In my first ever blog post, I wrote about the difference in mindset and approach to patient care between critical care providers and medical providers of less acute disciplines.
This past week in Poland I have been the antagonist of several doctors who are upset over the mandated changes in Primary Care by agreeing with the dictates of the Ministry. I stand by that position.
Despite the dictate being deftly packaged as earlier detection of cancer, what it really is demanding is a change in the way which Polish primary care providers practice. While they may not want to change practice for a variety of reasons, like an ultraconservative culture, a completely unnatural level of focus on wealth and material possessions, or just people set in their ways who don’t want to do something new in order to justify to themselves what they have been doing all along.
Polish primary care is broken. It is broken beyond repair. In my observation and experience it is not worth paying for in its current form. Not by individuals and not by the national health system.
But it is not alone. I do not know of even 1 country in the world that has an effective functioning primary care system. Unlike the US, which limits access to primary care, primary care access in Poland is in abundance. You don’t even need an appointment. Walk right in, first come first served. There is not even triage to give priority to the patients who might be on death’s door. Pay nothing out of pocket. If you like you can go to a doctor and pay out of pocket for private non-national health service. Most doctors I know work in both. I even know a few that do not work for the national service (NFZ) at all, preferring private practice and its increased income.
I actually see that as a strength of the Polish system. Everyone is guaranteed a basic level, but if you can buy more, you can have more. How is it even possible to find fault in that? Nobody goes without and nobody stops you from spending extra to get more. Maybe it’s just the American culture in me who appreciates that?
That is the theory anyway, but…being a tried and true, in the trenches, operations guy let’s look at how it plays out in the real world? I have actually had to go see a doctor a few times during my stay in Poland. My family has had to as well. I also spent many hellish hours over my internship in a PCP office endlessly writing prescriptions and counting the minutes until I could escape each day. As I already attested, I have had not one, not 2, but now 3 people show up at my door to ask me my opinion on what their doctor’s advice was. I suspect this will continue.
You go to the Polish GP, if you don’t die waiting in line for an hour or two, and I have not seen even 1 who has, you get to go in to see the doctor. When you enter the office, there is usually a desk, a chair, a sink, and an exam table that barely functions, when it is not outright broke anyway. It is no frills. In fact, you could replace it with an actual table and it would cost more for the table than these things do. You of course get what you pay for. The equipment to be found in the office usually consists only of the stethoscope and blood pressure cuff the doctor brought with them and a box full of tongue depressors. When I take my daughter to see her official pediatrician, I actually have to bring my own otoscope for the doctor to use. The same applied when I took her to both an urgent care and the ED once in the same night. The only place I have actually seen an exam light is in an ENT clinic. It too is an old school head mounted device with a mirror. In one PCP clinic they actually had a 12 lead EKG machine. The long and short of it is, they have no equipment to speak of. Certainly not enough to do any sort of quality level exam. If you need blood tests, x-rays, or the like, you get a referral. As before these centers which are often not even in the same area of the city, are first come, first serve. They also limit their hours. So for example, they will say “We draw blood from 7am until 9am.” So if you miss the window you wait until tomorrow. You then wait a day or two pick up your results, and go back to the doctor who referred you. Total time lost: 3 whole days.
But most often, the primary care doctor doesn’t even believe they need diagnostic tests or labs. They do a cursory and often pointless physical exam which consists of: depressing your tongue as you tilt your head towards the overhead lights meant for the room. (Never once could I ever see anything but a big black hole doing this with my 5:1 acute vision, but they pretend like they can) Then they listen to your lungs and bronchial sounds with their Littmann stethoscope. (After all, have to demonstrate the ability to afford one) Some will listen to your heart sounds, some will not. Then they will palpate your abdomen. All of this is totally independent of presentation or complaint. So If you come in with a chief complaint of not being able to shit, they will “look into your throat.” (and still only see a big black hole) I was present once for a patient concerned he had herpes, forget a swab, the doctor didn’t even look at his penis. She just said “I don’t think you have herpes” and prescribed him a topical antifungal. But she is not alone. This is how they all operate. At least everyone I have encountered in the past 8 years. Sexual history is not even part of the exam for STD patients! I am told because in Poland that topic is taboo.
These doctors do not believe as I do, that if you must provide your own equipment to do an acceptable job, that is a necessary out of pocket expense. Consequently, my home has more and better medical equipment than most PCPs. As a personal value, I believe to do a quality job, you need quality equipment. I am also at the point in my career where I can appreciate quality equipment. There is also something about professionalism demanding that your tools be a reflection on pride in your work. 1st that you actually have them. 2nd that they be in good working order. 3rd that they be presentable. It is clear Polish primary care providers working with NFZ and even the private ones I have seen do not share my beliefs nor have any professional pride. Yet those same ones like to buy the finest quality automobiles, homes, and other such things, they cannot spare even 1% of their salary to effectively do their jobs.
