Physicians and patients both share the same goals – speedy diagnosis, timely treatment, and a quick recovery. However, as we approach the millennium, both the recipients (patients) and deliverers (physicians) of health care face an increasing number of roadblocks, frustrations and hassles.
"Health care is not as hassle free as it used to be, and the trend is expected to continue," Dr. Gupta says.
In this first article of a series, Dr. Gupta discusses the role that provider factors play in his blueprint for maximizing patient outcomes.
"The first key in maximizing outcome is that you must have an organized, thoughtful effort by your physician. There are several factors to consider when choosing your doctor. We call these provider factors, and they include three primary components – prognosis, diagnosis, and treatment."
Prognosis – An initial overview
In Dr. Gupta's opinion, a clinician should be able to make an assessment of the anticipated outcome of the patient's case on the first visit.
This long-range assessment is an essential step. "We ask ourselves, What are we trying to achieve? What is a reasonable expectation?"
According to Dr. Gupta, "We routinely assess prognosis at the initial encounter and then take the proper steps to maximize outcomes of each case."
The Challenge of Differential Diagnosis
Understanding prevalent factors – demographics
"In making a diagnosis, the physician is aware that what illnesses a patient is likely to have are largely dependent on demographic factors – such as age, sex, geographic location, membership in an ethnic group," Dr. Gupta says.
"Astute clinicians will assess prevalent factors in your specific case." "For example, if I am a doctor in Mexico, and a patient comes to my office complaining of bloody diarrhea, chances are good that the individual is suffering from infectious colitis, otherwise known as dysentery.
"However, if I were to see a patient in my office in the Michiana Area with the same symptoms, the probability would be that the patient was suffering from Crohn's Colitis or ulcerative colitis", Dr. Gupta explains.
Comobidities vs. a simple diagnosis
"When we're ill we hope for a speedy diagnosis, prompt treatment and a quick recovery. This is our wish. In a perfect world we would become ill, visit our physician, receive a diagnosis, and fix the problem."
"In reality, a thorough diagnosis often does not result in simple answer," Dr. Gupta explains.
"Our experience has shown that patients with chronic symptoms or illness tend to have more than one problem. There may be one or two major problems, as well as other minor problems. These multiple problems are called comobidities.
One of the most frequent causes of unneeded hospitalization for patients is a failure of the physician to address comobidities," Dr. Gupta says.
"In our clinic, we try to address as many comobidities as possible in a maximum number of patients. Sometimes, one diagnosis is simply not enough."
Matching the diagnosis with the patient's problems
Dr. Gupta acknowledges that we all live in a world in which time is precious and our tolerance for uncertainty is limited.
"Patients want a diagnosis that explains the entire range of their symptoms. Unfortunately, the reality is often not so simple."
"In our clinic, we try to find explanations, for as many of the patient's problems as possible – even if we have to seek consultation from specialists outside our clinic."
"We are persistent. We don’t stop looking with the easy answer because we feel that this simplistic approach is not in the long term best interest of the patient."
"In the tightening managed care environment, the abilities to address comobidities is likely to be reduced, therefore, increasing frustrations. That leads into our next concern, technical and resource limitations.
Technical and resource limitations
Many times, not having adequate technical skills or access to certain resources puts a restraint on pursuing a problem. "We try to be technically competent as best we can. However, we frequently seek consultations and refer patients to university hospitals where a higher level of technical skills and resources exist," Dr. Gupta says.
"Unfortunately, the primary goal of HMO's and other forms of managed care is to cut and control heath care costs. Patients under these plans are often restricted as to where they can seek care. This in turn ties the hands of the physician."
"When you are seriously ill, it is no time to discover that your health insurance won't provide a diagnostic test or treatment that your physician thinks is needed."
"Patients can minimize the chances of this happening by choosing their health plans wisely – by discussing and exploring their options for insurance coverage in a thoughtful and timely manner. Then, they'll be prepared should they become ill."
"We recommend that citizens select a health plan that at the very least preserves your right to choose the physician of your choice," Dr. Gupta says.
Atypical symptoms with common illnesses
The physician's art of diagnosis is based on years of training and experience. However, a special challenge occurs for the physician when a common illness is marked by uncommon, or atypical symptoms.
"An example is a heart attack. In some cases, the only symptoms present are a pain in the belly. Usually a pain in the belly is not a primary symptom of a heart attack – we associate it more with an ulcer," Dr. Gupta says.
Common symptoms pointing to an atypical diagnosis
Conversely, common symptoms such as a mild indigestion over a period of weeks may indicate an atypical illness, such as colon cancer. These common symptoms are not usually associated with colon cancer," Dr. Gupta explains.
Treatment - Understanding pharmacological synergies
Certain drugs enhance the clinical benefit of others if taken at the same time. Other drugs produce antagonistic effects that can harm the patient. According to Dr. Gupta, the art of prescription writing depends upon the physician's understanding of pharmacological synergies.
Focussing on priorities
Many times, when a problem is uncovered it may not be wise to treat it because of other factors.
"For example, if we discover stones in the gallbladder of an elderly patient, but that patient also has heart and lung problems, our most prudent course would be to leave the gallstones alone. There are more serious concerns with the lungs and heart," Dr. Gupta explains.
"As risk managers, it is our responsibility to maximize the benefit for the patient, while minimizing harm," Dr. Gupta explains. He points out that failure to do so may lead to iatrogenic illness – illnesses inadvertently attributed to the good intentions of the health care provider.
