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    P4P is changing me

    Financial pressures and monetary incentives have changed the way this internist practices. Will they change you, too?



    For the first time I found myself truly caught between my own needs and those of my patient. I was 34, five years out of residency, three years out of fellowship, halfway through a divorce, and about to let a $50 incentive influence the way I practice medicine.

    My story? I was angry about dealing with a divorce I didn't see coming. But what got me was the money that had crept into clinic: med school loans, mortgage (and rent now), and looming alimony and child support. My paycheck couldn't keep all these balls in the air, not without the help of my credit card.

    I am an internist in a group practice in rural Vermont. It has been a salaried position blessedly unaffected by my panel size, the number of patients I see a day, or the tests that I order. Sure, we've discussed compliance with practice guidelines at our regular staff meetings, but it has been academic.

    That is, until recently. The following is part of a memo I received in the summer of 2006:

    In another part of the memo I learned that I'm currently 83.1 percent compliant with the measured measures.

    In that moment I changed my mind. Because of my financial pressures outside the clinic, I would change my behavior inside the clinic. I had always intended to practice the best medicine possible. The difference is that instead of doing what seems best for the patient, I'll first consider what's best for me. And what's the difference, really? For example, either way a diabetic should have an A1C checked, right?

    Now, his story: Mr. Nickels (a pseudonym) was an 84-year-old World War II veteran who had stormed the beach at Normandy. A left renal mass was discovered in the past year that he didn't want evaluated any further. He was the first patient I saw after having read the memo and changing my mindset.

    "I was 17 when I went in," he winced. "I did what they told me. I did it because I thought it was right. I ran up the beach with the rest of them. The guy on my left and my right went down—but not me. Two more men came alongside me as we went up the beach. They were killed, too—but not me. I stopped to help one man up. They shot him while I was holding him—but not me. They told me I was a hero. Look at me! Am I a hero? Is this how heroes are treated?"

    Divorce destroyed his love. The cataracts took away his books. Arthritis left him crippled. Financial ambush took his retirement. And now this likely kidney cancer is the final undignified bullet that will snuff out this soldier's life.

    There's very little I could do to improve Mr. Nickels' life. I asked him once what I could do to help, and he requested merely that I talk with him. That's what I've done, every three months, but I won't get any extra pay for that. I could check his A1C, though—after all, he does have diabetes, and it has been more than a year since it's been checked.



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