worse in other countries with no free speech

 

[NewYorkDoctors]

I prefer the "bad" parts of outpatient over the "bad" parts of inpatient....but yeah, outpatient is getting pretty bad. Patient's attitudes seem worse in general. Doctors are not respected like we used to be (from what im told), I get treated like a vending machine. We get evaluated on patient satisfaction scores...

I've had some patients get mad when I mention diet & exercise at a visit they made for obesity. They just want wegovy cause, you know, theyve "already tried everything"

I get messages through portal requesting antibiotics cause theyre sick. When I decline and ask them to schedule an office visit for an evaluation first, some get angry cause "i know my body" "you just want to charge insurance!"

I had a recent patient complaint: Patient upset about not hearing about knee xray results. I check the chart... Knee X ray was ordered by a different provider. Results were available 2 weeks after our last visit which was for DM follow up and patient didnt mention the knee. Apparently they think I'm responsible for following up on another doctor's workup in addition to everything i do. Its silly, but they have an avenue to file complaints and therefore leverage.

I put my obese patients with OSA onto the CPET machine and then prove to them they have no cardiopulmonary disease but are deconditioned Then I take the time to be empathetic with them and tell them that they have no organic disease and that weight loss will help them.
Then I use the resting VO2 to calculate their metabolic rate and tell them this is them magical calorie number. Then I tell them to use Noom and/or see an R.D. and work at that calorie deficit.

Then I give them a pedometer ($3 on amazon... most people are not going to get it themselves because... people....) and tell them to get those steps up there and to increase their N.E.A.T.

Then I tell them I hate going to the gym also as I see lots of giant muscle steroid heads hoo-ing and hah-ing and I get shy and want to leave too.

Then I tell them if you can get these things done for a month and use the CPAP (which will give you more energy to do these things!) and it begins to come down, then I'll help you get your GLP1 agonist therapy (provided its covered.... if they have DM its so much easier for Ozempic)

when the patients give me the "i've tried everything line." I tell them, you've not tried these steps. you've not attained a caloric deficit despite what you think. now I empathize and tell them "I believe that you believe that you have tried everything. but if you did we wouldn't be having this conversation. now email me your Noom progress through the app so I can guide you through on my cell phone when im doing my walking at night in my home."

for reference I get 15,000 - 20,000 steps in per day (measured by pedometer and most of which I literally hop and prance around in my office room in between patients while typing on the keyboard) and the rest I get on an incline treadmill I do for about 20 minutes a day on weekdays (and 1 hour on weekends) doing 12% at 3MPH or a bit faster sometimes as well as walking in circles in my home at night while im on the phone (as I am doing now... posting on SDN...) and I maintain 12% body fat. I work 80 hours a week as well. I was never an athlete growing up. But as I approach my middle age, I must take all the efforts to stay in shape to prevent disease.


yeah the Z-pak mania is annoying. for those who just want some antibiotics because... I tell them how about I prescribe some cough / URI therapies / viscous lidocaine over the phone? free of charge its on the house. if its not better, then you come in and if you have signs of pharyngitis, pneumonia, sinusitis over 10 days etc... then we get you those antibiotics.

of course all of these things I do are only easy as I own my own practice. I can imagine all the "red tape" involved in a hospital based practice in which a doctor cannot just "give the patient a $3 pedometer"

luckily deal with a lot of bronchiectasis and COPD patients in whom any report of purulent sputum and worsening cough is good enough for me to give them something (provided they gave me sputum cultures before to ensure its not some crazy Pseudomonas in there)

it's also annoying when I see an NTM-LD patient who has smaer positive disease and cavitary disease but whose MAC or other organism is resistant to macrolides. I ask them did you have a lot of Z-paks in the past? the answer is yes everytime they had a cough. sign.

 

[Angler]

for reference I get 15,000 - 20,000 steps in per day (measured by pedometer and most of which I literally hop and prance around in my office room in between patients while typing on the keyboard) and the rest I get on an incline treadmill I do for about 20 minutes a day on weekdays (and 1 hour on weekends) doing 12% at 3MPH or a bit faster sometimes as well as walking in circles in my home at night while im on the phone (as I am doing now... posting on SDN...) and I maintain 12% body fat. I work 80 hours a week as well. I was never an athlete growing up. But as I approach my middle age, I must take all the efforts to stay in shape to prevent disease.

