Simon G. Talbot, MD, and Wendy Dean, MD, in “Beyond Burnout: Moral injury is the real problem” (August 25, 2019 issue) are to be congratulated by all physicians for their courageous statements on physician burnout.
	
	Every paragraph of their article is truthful and speaks to the dissatisfaction, the demoralization, the anxiety and the frustration that most doctors feel in our over-regulated and exploited profession.
	
	As they said, we doctors have “…taken on the job of data entry clerks, insurance go-betweens…coders/billers..[ that] …we are pulled in too many directions…” 
	
	Their comments that we are not taught or encouraged or empowered to set boundaries must be read by our medical leaders in our state and county medical societies; and in our specialty societies and the American Medical Association.
	
	Their most telling comment was that physicians can free themselves from the exploitive constraints that sicken them like a malignant virus  by saying ‘no’ to the unfair demands asked of us.
	
	Here is my personal example of frustration and dissatisfaction.  I know that other physicians have experienced the same:
	
	I recently was informed by Medicare that I must re-validate my enrollment with PECOS (Provider Enrollment Chain and Ownership System). I spent over 6 hours navigating the labyrinth of prompts and finally (so I thought) completed this needlessly complicated task.
	
	A few days later I received an email stating that my submission was rejected because it was ‘unsolicited’, meaning I think not needed. I followed all the prompts to clarify the issue but after several hours of frustration I gave up and sent Medicare a letter (at the cost of $25) explaining the problem and my lack of success with their user-unfriendly electronic system. No answer yet.
	
	I even contacted my state medical society and was told that other doctors had the same problem; and that the society had someone who could walk me through the submission form.
	
	That my medical society could walk me or any colleague through the submission process is good, but I have been practicing primary care for 44 years and in good standing with Medicare; and that I or any colleague needs help to fill a Medicare revalidation form is nonsensical.
	
	I replied that the real problem here is physicians’ fears of not bringing this to Medicare’s attention-and to our lawmakers and representatives. Not doing it just prolongs the problem and enforces Medicare’s impression that physicians are a pliable, easily manipulated group.
	
	The time is way overdue for physicians to say “no” and not to hold back any harsh words against those who for one reason or another are the cause of our dissatisfaction and demoralization. The problems with the Medicare re-validation form is a good place to start.

Articles

Your voice: Why medical leaders must pay attention to physician frustration, dissatisfaction

Over the course of their careers, physicians face several major financial decisions that can have a lasting impact on their financial well-being. Here’s a look at some of these key decisions and advice physicians should consider when making them.
	
	


	
	According to the Association of American Medical Colleges, three-fourths of medical students carry education debt (including college and medical school), with the median debt level hitting $200,000 in 2018. A 2018 Medical Economics survey of physician readers found that 30 percent of respondents had student loans upwards of $200,000.
	
	Whether physicians should refinance their debt hinges on the types of loans they have, says Carolyn McClanahan, MD, CFP, director of financial planning at Life Planning Partners, Inc., in Jacksonville, Fla. Her advice: If physicians have loans with high interest rates that aren’t available for forgiveness, they should shop around for better rates. “You could save a lot of money over a long period of time just by decreasing the interest rate by 1 percent or more,” she says.
	
	In fact, physicians should consider refinancing their private loans as early as the first year of residency, according to Andrew Musbach, CFP, co-founder and financial advisor with MD Wealth Management, LLC, in Chelsea, Mich. However, those with federal loans may already have low effective interest rates or may be pursuing public service loan forgiveness, so refinancing may not be beneficial, he says.
	
	Roozehra Khan, DO, assistant professor of clinical medicine at Western University of Health Sciences in Pomona, Calif., paid off $289,000 in student loans in three years without refinancing. She started by whittling down her government loans with 7 to 8 percent interest rates and then moved on to loans with 2 percent interest rates.
	
	As a single professional, she was able to keep her rent and other expenses low while paying down debt. “I continued to live like a fellow when I was an attending-I put almost all of my paycheck toward my loan repayment every month,” says Khan. She made sure to direct the additional payments toward reducing the loan’s principal balance, not the interest.
	
	“I want young people to know this is completely possible,” she says. “When you are able to take financial control, it creates a mental freedom that allows you to be the doctor you want to be.”
	
	


	
	Many physicians make the mistake of relying solely on the life and disability insurance they receive from their employers when they should also have their own individual coverage, McClanahan says. “I tell everyone, especially young physicians who may be thinking about having children, to get a cheap term life insurance policy right out of the gate that you own and that goes with you if you leave your job,” she says.
	
