A reader writes:

I agree with you completely on the importance of having a physician functioning as the coordinator of care for a patient (I have always assumed that a primary care physician would do that) my experience has been that they resist that role. I have become my own and my wife’s primary care person because of that.

There are hospitals that discourage primary care doctor participation. If you are admitted to the hospital, then primary care is not permitted to participate in treatment even if they on the staff. Rather you are under the care of the “attending physician” or the “hospitalist”. If you are discharged and readmitted a few days or weeks later you have a completely different set of physicians. Your primary care is not permitted to intervene (and doesn’t feel like endangering their position by forcing intervention).

In these situations a third party (in this example it was me) forced coordination by hand caring documents and reports, and running down staff members and having adhoc meetings. Primary care physicians don’t do that.

Welcome to the today's hospitalist model, a trend entirely dictated by the physician payment system. Primary care physicians are now able to stay in the office, where they can see patients more efficiently, instead of dividing their time between the hospital and clinic.

The downside is the lack of continuity, as this reader has experienced. Indeed, if an inpatient is discharged and readmitted, an entirely new set of doctors may assume care. In many cases, the primary care physician does not have say in this matter.

That is why the implications of allowing hospitalists to care for inpatients need to be clearly communicated to patients.

Regarding the coordination of care, this often is done inadequately. Again, the payment system does not offer any economic incentive to do so. Time spent away from the patient coordinating care is done pro-bono, and the already strained generalist can ill-afford to do so in these trying financial times.

Good news is on the horizon. The so-called "medical home" model is being piloted on select Medicare populations, where money is alloted for coordination of care between hospitals and specialists. Initial results are promising, and can help reduce overall health costs.

Until this model is widely adopted, the current patchwork of providers providing the majority of the care in this country will continue to be the norm.

Plastic surgeons and dermatologists are abuzz about yesterday's appearance.

A seemingly paradoxical result from a study.

One reason is that patients who are seen same-day are less likely to see their personal physician. Instead, an NP, PA or covering doctor may be providing care.

This lack of continuity may be an explanation for the findings.

Nice op-ed from two primary care physicians in Pittsburgh. Nothing that hasn't been discussed here, but I would have further emphasized the disparity between specialist and generalist pay.

This is the chief reason why medical students aren't entering any generalist fields. Finances and money needs to enter the public consciousness when discussing the primary care shortage.

People writing about their medical conditions have become commonplace, including this young woman blogging about her impending abortion.

Mothers in Medicine: "Delivering the baby, like the first day in anatomy lab, doesn’t suddenly make you a mom, or a doctor, not the way you imagined it would. It takes time, sleepless nights, anxious days, moments of profound resentment and moments of even greater tenderness before you fall in love with this child, a love that evolves and changes as the child becomes more and more complex and separate from you."

Forget about measles, it's polio that has Dr. Farrago worried about the effects antivaccination trend.

It's not just happening with primary care, but with cardiology practices as well.

This makes sense for both the hospital and the physicians, where operating a private practice becomes more difficult by the day.

What does this trend mean for patients?

For athletes considering anabolic steroids, you may want to reconsider.

Reader Takes is a regular feature where selected op-ed style pieces from the audience at Kevin, M.D. will be published on the blog.

Posts are between 500 and 600 words in length, and can argue any opinion related to medicine and health care.

Original articles that are provocative, well-written, free of grammatical or spelling errors, and generally follow these guidelines are preferred.

Once a reader take is published, it will remain at the top of the blog above the fold for one day. A link to the author's book, blog, or website will be included.

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A fairly good article in the NY Times talking about a new blood test screening for ovarian cancer.

Ovarian cancer is normally not detected until the late stage of the disease, so patients have been eager to find an early screening test.

The downside is the unacceptable "false positive" rate (0.6 percent in this case), where the test is positive in the absence of disease. This often leads to removing the ovaries unnecessarily.