My conclusion: They have no pride in their profession, but they are greedy. They also demand their status at the various level of doctor and experience be held in highest esteem and respect.
Not only do I take issue with it, the patients do. They actually write op eds in the local newspapers about the poor care they receive regularly. There are websites devoted to rating doctors. They even research what the standards of care are in other nations. They research what diagnostic tests should be ordered. They research the treatment options. They even examine themselves before they come. Polish doctors know about this, they talk about it. Rather they complain about it. “Who do these patients think they are? I am the doctor!” Well… It’s my opinion they are looking out for themselves and doing what the doctors should be doing. But Polish doctors not only ignore these patient expectations, they purposefully act out against them.
The doctors diagnosis is often based solely on epidemiology. Exam findings if even available, overlooked. I can assure you not one will ever diagnose you with upper respiratory bacterial infection requiring antibiotics, In fact the last time I went to one, I already knew I had a peritonislar abscess. I knew because I examined myself, drained it myself, and wanted a referral to ENT so I didn’t have to pay a private one. I was told, “I think it is a virus.” You can imagine the surprise on the doctor’s face when I told her I was also a doctor, my findings, and treatment. There is now a big note at the top of my chart warning subsequent doctors I am also. That is one example, but it happens all the time. I have witnessed it countless time from the other side of the desk. If a patient is not a physician, it is even worse. They get their diagnosis of “viral infection” a prescription for a bunch of highly priced over the counter and herbal remedies. (naturopathy is really taking hold here) and then sent on their way. A few days later the patient comes back, finally gets some diagnostics ordered, 3 days later usually gets the absolute most basic prescription treatment, and referred to a specialist. Time lost: minimum 5-7 days.
Not surprisingly, with no diagnostics and no meaningful physical exam, patients are misdiagnosed all the time. The doctors are essentially trying to guess the diagnosis. Because it is epidemiologically based and reinforced with the bias of experience without any evidence at all, diseases like cancer are rarely diagnosed, much less diagnosed in time to actually help.
When the PCP sees something they cannot treat in the office or forces them to do things like prescribe potent antibiotics, like a patient with scalded skin syndrome, they refer them to specialists, often the wrong specialist because of their utter lack of familiarity with all but the most common diseases. So this such patient, who could easily have been treated out patient, was sent for a vascular surgical consult to rule out bilateral DVT. The doctor did not recognize the disease and their best guess demonstrated they didn’t even know much about the disease they were writing a referral for! Again this is one story, but I have many drinks worth.
So, the long and short, the ministry has stepped in where doctors have failed to oversee themselves. A directive was issued, and all the doctors are complaining, signing petitions, and striking. They are not too impressed with my opinion either.
Now they will be required to actually perform some diagnostics. They will have to buy the machines which are often relatively inexpensive to buy and operate, and compact enough to fit on a table. They will not be paid more for it. But being as they are essentially paid for nothing as it is, it will cut into the car payment fund. Maybe they will have to buy a VW instead of a Mercedes. Tragic I know. But what really bothers them seems to be they do not feel like they should have to change. They want to continue to be paid for poor guessing and even poor medical care. Their delusional belief is they are acceptable just how they are and they should be permitted to keep doing what they are doing. That they should be paid more for doing something they should have been doing all along.
They also wrongly believe that what I have described here are a few “bad” doctors and not systemic problems. Some have even tried to deflect their failures on the systems design. The system design is not bad, the problem is the doctors are basically gaming the system to get paid for doing as little as possible or nothing at all.
They are lucky I am not the minister, because there would be some serious quality control put into place. Mandatory equipment, regularly inspected. Mandatory chart review. No payment for complications of misdiagnosis. No payment when the only service is referral to a specialist. Reduction of payments when patients are excessively referred to specialists for easily treatable conditions.
The goal of Primary care would once again be to treat as much as possible without having to refer to a specialist. If that meant doctors had to spend more time with continuing education, so be it. If that time was uncompensated, that dedication is part of professional pride. If it cuts into the earning power of doctors who are already top earners in society. Well…Too fucking bad. If they don’t like it, they can go work in another country that pays more. But they won’t. Not because they don’t speak the language. Because they will not be paid in those systems for doing the nothing they are getting paid for doing now. They would also likely face far more deserving lawsuits as well as professional censure.
But the best part of the whole thing is they are claiming changing what they are currently doing would be bad for patients. How could it possibly be any fucking worse?