What’s Up, Doc?

When it comes to health, most of us want a second opinion. New Jersey Monthly wanted six. We selected a half-dozen of this year’s Top Doctors and peppered them with questions about the patient-doctor relationship, the health-care establishment, and their lives as physicians. The questions were e-mailed to the individual physicians, and their answers to each were compiled in alphabetical order.

The doctors on our panel represent six different specialties in practices throughout New Jersey. They are: Dr. Mamie Bowers, a specialist in obstetrics and gynecology, based in Flemington; Dr. Elliot Brown, a cardiovascular disease specialist, based in Clifton; Dr. Jose Flores, a family practitioner, based in Glen Ridge; Dr. Bryan Ho, an otolaryngologist, based in Englewood; Dr. Marie E. Nevin, an endocrinologist, based in Morristown; and Dr. Gary Rombough, an orthopedic surgeon, based in Montclair.

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Question one: What would you change about the health-care system?

MAMIE Bowers: Make it more efficient and much less bureaucratic. Facilitate a more effective partnership between patients, their providers, and their insurance companies. Currently, we all seem to antagonize each other instead of facilitating one another.

ELLIOT Brown: Physicians who train in accredited programs and are board certified in specific specialties should have the poetic license to use their clinical judgment when it comes to ordering tests and medications.

JOSE Flores: Medical insurance companies should be not-for-profit. They should not be traded on Wall Street—that only places profit ahead of patient care. Some of these companies are making 30 to 40 percent profit at patients’ and doctors’ expense and expect the same year after year. Government should move in and cap their profits at 8 to 10 percent, and cap employee salaries just as has been done with physicians by the advent of managed care. I fail to understand how many of these insurance executives can explain their multimillion dollar salaries; they are middlemen/women.

BRYAN Ho: It is a fact that the practice culture of physicians has drastically changed over the past two decades. The threat of being sued for missing a diagnosis has enormous ramifications for the patient and state of medicine. Overuse of diagnostic imaging studies is a staple of practicing paranoid medicine. In many instances, doctors order unnecessary tests simply to avoid missing anything that eventually could be construed as malpractice. If this is done once a day in an office, it is done a thousand times across the state on a daily basis.

MARIE E. NEVIN: Requiring insurance-company authorization for patient testing wastes vast sums of health care dollars and doctor/staff time. Doctors order tests to make correct diagnoses, with patients’ health as their first priority.  A physician who has examined a patient is in a better position than any insurance clerk to determine if a particular test is necessary.

GARY Rombough: Malpractice reform would be helpful. Many of our specialists in high-risk areas are having difficulty continuing in practice. If something is not done, we are going to lose the specialists we need in many areas such as obstetrics and neurosurgery.

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Question two: How does the health insurance system affect treatment?

Bowers: Overall, it is not a very efficient system. If, as providers, we try to be efficient in rendering care, we are essentially penalized because we didn’t get approval or referrals, or we don’t receive compensation for all the work that we did because it was all done on the same day. The delay required by the current system does not usually compromise care of the patient, but it can mean more time lost from work or poor compliance with follow-up because of the time restraints on the patient’s part. There are many layers to this onion!

Brown: The health insurance system drastically impacts diagnostic-test choices and medication choices. It is designed to keep costs down wherever possible. Practices require specialists in test approval and claim submission in order to participate in many health insurance programs.

Flores: It strains our office resources; we spend too much time pre-authorizing tests and medications. The amount of time spent with documentation and paperwork just gets out of hand at times.

Ho: Unfortunately, in the current manner in which health care is managed in our country, patient care is compromised, plain and simple. Insurance companies are incentivized to keep expenses down and are driven to increase revenue so that top management and shareholders are maximally reimbursed. That’s the big picture. How this is translated for the average patient is simple: Insurance premiums rise, and your ability to get an MRI, a new medication, or a specific surgical procedure is limited. There is nothing more frustrating to the physician than to have a blood test, X-ray, or routine procedure denied by nonmedically trained personnel who are essentially given first-line power to make these critical decisions. Gauntlets in the form of appeal levels present further obstacles for office staff and physicians to order diagnostic tests and therapeutic procedures.

Nevin: Health insurance affects treatment of patients by limiting access to particular doctors or hospitals. Patients’ health may be compromised when they are not able to go to doctors or hospitals having a greater expertise in a complex or uncommon problem.

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Dr. Gary Rombough is an orthopedic surgeon, based in Montclair. Photo by John Emerson.

 

Question three: What is the best way to choose a doctor?