At $240 per test, companies profit from the public's fear of cancer and capitalize on the myth that "more testing must equal better medicine."

However, they leave out the thousands of unnecessary surgeries and procedures that arise from false positive readings. Equal weight to this complication should be included in their advertisements.

Both candidates make prevention a focus of their health reform plans. Whether they truly save money or not is unclear at this point.

It seems like retail clinics aren't the gold mine companies thought they would be:

In the past year, Merchant Medicine estimates that 136 clinics have closed up shop, a trend it blames in part on financiers who lost patience when the clinics weren't showing quick profits.

These clinics face the same payment pressures afflicting primary care doctors. If office-based physicians have trouble making ends meet, there's very little chance that the retail clinic model will profit.

This is especially true if retail clinics accept insurance, which dooms them to poor-paying cognitive reimbursement rates.

Also, a single malpractice suit against one of these clinics has the potential to wipe them off the map completely.

In order to survive, they need to be i) cash-only, ii) start doing minor procedures, iii) consider expanding into cosmetic dermatology (like Botox).

Just like a real primary care practice.

Rural Doctoring hosts the weekly best of the medical blogosphere.

See how this physician responded to an anaphylactic reaction at Fenway Park.

Absolutely not. This comment sums it up nicely:

Why, in a country where First Amendment rights are defended so passionately, should physicians–of all groups–have their views censored, either by outside agencies or within their own ranks?

It's sad that this is the easiest way to do it: "If a patient is stable - and can be driven to the other hospital by family or friends, you can gently suggest they sign out AMA and just show up over in the other ER. Then the HAVE to take care of the patient. Ola! No transfer paperwork, calls, or legal issues."

The AMA's Ethics Forum takes on the following question: "Can physician-written blogs meet legal and ethical professionalism standards?"

Maurice Bernstein: "Medical blogs, moderated with attention to civil and open discussion among the visitors and following guidelines for ethical operations, make a significant contribution to the medical education of the public and, I dare say, the profession."

Rob Lamberts: "Physician blogs should not be seen as an attempt to replace other sources of information, but instead as a new kind of medium -- a view into the minds of the rank-and-file members of medicine.

Used properly, blogs can give voice to a group that has often felt powerless to affect change. Ultimately, the responsible use of this medium lies with the blogger."

A physician claims a patient wanted to thank him . . . with oral sex.

The Gone Wild series continues.

Rural Doc focuses on generalists opting for rural positions, but her advice can apply to every graduating resident.

Dr. Rob with tips on giving bad news to patients.

"I've been doing this 25 years and even I've never heard of that one!"

You know it's a rare case when that's the response you get from poison control.

We need to do a better job in managing patient expectations:

Healthcare is not a commodity like a Toyota that can be turned out, day after day, in exactly the same way. Every human body is unique. At any moment, a surgeon may run into a surprise. Your cancer may be hiding in place that makes it very difficult to detect on a mammogram—not impossible, but very difficult. And while the person reading your test probably would have caught it nine days out of ten, this is the day that he didn’t.

Expecting our physicians to be perfect only tempts them to “cover up” any mistakes, which leads, in turn, to worse outcomes.

Remove fault from the malpractice equation. Understand that mistakes happen, and in these cases, patients should be fairly compensated in an expedient manner. The current system is a complex, lengthy legal process that fails patients more often than not.

Instead, we're going the other way. Hospitals are being punished with an increasing list of "never" events - some of which cannot be prevented.

Expecting perfection from doctors and hospitals will further deteriorate the trust patients have in the profession. It's an ideal that can never be realized, which will inevitably lead to patient anger and disappointment.

The disgusting behavior of some on-call physicians.

(via Dr. Wes)

This is one of the ways government can help with the primary care shortage.

However, as Dr. Secretwave points out, the current example of such a program is not adequate.

The $20,000 amount does not influence medical students' decisions, and the fact that this amount is taxed makes this incentive more irrelevant.

