American College of Physicians: Internal Medicine — Doctors for Adults ®



From the June 1998 ACP Observer, copyright 1998 by the American College of Physicians.


I agree with Harold J. Fallon, MACP, that IMGs should not be blamed for our work force problems ("In the debate over work force, IMGs remain a difficult issue," February ACP Observer, p. 16), but I am concerned about the oversupply of subspecialty physicians. There is clearly a great excess of super-subspecialist cardiologists in areas such as electrophysiology and interventional cardiology, but not enough cardiology generalists.

Maybe the College could encourage the creation of subspecialty tracks to give internists abbreviated training in subspecialty programs. We do not need all internists to achieve the super sophistication in subspecialty medicine that is producing the current oversupply. Many small communities could use noninterventional cardiologists who can work with primary care physicians and fill a void for patients needing general cardiac care.

Gerald S. Berenson, FACP
New Orleans

E/M guidelines

I can't tell you how relieved I was to see the headline, "ACP will work to modify 'punitive' E/M guidelines," on page 1 of the February ACP Observer.

It was difficult enough to use the RBRVS system, but when I saw the complexity of the new guidelines, I was aghast. Even the quick reference sheets designed to simplify the new rules are horribly complex, and the permutations involved to calculate the number of systems would take all day.

Advertisements for expensive conferences have already begun arriving in my mail, offering instruction on how to "maximize income" with the new coding requirements. In an article in Medical Economics magazine on this topic, three consultants offer different ways of interpreting a single encounter.

Many office visits to primary care doctors involve issues that don't necessarily have a medical explanation. Several studies have shown that only a small percentage of common presenting complaints handled by internists have an organic etiology. Yet the new E/M guidelines force the components of the visit into this "organic disease" model of patient care. Ultimately, this will lead to excessive testing and not necessarily to improved patient care or satisfaction.

All of this effort is nothing more than trying to fit a round peg into a square hole, and each revision and update is more burdensome than the last. The words of Alvan Feinstein, MACP, which appeared in the May 1973 issue of Annals of Internal Medicine, were prophetic: "If the time needed for record-keeping begins to impinge substantially on the time available for thinking, planning, and communicating, the care of patients may suffer during the care of records." I submit that the new E/M guidelines make his words true.

Howard Homler, FACP
Carmichael, Calif.

I agree with many of the comments in your article "What's wrong with new E/M rules?" (April ACP Observer, p. 1). There is no doubt this new way of documenting and coding is laborious and time-consuming, especially for the first few weeks of application in one's practice. We have devised a template that greatly assists us in performing the task as expeditiously as possible. But it remains somewhat frustrating and stressful as we try to keep pace with a busy schedule and patients every 15 minutes. The template has become a part of our medical records; it offers us a clear document on our rationale for the E/M code chosen if we are later audited.

I now see perhaps one or two fewer patients a day as a result of this new documentation format. With managed care demanding that we see more patients, it becomes obvious that something will have to give.

Will PCs in exam rooms with electronic templates for documentation prove to be the answer? The article, "How benefits can outweigh costs of electronic records" (April ACP Observer, p. 6), seems to imply we can be more efficient with such aids. Thomas Barman, FACP, and his group either individually or collectively see "an extra four patients an hour" (an amazing accomplishment for an individual if this is indeed not a typographical error). The picture of Dr. Barman facing the PC and entering data while his patient looks on said more to me than anything else in the article. I still struggle with whether physician-patient bonding will suffer from this form of future record keeping.

Until we can solve some of these concerns and have electronic medical record-keeping technology affordable and user friendly, we are left struggling to better understand and comply with an E/M coding system that, although flawed, is far better than the system we all were utilizing in the past. The ultimate issue is whether we are willing to put time into such documentation when there are so many other demands on us.

We stand behind the efforts at reforming the archaic coding/documentation system of the past. Let's hope, however, that the onerous penalties for certain occasional, nonintentional errors incurred in trying to comply with these new guidelines are rescinded.

David J. Young, ACP Member
Holland, Mich.

I share the frustration of Paul Speckart, FACP, and William A. Reynolds, MACP, with the new E/M coding rules. The comment from Alan R. Nelson, FACP, that clinicians "look to the experienced attending as writing down what's really important and transmitting that experience efficiently" is crucial to understanding this problem.

One example from my own practice is a patient I admitted when first trying to wrestle with these guidelines. My focus on documenting all the necessary information led me a bit astray from efficient pursuit of the diagnosis. Fortunately, a colleague covering for me the next day was able to refocus me on what was important.

Another example is a patient I recently admitted with an acute inferior myocardial infarction and high grade AV block. This patient had been hospitalized only a month before, and I spent an hour and a half with him in the emergency room directing and coordinating his care. A complete review of systems is not important to this patient's care, but my undivided attention is.

The problem is with regulation and the need to simplify reviews so that clerical people can do their reviews. This leads to checklists. It is dangerous to place clinicians' focus on whether or not we have asked questions in 10 systems and described two bullets in at least nine systems, as opposed to focusing on the job we're trained to do, which is to try to solve the patient's problem.

Although much more difficult for review, I strongly feel that the major focus should be in the area of complexity. We are often intuitive about how we get from point A to point B. Our job is to listen to the patient and do our best to solve the patient's problem. This rather silly focus on somewhat byzantine rules threatens patient care in a very real way.

Roger A. Renfrew, FACP
Skowhegan, Maine

I was teaching a second-year student to do a patient presentation this week. We aim for our presentations to last five minutes, but hers was eight minutes long. Because her presentation didn't count for HCFA billing purpose, I dictated the note using our documentation guidelines and my presentation lasted 10 minutes! What a waste of physician time. When we sat down to look at what to bill, I threw up my hands and billed a level four based on complexity, knowing that if I counted everything it might be a level five. Now I'll probably get audited and be told I don't know what I'm doing. That's progress.

Dawn E. Dewitt, ACP Member
Seattle, Washington

Genetic testing

The patient described in the ethics case study in the March issue of ACP Observer ("The dilemma of genetic testing," p. 1) received insufficient counseling before she was tested for the BRCA1/2 genes. Her primary care physician was woefully untrained to counsel the patient and should not have tried. If possible, such patients should be referred to research centers studying familial breast and ovarian cancer. It is simply wrong for primary care physicians to order tests that they cannot interpret.

Edward S. Greenwald, FACP
New Rochelle, N.Y.

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