Therefore, the art of prescription writing, focusing on priorities, and managing risk are essential to achieving comprehensive and balanced treatment.
In conclusion, Dr. Gupta notes that provider factors are an important ingredient in maximizing outcome and minimizing patient frustration.
"Provider factors are like the three corners of an equilateral triangle. At the top is the patient's prognosis. At the bottom are the variables that directly affect the patient's prognosis – timely diagnosis and appropriate treatment. We try to make diagnosis accurately and promptly and provide treatment in an effective and balanced way."
"Through our philosophy of addressing all these factors, we hope to obtain the best possible outcome for each one of our patients", Dr. Gupta concludes.
Understanding Provider Factors
Prognosis
• Initial assessment
Diagnosis
Understanding prevalent factors
The role of comobidities
Matching to the patient's problems
Technical and resource limitations
Atypical symptoms ~ common illness
Atypical illness ~ common symptoms
Treatment
Understanding pharmacological synergies (prescription writing)
Focusing on priorities
Part B – Patient Factors
Just as a physician must be a skilled, insightful clinician, so must the patient be an "insightful patient", says Dr. Gupta.
"There are many choices that a patient makes before and while he or she is under a physician's care. By taking an aggressive, proactive attitude, the patient becomes a partner in managing his or her own care, and the chance for a positive outcome increases," Dr. Gupta emphasizes.
According to Dr. Gupta, there are several patient factors that need to be considered. These are: convenience factor; realistic expectations; compliance; patience; taking responsibility; and communicating with your physician.
Convenience Factor
Nowadays, insurance companies insist that most elective diagnostic workups be done on an outpatient basis. This often requires multiple trips to various physician offices, labs, and or hospitals.
"The diagnostic journey becomes a journey in a very real sense – encompassing hundreds of miles," Dr. Gupta explains. "The patient is traveling to one lab, then to another office, then to an outpatient center, and so on. Due to scheduling, the tests may take place over several weeks."
"This places an undue strain on the patient. The patient has the expense of travel, of time missed from work, and ultimately the frustration of prolonging uncertainty."
"Often, after the first one or two tests, the patient gives up. Since the tests are not completed, the physician is left with partial information. Therefore, we get an incomplete diagnosis."
"In our practice, we try to make a comprehensive evaluation on the first visit. We arrange for outpatient diagnostic work so that most of the work is done in one or two visits. By doing so, we ensure the completeness of the diagnostic workup and accuracy of diagnosis and treatment."
We all wish for perfect health. Unfortunately, in life there are no such guarantees. Sometimes, the patient's expectations about health care outcomes are unrealistic.
"One example is that no matter how thoroughly we follow an early detection and prevention program, some patients will still develop cancers," Dr. Gupta says.
"Understanding the limitations is important when working with your doctor. Since many problems require long term treatment with diet and medication, to expect a permanent resolution of the problem in the short term just isn't practical."
Compliance
Relapses of the patient's illness or symptoms can be frustrating. If analyzed carefully, the most common cause is often poor compliance – disregarding the physician's instructions. "Follow your diet, take your prescribed medication on time." In the words of Michael Jordan – Just do it! By following the physicians instructions, you can avoid many frustrations," Dr. Gupta says.
Patience
"It's true that time waits for no one, but please – give your doctor a little time! You don't become ill overnight.
Therefore, if you have a chronic illness, you need to on treatment for a few days or sometimes weeks before substantial clinical benefits are noticed."
"Sometimes, the initial treatment choice will not suit you. I may decide to change it after a follow-up evaluation."
"But be patient. And remember, as your physician, I want you to get well as much as you do!"
5. Taking Responsibility
As mentioned earlier, the patient and physician need to be partners in care. That's why it is essential that the patient take personal responsibility for helping to ensure a successful outcome. The patient has two very important responsibilities: To make sure test results are discussed; and to be knowledgeable about restrictions imposed by the patient's health care plan.
Make sure test results are discussed
"By all means, keep your follow-up appointment with your physician," Dr. Gupta exclaims. "This is essential to make sure that your test results are discussed. It is not wise to assume that if the physician's office does not call, everything is ok. The follow-up appointment gives you and your doctor time to discuss in detail the implications of the findings."
If you miss your follow-up appointment, your physician interprets this as a refusal for treatment," Dr. Gupta says.
Know your health plan
Physicians are approached by scores of managed health care plans and there is pressure on your doctor to join these plans. Some are better than others. "We try not to sign up with those plans that restrict our clinical judgement," Dr. Gupta says.
"However, if you do have a plan that is restrictive, or if you choose us as an out-of-plan provider, we will try to accommodate reduced benefits. We try not to sacrifice quality of care."
Communication
The final, and in some respects the most important patient factor, is communication with your physician. "As my patient, I want you to feel free to express your concerns to me from day one. By doing so, we can avoid future problems."
"We encourage you to discuss your concerns and talk freely and without hesitation, whether those concerns are clinical or financial."
"Our office staff is trained to respond professionally to your needs. However, if you do not receive a satisfactory response, please do not hesitate to speak directly to me. We can do this by phone or in person.
In conclusion, you, the patient have a direct bearing on the outcome of your treatment. By working as partners in health care, you and your physician can maximize the gain and reduce the frustration – even in today's managed care environment.
Patient Factors
Convenience
Realistic Expectations
Patience
Taking Responsibility
Discuss test results
Know your health plan
Communication
Accepts Reduced Benefits If Not Listed on Any
P.P.O. – Plan List.
Dr. Gupta takes assignments on most private insurance plans and tries to offer mutually suitable payment plans.