Money talks, and so far, the government is barely whispering.

This should be on a pre-medical school screening questionnaire: "If money is you main object, avoid medicine. We make decent money, but we invest so much time getting there, that from a pure financial calculation, medicine is not your best choice.

If you do not like people, and here I mean all types of people, all social classes of people, then you should avoid medicine. If you cannot accept uncertainty, then you should avoid medicine. If you cannot accept that eventually you will make a mistake (or several) that will negatively impact a patient, then you should avoid medicine."

Good point here. Medicare and other payers pay the same for each medical service or procedure, regardless of whether it's done by a new doctor or a 30-year veteran:

Differentiating one physician from another or one surgeon from another is very difficult. Additionally, seniority does not necessarily mean that the product or service is better.

The only way that pay increases with age is the increased efficiency that comes with experience.

This isn't always a good thing, since doing things faster in medicine isn't always better.

It's the real estate:

One strategy some physicians utilize is to buy larger space than they typically utilize. Then they rent out space to other physicians. This is an excellent strategy for those physicians who have the means to do this. In some respects it turns the physician into a real estate investor rather than just a business owner.

Outrage at kids being priced out of these expensive programs:

Several national groups are pressing for government financing or insurance reimbursement for more intensive weight loss treatment for children, including weight loss camps.

Wouldn't it be better use of funds to focus on preventing kids to be so heavy in the first place?

In the midst of their boom, here's an article about an institution considering laying off hospitalists.

Hospitalist programs typically operate at a loss, with the financial gains not apparent for years to come. The benefits of these programs also do not directly impact the bottom line, but instead help with recruiting, as well as the primary care physicians affiliated with the hospital.

Cash-strapped facilities, like Cape Cod Healthcare, may not have the long-term vision or resources to wait out the initial capital costs of running a hospitalist program.

(via The Hospitalist Blog)

Trust between patients and physicians are at an all-time low. Although we blame a variety of reasons - ranging from third-party payers to malpractice fears - for this, simply being nice and appearing human can do wonders for the medical profession.

An abridged version of my op-ed was published in this morning's USA Today: Doctors' pay cuts save little in health costs.

It discusses whether targeting physician pay as a means to control health care spending makes sense and touches on Congress' recent passage of the Medicare bill.

For those new here, my name is Kevin Pho and I practice primary care internal medicine in New Hampshire. This blog explores the issues facing medical providers on a daily basis. Health care is a major domestic concern, and the public deserves to see what goes on "behind the curtain."

By providing a physician perspective on issues that the mainstream media may ignore, perhaps we can get one step closer to solving the problems crippling our health care system.

Some of my regular features include:

My Take: Quick-hitting quips on pretty much anything that crosses my mind.

Reader Takes: Provocative opinion pieces from the readers of this blog.

MedBlog Power 8: A weekly-updated list of medical blogs that had an exceptional week of blogging.

Of course, you can always jump in and join the debate on controversial issues like health reform, defensive medicine, the primary care crisis, medical malpractice, cancer screening, and emergency room struggles.

My previous opinion pieces and interviews have appeared in national and local media outlets, discussing defensive medicine (Defensive medicine: Cautious or costly?, Wasted medical dollars), primary care (Shortage of primary care threatens health care system), Medicare payments (Cut Medicare payments for doctors, you'll have fewer doctors), and poor communication in medicine (What we have in health care today is a failure to communicate).

Thanks for stopping by, and I appreciate your readership.

Regular blogging will resume on Monday, August 25th.

The story of an illegal immigrant in a coma. He is scheduled to be deported to Mexico.

Tough position for the hospital to be in. With limited resources, it is not financially viable for hospitals to foot the bill for illegal immigrants.

However, any solution is likely to cast a negative PR light on the hospital.

(via WSJ Health Blog)

And touches off a firestorm of debate on the WSJ Health Blog.

If there was a single thing he could do to lose my vote, endorsing single-payer would be it.