Bowers: A personal recommendation by word of mouth works well, or even better is a recommendation from someone in the medical field, such as a nurse, your primary physician, or another health-care provider.

Nevin: If you need to see a specialist, ask your internist or family practitioner whom they would recommend to a family member. If you move to any area where you know no one, call the medical staff office at the largest hospital near you and ask the secretary the name of the doctor whom the chief of the medical staff uses or recommends to patients.

Rombough
: Ask friends and family about a good experience they have had with a doctor in the area of expertise that you need. If you don’t have a good feeling at the actual encounter, then it would be time to move on for another opinion.

 

 

 

Dr. Bryan Ho is an otolaryngologist, based in Englewood. Photo by John Emerson.

Question four: What are the most common mistakes made by patients?

Bowers: Assuming everything is okay because they haven’t heard anything. It is important to be your own health advocate. Test results can be overlooked, or sometimes they are not sent to the right health-care provider. Be proactive as a health-care consumer—know what tests were ordered, why they were ordered, and what the results mean.

Brown: Patients often stay in relationships with doctors because they fear that if they change physicians, their doctor will get “mad” at them, or they will be embarrassed. Also, patients make a mistake when they don’t get some basic education about their problem so they can work with the physician.

Flores: Noncompliance with appointments or treatment regimen. Sometimes it results from poor communication with physicians; thus, patients should clarify all instructions during their office visit. Another common mistake is presenting the office with a long list of chronic complaints that clouds some of the important problems that must be addressed during a regular visit.

Ho: Common mistakes include not revealing all pertinent information during the history-taking part of the exam. Sometimes this is done consciously; more often than not, it’s because of nervousness and forgetfulness. If there is a complex medical problem, it is always best to bring a friend or family member with you to be sure nothing is missed and that all questions have been answered.

Nevin: Discontinuing medication without advising the doctor is a mistake with possible hazardous consequences. If a patient is concerned about possible untoward side effects or cost, let the doctor know so that these issues can be resolved. Another mistake is not following through on obtaining tests that were ordered to confirm a diagnosis or to monitor a known condition. This can result in a missed diagnosis or a harmful side effect.

Rombough: At the first office visit, it is imperative to bring the names of all your medications with the doses. That way, if the doctor wants to prescribe an additional medication, there is less chance of interaction.

 



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Question five: What are the most common mistakes made by doctors?

Brown: They don’t take the extra time to communicate with the patient. They also are often problem focused. They may take care of the primary medical problem, like the hypertension, but not address the insomnia that the patient is actually complaining about.

Ho: Communication works both ways. The most common mistake I see among some physicians is that they do not listen to their patients as carefully as they should. Spending a few extra minutes with a patient can go a long way in terms of diagnosing a difficult problem, making the patient feel more at ease, and generally building a better rapport with them. Distractions are commonplace during a routine visit.

Nevin: Assuming the patient is taking medication that was previously prescribed, or assuming patients went for the tests that were ordered. Not reviewing test results with patients in a simple and straightforward manner.

Rombough: Doctors can make mistakes by not having enough information about the patient. He needs information about the problem he is seeing the patient for, and he also needs information about seemingly unrelated problems, so there will not be any chance of adverse interactions with medication or treatments he plans on recommending.

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Question six: How can patients help you do your job more effectively?

Bowers: Know your health history, including allergies, surgeries, what medications and supplements you take, and your family history. I am surprised at how often patients who visit our office seem perturbed when we ask them to provide us with an update of their medical history.

Flores: Patients should arrive on time for their appointments; they should be aware of any changes in their medical insurance plans and inform the office staff. They should at times write down their major complaints to ensure that they don’t forget to bring them up during the visit.

Ho: Oftentimes, patients come in with a long list of complaints and information that may not be necessarily relevant to the visit. A good doctor will listen for some time, then ask directed questions that will both clarify the issue and lead to the proper treatment course. When a doctor asks a question, answer it as directly as you can. Bringing in copies of test results or actual imaging studies is also helpful.

Nevin: Bring a family member or trusted friend to an appointment if complicated results or information is to be reviewed. A wise friend once told me that when patients are nervous, they may develop “hysterical deafness.” They see the doctor’s lips moving but no words seem to come out. Sometimes two sets of ears are better than one. Patients should also understand that not all information on the Internet is accurate. Keep an open mind if the doctor’s opinion is different from what you Googled!

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Question seven: At what point, if any, would you fire a patient?

Bowers: When I have been threatened by a patient or her family, or when a patient has been abusive to me or my office staff, I draw the line and dismiss them from the care of our practice.