	Another mistake is purchasing whole life insurance rather than a term policy, Musbach says. While term life insurance provides coverage for a fixed amount of time (often 10 to 30 years), whole life provides permanent coverage along with a savings and investment component. “On the surface, it sounds like a good idea. But in the end, it’s just expensive insurance coverage with mediocre investment returns,” he explains.
	He also recommends that residents purchase an individual, “own occupation” disability insurance policy (which provides benefits if they are disabled and unable to work in their “own occupation”) specific to their specialty with a rider that allows them to buy more coverage when they become attendings and their salaries increase. This helps them avoid another lengthy medical underwriting process when they are older and may no longer be as healthy, he says.


	
	According to McClanahan, many young physicians are behind when it comes to estate planning. At a minimum, every physician should have documents designating a healthcare surrogate and a power of attorney, she says.
	
	As soon as they have children, physicians also should draw up wills or trusts that allow them to name guardians for their children and dictate what happens to their estate after their death, Musbach says. “Having an estate plan is going to help your kids save a lot of headaches and also minimize the potential for family conflict,” he adds.


	
	Many young physicians have difficulty prioritizing their money goals once they begin practice and see their salary jump, experts say. Physicians likely still have student loans and are many years behind their peers in other professions who required less education and training, Musbach says. At the same time, they may have a family and want to save for college or a home.
	
	John Cullen, MD, FAAFP, a family physician practicing in Valdez, Alaska, recalls such struggles early in his career. Nearly 30 years ago, Cullen and his wife, who was earning her teaching degree, had their first of three children while he was in medical school and their second during his residency. The young couple had accumulated about $130,000 in student debt, which they consolidated into one low-rate loan.
	
	Even though both of their incomes were modest, they made it a priority to start investing for retirement right away. To save for college, they took advantage of state-sponsored 529 college savings plans soon after their first child was born.
	
	Comparing his experience with young physicians today, he recognizes that many have a tough time getting an early start on investing while balancing other financial priorities.
	
	“Medical students and residents don’t get nearly enough education on investment strategies for retirement,” says Cullen, who hopes to promote greater financial education in his role as president of the American Academy of Family Physicians.
	
	Last year he and his wife, both in their mid-50s, paid off all of their consolidated debt for their house, a sailboat, and loans, so they are able to put away even more money for retirement.
	
	Getting an early start on retirement savings is one of the best money moves physicians can make, experts say. In fact, financial advisors have a mantra: You can borrow for college, but you can’t borrow for retirement. That is why McClanahan and Musbach recommend that physicians save as much as they can in qualified retirement plans like 401k’s and 403b’s, which provide tax benefits and are protected from creditors.
	
	For those in training, contributing post-tax dollars to Roth accounts can provide additional tax diversification before their jump in income makes traditional 401k or 403b contributions (which are made with pre-tax dollars) more beneficial, Musbach adds.

Investment strategies beyond the 401k or 403b


	
	If physicians have maximized their 401k or 403b contributions, they can explore other savings vehicles that may offer tax advantages, Musbach says. Depending on their situation, practice owners may want to consider cash-balance plans, a type of qualified retirement plan that allows them to save considerably more on a pre-tax basis than 401k plan contributions. And for certain physicians who also work in a locum tenens role, a simplified employee pension IRA or 401k may provide an additional tax-advantaged vehicle to save some of their independent contracting income, he adds.
	
	Given their high incomes, there is no need for physicians to take on the additional risk-and hassles-of investing in startups, private deals, or rental real estate to meet their financial objectives, Musbach says. “The goal isn’t to chase the highest return every year, but rather to make sure the way you are investing is aligned with your goals,” he says.
	
	If physicians do invest in a startup or another risky investment, they should use their “play money,” McClanahan advises. But they should shy away from making “friend of a friend” investments in what’s billed as the next big thing, she says.
	“Private placements lack transparency, and because of this physicians are often hoodwinked,” she notes.


	
	AAFP’s Cullen has no plans to stop seeing patients, although he thinks he could do so while maintaining his financial independence.
	Becoming financially independent for life transitions, rather than focusing on retirement, should be every physician’s goal, says McClanahan.
	She believes the biggest determinant of when physicians can reach financial independence is how much they spend, not how much they save. “If you develop an expensive lifestyle that you become locked into, it’s going to be hard to achieve financial independence or retirement at a young age,” she says.
	
	Physicians shouldn’t count on the sale of their practice as their nest egg, she adds. Smart investing and modest spending over the long run will likely bring greater returns.
	
	Musbach urges physicians to aim for a state of financial independence where work is optional, not required. As a general rule, retirees can safely withdraw 4 percent from their portfolio each year, he says. That means a doctor looking to draw $100,000 each year would need to save about $2.5 million. Reaching that goal requires saving at least 15 to 20 percent each year, he says.


	
	There is no set moment, such as when physicians reach a certain savings target or income bracket, when they should consider working with an investment professional, says Gerri Walsh, senior vice president for investor education at FINRA, the Washington, D.C.-based organization that licenses and registers all brokers in the United States. Rather, physicians should contact an advisor whenever they want guidance on managing their money.
	