... or just get a dog.

 

[NewYorkDoctors]

... or just get a dog.

but i work 80 hours a week and live in New york city. no time for that.

i have two little kids though. that keeps me busy when i go home at night and walking around and getting those steps up also. maybe ill get a dog later on when im retired as well.

 

[Angler]

but i work 80 hours a week and live in New york city. no time for that.

yeah, I get it. I'm retired. Not trying to rub it in.

 

[gutonc]

The worst patients are those who are too smart for their own good. Dunning Krugers

I had 2 of them yesterday. One who name dropped a dozen people she worked with when she was in high school (she's in her 70s now) at the academic place I left a few months ago and then told me she worked at NIH and NAM (I googled her...she was an accountant for both of them) and another who wouldn't stop telling me about his masters in biology which was why he knew so much about the ingredients going into the smoothies he was drinking that were fighting his cancer.

I smiled, nodded, signed their chemo orders and walked them over to the infusion unit.

 

[NewYorkDoctors]

I had 2 of them yesterday. One who name dropped a dozen people she worked with when she was in high school (she's in her 70s now) at the academic place I left a few months ago and then told me she worked at NIH and NAM (I googled her...she was an accountant for both of them) and another who wouldn't stop telling me about his masters in biology which was why he knew so much about the ingredients going into the smoothies he was drinking that were fighting his cancer.

I smiled, nodded, signed their chemo orders and walked them over to the infusion unit.

nice

in general I encourage patient to use holistic medicine if they are doing in conjunction with evidence based medicine. (and as long it is not dangerous) .

this "supportive attitude" seems to get patient to buy into the EBM practice a bit more and see the doctor as "an ally."

 

[dozitgetchahi]

Even if you maximize the time you take, you have a finite cognitive load. The more pts you see the smaller the differentials, the more consults, the worse medicine.

I agree with this. I can definitely “feel” the difference between seeing 15/day and 25/day. The cognitive load thing is very real.

 

[DrMetal]

“Listen, I’m an engineer.”

“Listen, I’m a lawyer.”

Oh boy…here we go.

The worst is: "Listen, I'm a doctor."

US healthcare system is a mess. You are somewhat forced to treat grown ups like children

It's really not. Believe it or not, the US healthcare system is still head and shoulders above many other countries (please don't bring up Sweden or Norway, or any other country with a homogenous white population of 3 million)

The problem with US healthcare is that we don't always utilize it correctly. We allow some to have too much access to care (mostly because we're too afraid to say 'No) while others don't get enough access.

When used correctly and appropriately, the US system of healthcare is actually quite good and envied by the rest of the world.

 

[PikminOC]

The worst is: "Listen, I'm a doctor."



It's really not. Believe it or not, the US healthcare system is still head and shoulders above many other countries (please don't bring up Sweden or Norway, or any other country with a homogenous white population of 3 million)

The problem with US healthcare is that we don't always utilize it correctly. We allow some to have too much access to care (mostly because we're too afraid to say 'No) while others don't get enough access.

When used correctly and appropriately, the US system of healthcare is actually quite good and envied by the rest of the world.

Yes my brother works at Henry Ford and the Canadians pour over there since they can't get timely access to care

 

[VA Hopeful Dr]

The worst is: "Listen, I'm a doctor."



It's really not. Believe it or not, the US healthcare system is still head and shoulders above many other countries (please don't bring up Sweden or Norway, or any other country with a homogenous white population of 3 million)

The problem with US healthcare is that we don't always utilize it correctly. We allow some to have too much access to care (mostly because we're too afraid to say 'No) while others don't get enough access.

When used correctly and appropriately, the US system of healthcare is actually quite good and envied by the rest of the world.

If you can afford it.