Brown: Noncompliance is never a reason to dismiss a patient from your practice. When they are ready to get better, they will. You have to be there for the patient through it all.  Patients who are abusive to the staff are not tolerated and may require a dismissal letter.

Flores: It is a difficult and sometimes painful task, but if the patient is repeatedly rude or uses profanity when addressing our staff, or the patient consistently disrupts the patient flow by missing appointments, or is extremely noncompliant with the treatment that is recommended, then it is fair to dismiss a patient.

Ho: I will never outright dismiss a patient. Rather, if I feel the bond of trust between me and a patient is severed or no longer exists, for whatever reason, then I would recommend that the patient seek another opinion. A loss of confidence from a patient is very difficult to recover from. We have all experienced that.

Nevin: I have fired a patient for going against advice that could have prevented a serious or life-threatening illness.

Rombough: It would take a lot for me to fire a patient. Patients come to us with problems, some of which can make them very emotional. We must be sensitive to their needs. However, I did fire a patient recently for stealing a prescription pad.

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Question eight: In managing your practice, how do you find the time to recruit and train your staff?

Bowers: I try to delegate as much as possible to the office staff not directly involved with patient care so as to minimize the impact on the flow of patient care. For the providers in our office, it can mean devoting more time outside the scheduled office time. That can be stressful as it then impacts negatively on personal and family time.

Flores: We use electronic health records and billing; we have instructional CDs and web training. We send employees to conferences or courses if needed. Recruitment is usually done best by placing newspaper ads and attracting experienced people.

Ho: To a large extent, I count on my staff taking my lead when interacting with patients. When my staff sees how I speak to and treat patients firsthand, they know what is expected of them. I also have each new staff member accompany me on an operating day so they can experience exactly what patients go through, from the preoperative waiting area to the OR, to the recovery room. It also helps that I have handpicked each employee, who [all] happen to be kind, caring, and empathetic people.

Rombough: I have been very fortunate to be blessed with excellent staff. They are extremely sensitive to my patients’ needs. They are so well trained that when it comes time to recruit new staff, they are intimately involved in the process. They are good judges of who will make good employees.

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Question nine: What’s the worst part of your job?

Bowers: Delivering bad news such as a diagnosis of cancer or loss of a loved one.

Brown: Trying to navigate in a health care industry that has been declining for over a decade.

Flores: The worst part is to bear bad news to patients and families. Despite doing it in a respectful, caring, and professional manner, it is painful to all involved, including the physician. Sometimes there are bad outcomes or complications despite appropriate management and treatment, but that doesn’t make anyone involved feel any better.

Ho: The worst part is giving patients bad news. As physicians, we all know it’s just a matter of time before we are each on the other side of the exam table being told the same news. It is indeed a privilege to take care of patients, but at the same time, an all too humbling experience as well.

Nevin: The most difficult things about practicing medicine today are the long hours spent in doing paperwork and reviewing test results after the exam door closes and the last patient leaves.

Rombough: The worst part is seeing someone who you cannot help. Unfortunately, there are diseases that we can do very little for. It is disheartening to see patients and their families at times like that.

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Question ten: What’s the best part?

Bowers: The relationships that I have developed with my patients over the years. It is truly a pleasure to take care of them and to be part of their lives.

Brown: You get to touch the lives of so many people and help them make significant personal changes, which helps them heal and grow as individuals.

Flores: My interaction with patients and colleagues and the satisfaction I receive from knowing that each day I help and comfort patients. The impact we have as physicians in the lives of some patients is a tremendous responsibility, and the personal reward is just as large.
Ho: The best part of my job is the satisfaction I get from curing a simple or complex problem and having the patient acknowledge that with a genuine thank you.

Nevin: I have enjoyed getting to know my patients. I’ve come to know if they like to vacation in Vermont or Cape May, whether they plant tomatoes or zucchini in their gardens, and whether their daughters play field hockey or tennis. I have also enjoyed the opportunity to work with my colleagues in different specialties, who remain enthusiastic and dedicated to providing excellent medical care despite the challenges of practicing medicine today. Being a doctor is somewhat akin to being a journalist. We interview, gather facts, and put a story together. It is always stimulating. Every day the stories and the facts change. Every day there are new and interesting developments in medicine that give the plot a different twist.

Rombough: The best part of my job is the joy of seeing someone recover from the problem that they came to me with. Many of the patients are like family. Having treated several members of their family, you get to know them very well.

 

 

 

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