Don’t cut procedures from your practice

By John L. Pfenninger, M.D.

Nearly all physicians experience the financial pressures of providing medical care. Certainly those in private practice know the difficulty of making ends meet, but employed physicians are also feeling the crunch as they are more commonly being reimbursed based on their productivity and “relative value units.” The “old GPs” did everything. They delivered babies, they performed appendectomies and hysterectomies, repaired hernias, and more. As medicine specialized, many primary care physicians dropped these procedures along with simpler things like skin biopsies, treatment of hemorrhoids, vasectomies, and even incision and drainage of abscesses. It’s time to reconsider acquiring some of these basic skills, if you don’t already have them.

Primary care physicians have many excuses as to why they exclude procedural skills from their practices. They cite liability concerns, start-up costs and lack of training, among other things. These are lame excuses and don’t justify the loss of benefits that procedures could provide.

When physicians offer procedural skills to patients, they provide a more comprehensive quality of care. Too often I have patients referred to me for a single genital wart that has been treated with multiple courses of Imiquimod. The patient comes in, I simply snip off the wart, and it’s done. My charges are far less than the two courses of Imiquimod, the patients’ prolonged discomfort and psychological anxiety.

When a patient presents with an infected toenail, rather than using a course of antibiotics, which not only costs money but also increases the risk of antibiotic resistance, physicians should be able to remove the corner of the nail and resolve the problem right there. The treatment for a foreign body—the ingrown nail—is removal, and the procedure avoids the potential diarrhea or yeast infections often associated with antibiotics.

Doing procedures helps the provider learn more about the disease process. When a gastroscope is passed, one can see the subtle nuances in patients’ descriptions about GERD versus peptic ulcer disease. When a patient presents with an unknown skin lesion and is referred to a dermatologist, feedback is often delayed six to eight weeks if it comes at all. By performing the skin biopsy immediately, you and the patient can have the results in a matter of days. You may not know initially that the lesion is a keratoacanthoma, but the biopsy provides the information necessary to treat it, and by performing the biopsies yourself, you will become more comfortable with the clinical diagnoses. Over time, you may even be able to avoid the biopsy completely with certain lesions.

Doing procedures can reduce health care costs. Whenever a patient is referred, the initial charge for the consult is significant. When the physician is seeing a patient who has been evaluated within the previous three years, an office visit isn’t even charged. This provides a savings to the system. What really saves is the fact that most procedures performed by other specialists are carried out in ambulatory surgery centers and in hospital operating rooms. Sebaceous cysts, lipomas, skin cancers (basal cells, squamous cells, melanomas), and more can all be easily treated in the office.

A surgeon recently wanted to remove a sebaceous cyst on my neck in the operating room. I told him that I’d be glad to pay him my $2,500 deductible, but I was not going to pay it to the hospital. I gave him three options: he could come to my office and do the procedure, I could bring my equipment to his office since he claimed not to have it, or I could go elsewhere. I ended up taking my minor surgery pack to his office and he took out the cyst in about 25 minutes with somewhere between $1,500 and $3,000 in savings to the system!

People prefer to be treated by someone they know and trust. They don’t want to be sent somewhere else where they will have to take more time off work and most likely wait to be seen. They don’t want the anxiety of not knowing their diagnosis. They want their doctor to do it, as soon as possible, with expertise that is easily acquired.

Family physicians pride themselves on the continuity of the care they deliver. Yet we are giving up obstetrical and hospital care. By not doing procedures, we become more like the “triage officers” that we so commonly decry. If we don’t do the smaller, simpler procedures in the office, patients soon start going elsewhere for care. Continuity is lost. When someone in your practice comes in for a sebaceous cyst or follow-up of a small basal cell that you treated, you can also follow-up on whether or not he had the colonoscopy you recommended and how he is doing on his efforts to stop smoking, as well as follow-up on myriad other problems if necessary. Performing procedures provides more opportunities to enhance all health care efforts.

Here’s a shocker: doing procedures may actually reduce liability risks. Yes, reduce them. When one is comfortable doing procedures, it’s easier to recognize and address problems. Take for instance a mole that might look a little atypical. It’s easy to do a punch biopsy. If one doesn’t have those skills, one is more likely to avoid doing anything since setting up a referral takes time and energy. And, one doesn’t want to appear “stupid” before the specialists. So, the biopsy is deferred and the patient dies of metastatic melanoma. Physicians who have procedural skills do not abuse the system to make more money. Rather, they provide a level of care that is desirable and preventive in nature.

Performing procedures in the office and the hospital doesn’t just improve quality of care, decrease costs, improve patient satisfaction and decrease liability; it also increases your financial bottom line.

Primary care physicians too often screen problems and get paid a paltry amount for the difficult care of diabetes, chronic pain and hypertension, while they send away the higher-paying procedures that take less time and less expertise. Studies have confirmed that physicians providing procedures during their patient care receive a higher financial return. That makes sense—just think about how many patients you have to see to charge out the $600 or more that a 30-minute vasectomy reimburses. Similarly, the majority of basal cell cancers can be treated in less than five minutes using cautery and curettement with a reimbursement that averages over $250.

Here’s the secret those of us who offer procedures are happiest to share: doing procedures is fun! Many of us look forward to performing procedures. There is immediate feedback on the benefits that procedures provide. Patients are thankful and their problems are resolved right there in your office.

Most surgical procedures can be learned after residency training. I learned 90 percent of what I do now after I left the teaching position I held for 12 years. These procedures include no-scalpel, no-needle vasectomy; colonoscopy; sclerotherapy; infrared coagulation of hemorrhoids; most of the aesthetic procedures, Botox, microdermabrasion, intense pulsed light and laser; and more.

Courses are available through many societies and educational organizations, including the National Procedures Institute, which now is directed by a joint venture of the Texas Academy of Family Physicians, the American Academy of Family Physicians, and the Society of Teachers of Family Medicine. Through textbooks, videotapes, Web sites, models and simulators, and willing teachers, you can learn to perform procedural skills well, and you can enjoy the many benefits.

If you say you can’t, you’ll be correct—you can’t. But, if you say you can, you will also be correct! Not only can you perform procedures, but you can do them well, and with your broad background and expertise, you will give your patients so much more than they would receive if you sent them to other specialists.

John L. Pfenninger, M.D., is the founder the National Procedures Institute, which teaches outpatient diagnostic and therapeutic procedural skills to primary care physicians. A clinical professor in the Department of Family Medicine at Michigan State University in East Lansing, Michigan, Pfenninger is the editor of the comprehensive text “Procedures for Primary Care Physicians” (Mosby, 1994) and “Pfenninger and Fowler’s Procedures for Primary Care” (Mosby 2003, 224 Chapters). For more information, visit the NPI website, www.npinstitute.com.