 

[Splenda88]

Yes my brother works at Henry Ford and the Canadians pour over there since they can't get timely access to care

Interesting. I did an IM sub-I rotation (2017) at Henry Ford downtown Detroit and did not notice such thing.

 

[PikminOC]

Interesting. I did an IM sub-I rotation (2017) at Henry Ford downtown Detroit and did not notice such thing.

He's been there for over 10 years

 

[DrMetal]

If you can afford it.

Even if you can't, even if you have no insurance . . .I've seen these social workers and case managers work some true magic. They'll take a Mexican immigrant (I'm near the border) that has no more than $100 to his name, find a way to enroll him in MediCal, and get him full treatment for his newly diagnosed colon cancer. I've seen them even do the same for middle class boneheads who refuse to buy health insurance (even though they can afford it). And no kid (<18yo) in this country goes untreated (sometimes they're late to present, but that's a different issue).

In most parts of Asia, Africa . . . immigrants and kids are left for dead.

The US is the most generous and capable country. I would argue too generous (we should have a 3-strikes AMA rule: If you've signed out 3 times AMA, next time, you just have to die).

 

[VA Hopeful Dr]

Even if you can't, even if you have no insurance . . .I've seen these social workers and case managers work some true magic. They'll take a Mexican immigrant (I'm near the border) that has no more than $100 to his name, find a way to enroll him in MediCal, and get him full treatment for his newly diagnosed colon cancer. I've seen them even do the same for middle class boneheads who refuse to buy health insurance (even though they can afford it). And no kid (<18yo) in this country goes untreated (sometimes they're late to present, but that's a different issue).

In most parts of Asia, Africa . . . immigrants and kids are left for dead.

The US is the most generous and capable country. I would argue too generous (we should have a 3-strikes AMA rule: If you've signed out 3 times AMA, next time, you just have to die).

You are apparently in a very blue state. Not all of us have access to the same resources you do.

And its typically your lower middle class people with jobs who get hosed.

 

[NewYorkDoctors]

Here in nyc all undocumented illegals (I’m not just singling out the recent border crossers but all undocumented immigrants from Asia, Africa, South America and Europe ) can easily get managed Medicaid and thus FREE healthcare with zero deductibles and zero copays/coinsurances. The formulary for NYS Medicaid this yaer has become outrageously good and so many things are fully covered and FREE. The health systems and big pharma love it . I can’t complain as I benefit pay wise so I will never run for politics. But then I have legal immigrants who are either in green card or naturalized citizens and also us born citizens who happen to just be middle class or make just a little more money than the poverty line and get absolutely HOSED and pay out the you know what for their healthcare.

but yes i agree with Drmetal. Our health care technology and medical expertise and knowledge are second to none... but deployment is another issue. I cannot fix it and I do not have delusions I can. I just use all this easy money I make to go the extra mile for each patient of mine regardless of the patient's background and situation.

 

[PikminOC]

He's been there for over 10 years

Interesting. I did an IM sub-I rotation (2017) at Henry Ford downtown Detroit and did not notice such thing.

Medical Care for Canadian Patients

Canadian patients visit Henry Ford Health in the United States for advanced, affordable medical care.

www.henryford.com

Other Michigan hospital

Michigan Hospital Looks for Patients North of the Border

Promoting healthcare services to Canadians is nothing new for hospitals in border communities. But a campaign launched by a Michigan hospital is targeting procedures and operations Canadians need the most.

www.healthleadersmedia.com

 

[Drrrrrr. Celty]

The worst is: "Listen, I'm a doctor."



It's really not. Believe it or not, the US healthcare system is still head and shoulders above many other countries (please don't bring up Sweden or Norway, or any other country with a homogenous white population of 3 million)

The problem with US healthcare is that we don't always utilize it correctly. We allow some to have too much access to care (mostly because we're too afraid to say 'No) while others don't get enough access.

When used correctly and appropriately, the US system of healthcare is actually quite good and envied by the rest of the world.

I think this hits the nail on the head tbh.

We misuse resources. And people expect care that is unreasonable because we cannot say no for fear we will miss something and get sued. So now we have ballooning healthcare spending nationally that overtakes the GDP of entire first world nations.

 

[chessknt]

80 year olds deserve their tavr, 2x hip replacement, perm cath for dialysis and 250k chemo infusions. If they don't get that how else do we expect the medicare fund to be depleted by the time anyone else gets old?

 

[dozitgetchahi]

The worst is: "Listen, I'm a doctor."



It's really not. Believe it or not, the US healthcare system is still head and shoulders above many other countries (please don't bring up Sweden or Norway, or any other country with a homogenous white population of 3 million)

The problem with US healthcare is that we don't always utilize it correctly. We allow some to have too much access to care (mostly because we're too afraid to say 'No) while others don't get enough access.

When used correctly and appropriately, the US system of healthcare is actually quite good and envied by the rest of the world.

We also have a geographical issue.

If you are a middle/upper class person living in urban or suburban America, then I agree you may well be getting the best care in the world.

If you are in a rural area or you’re poor and living in an urban area, then you know exactly why American healthcare quality numbers suck as much as they do in some metrics.

I work in rural flyover country and the difference in quality out here on some things is just staggering.

 

[Splenda88]

We also have a geographical issue.

If you are a middle/upper class person living in urban or suburban America, then I agree you may well be getting the best care in the world.

If you are in a rural area or you’re poor and living in an urban area, then you know exactly why American healthcare quality numbers suck as much as they do in some metrics.

I work in rural flyover country and the difference in quality out here on some things is just staggering.

The other issue you fail to mention is that many (or arguably most) of these don't give a f... about their health,

 

[VA Hopeful Dr]

The other issue you fail to mention is that many (or arguably most) of these don't give a f... about their health,

That's not unique to us

 

[PikminOC]

The other issue you fail to mention is that many (or arguably most) of these don't give a f... about their health,

Yes that's the US. Do whatever feels good in the moment. Consequences be damned. US has a high rate of obesity

 

[Splenda88]

Yes that's the US. Do whatever feels good in the moment. Consequences be damned. US has a high rate of obesity

True story

Patient with hx of COPD, HTN, class II obesity presented w/ dysphagia, N/V, SOB.

Diagnoses: Stage IV gastric adenocarcinoma, PE, probable pneumonia.

Surgeon said nope to PEG tube. Patient placed on TPN

Oncologist said he will treat

Patient spent almost 2 wks in hospital. Discharged home on Friday on TPN, Lovenox etc... and will see oncologist on Monday.

Went home and continue to smoke. Came back to the ED with c/o SOB.

Daughter filed a complaint saying that hospitalist discharged patient too soon.

You can't make that [insert] up!

 

[NewYorkDoctors]

True story

Patient with hx of COPD, HTN, class II obesity presented w/ dysphagia, N/V, SOB.

Diagnoses: Stage IV gastric adenocarcinoma, PE, probable pneumonia.

Surgeon said nope to PEG tube. Patient placed on TPN

Oncologist said he will treat

Patient spent almost 2 wks in hospital. Discharged home on Friday on TPN, Lovenox etc... and will see oncologist on Monday.

Went home and continue to smoke. Came back to the ED with c/o SOB.

Daughter filed a complaint saying that hospitalist discharged patient too soon.

You can't make that [insert] up!

yeah i tell my GOLD 4 / E patients you're (expletive in past tense) in a nice way... as soon as they start supplemental oxygen or qualify for home BiPAP.

it helps to set expectations early.

addendum: I'm nice about it and I give them all of the things they need to try to keep them out of the hospital... even if they keep smoking...
i'm talking about chest physiotherapy, hypertonic saline to clear the airways, Breztri Aerosphere, roflumilast, hospital bed, that nice Inogen portable oxygen... it costs quite a bit but sure is cheaper than an hospital or ICU stay.
Pulmonary rehabilitation is not readily available in the community, but I give them a pedometer and get them onto high step counts throughout the day and teach them how to do the proper exercises via youtube videos.

 

[PikminOC]

That's not unique to us

yeah i tell my GOLD 4 / E patients you're (expletive in past tense) in a nice way... as soon as they start supplemental oxygen or qualify for home BiPAP.

it helps to set expectations early.

addendum: I'm nice about it and I give them all of the things they need to try to keep them out of the hospital... even if they keep smoking...
i'm talking about chest physiotherapy, hypertonic saline to clear the airways, Breztri Aerosphere, roflumilast, hospital bed, that nice Inogen portable oxygen... it costs quite a bit but sure is cheaper than an hospital or ICU stay.
Pulmonary rehabilitation is not readily available in the community, but I give them a pedometer and get them onto high step counts throughout the day and teach them how to do the proper exercises via youtube videos.

Is home bipap on its own bad?

 

[dozitgetchahi]

The other issue you fail to mention is that many (or arguably most) of these don't give a f... about their health,

That’s true. But that’s also not the point I was making.

What I mean by “healthcare quality” is what happens to you after you present for care, even if you didn’t give a **** about getting care or managing your health before that. (I don’t care much about population metrics that describe how big swaths of America are sick and obese and unwell - that’s indeed a structural, societal problem but not actually a healthcare problem. As a doc, I can’t kick down someone’s door who’s never been to a doctor in years and forcibly administer care.)

As you step out of the cities further into rural America, everything about the quality of healthcare declines dramatically. Hospitals and healthcare facilities are under resourced and short staffed. Rural doctors are often atrocious - not members of the medical A-team, B-team, or hell even C-team. In more rural areas I’ve encountered dinosaurs practicing medicine 40 years out of date, washed up doctors with board actions against them in several states, lots and lots (and lots) of colleagues who are in the state PHP, etc. Rural areas don’t exactly employ America’s medical best and brightest, and everyone knows it.

 

[Osteoth]

That’s true. But that’s also not the point I was making.

What I mean by “healthcare quality” is what happens to you after you present for care, even if you didn’t give a **** about getting care or managing your health before that. (I don’t care much about population metrics that describe how big swaths of America are sick and obese and unwell - that’s indeed a structural, societal problem but not actually a healthcare problem. As a doc, I can’t kick down someone’s door who’s never been to a doctor in years and forcibly administer care.)

As you step out of the cities further into rural America, everything about the quality of healthcare declines dramatically. Hospitals and healthcare facilities are under resourced and short staffed. Rural doctors are often atrocious - not members of the medical A-team, B-team, or hell even C-team. In more rural areas I’ve encountered dinosaurs practicing medicine 40 years out of date, washed up doctors with board actions against them in several states, lots and lots (and lots) of colleagues who are in the state PHP, etc. Rural areas don’t exactly employ America’s medical best and brightest, and everyone knows it.

Because no one wants to live there. Only solution is $ which they don’t have because of poverty and low patient volumes or taxes which usually people don’t like.

 

[anonperson]

of course all of these things I do are only easy as I own my own practice. I can imagine all the "red tape" involved in a hospital based practice in which a doctor cannot just "give the patient a $3 pedometer"

Everyone has smart phones with built in pedometers. Even the illegal aliens I see roll in with I phones. It's good enough to get a general idea of number of steps.

 

[NewYorkDoctors]

Everyone has smart phones with built in pedometers. Even the illegal aliens I see roll in with I phones. It's good enough to get a general idea of number of steps.

True true . But unless one clips it to the belt all day(not everyone does ) then it’s not getting the true steps every day and it might be discourage some from thinking wow it’s so hard to get 10,000. Plus some may not want a phone so close to Down there all the time.

Plus many folk are very tech illiterate . Accessing the fitness app is an impossible task for some

ADdendum: there is no EBM for 10,000 steps. I tell patients 10,001 is the same as 9999
It seems 10,000 came from a decades old Japanese advertisement for a pedometer and "health"

Nonetheless, 10,000 steps is about 1,000 steps per 10 minutes of walking at about 2-3MPH for most people. So that would be about 140 minute sof walking per day at least
that would fall in line with the AHA recommendations and then more than that as well

American Heart Association Recommendations for Physical Activity in Adults and Kids

Learn how much daily exercise or physical activity you need to stay healthy and what counts as moderate and vigorous intensity aerobic activity.

www.heart.org