	When selecting an advisor, Walsh recommends visiting FINRA’s BrokerCheck, a free tool for researching investment professionals that provides information on brokers’ licensing, experience, and history of customer complaints.
	
	When might physicians want to switch advisors? One cause is when they suspect the advisor of engaging in problematic behavior, such as making unauthorized trades, Walsh says. If physicians are not satisfied with their advisor’s explanation, they can contact the firm’s branch manager and visit FINRA’s investor complaint center for more guidance.
	
	Another cause for switching would be if the physician does not believe the advisor is offering unbiased advice. As Walsh says, “If you ever feel discomfort with the products, services, and strategies that are being recommended to you, that is an important point to pause and reflect on the relationship-especially if the products, services, and strategies don’t align with your goals.”

Over the course of their careers, physicians face several major financial decisions that can have a lasting impact on their financial well-being. Here’s a look at some of these key decisions and advice physicians should consider when making them.

How physicians should tackle their toughest money decisions

Q: Is reporting of Current Procedural Terminology (CPT) codes 99218-99220 restricted to a single physician?

 According to CPT guidelines, only the physician or non-physician practitioner (NPP) placing the patient in observation status (and subsequently discharging the patient) may report the appropriate initial observation code (99218, 99219, 99220). This refers to the initiation of observation status and the supervision of the care plan for observation. Encounters by physicians/NPPs other than the supervising (admitting) physician for same day services may be reported with outpatient consultations codes (99241-99245) or subsequent observation codes (99224-99226), as appropriate. 
	
	Be sure to check with your payers to verify that they follow CPT guidelines. Some Medicare contractors and other payers may instruct to bill outpatient office visit codes (99201-99215) to report all subsequent observation care, regardless of whether the provider is the “admitting” physician or not.

Q: If a patient is admitted to observation status (99218-99220) and remains for two days before  being admitted as an inpatient, is it appropriate to report the initial hospital care codes (99221-99223)?

If a patient is admitted to the hospital on a date subsequent to the date of observation placement, the hospital admission may be reported with the appropriate initial hospital care code (99221-99223). The initial hospital care level of service reported should include all evaluation and management (E/M) services provided to that patient in conjunction with that admission on the same date by the admitting physician. This means that an observation discharge should not be billed on the same date that the initial hospital care code is billed.

Q: Does code 99226 require medical decision making of high complexity?

 Not if both of the other two components (history and exam) in the code are performed. When subsequent observation care is reported, at least two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service, as stated in the descriptor of code:

99226: Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:

Medical decision making of high complexity.

High complexity means counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable, has developed a significant complication, or a significant new problem. Typically, 35 minutes are spent at the bedside. 
	
	Two of the three key components must be met or exceeded for the level of service selected. Time may be used to select the level of service when counseling and coordination of care are documented as at least half of the time spent face-to-face with the patient.
	
	Check with payers regarding specific reporting and payment policies.

Make sure you are using the right codes when dealing with hospitalized patients.

Coding for  hospital observation 

An estimated 2.4 million people in the United States are living with hepatitis C, and in 2016, the Centers for Disease Controls and Prevention (CDC) reported approximately 18,000 U.S. deaths were the result of the hepatitis C virus (HCV) as an underlying or contributing cause. And the CDC believes that number is a low estimation of what the true figure is.
	
	The problem is, a majority of those living with the virus don’t even know they have it.
	
	That’s why the CDC recommends one-time screening for hepatitis C for Baby Boomers (those born between 1945 and 1965), regardless of apparent risk factors.
	
	Yet despite the recommended guidelines, only a small fraction of this segment has actually been screened. For that reason, it’s vital that primary care physicians play a more active role.
	
	Alexea M. Gaffney, MD, an internist in Stony Brook, N.Y., says hepatitis C screening is so important because the vast majority of individuals with the infection will have no symptoms or will have symptoms that physicians describe as “extra-hepatic” outside of the liver. 
	
	“Without screening, we miss the opportunity to treat and cure this infection before patients or infected individuals become symptomatic or progress to irreversible liver disease or scarring such as cirrhosis or develop cancer of the liver,” she says. “We also miss the opportunity to prevent liver failure and the need for liver transplants in significant numbers of patients.”
	
	Janette Nesheiwat, MD, a family doctor and the medical director at City MD, which operates more than 100 urgent care centers, says some routes of transmission include sexual activity, intravenous drug use, mother to child during pregnancy, a needlestick injury or blood transfusions. 
	
	“Early detection and screening is important because there is a better success rate and outcome if the disease is caught early before severe symptoms and complications occur. Early detection lowers the risk of worsening complications, such as a need for liver transplant, or cancer formation and death,” she says. “This is why doctors urge screening.”
	
	


	
	Rusha Modi, MD, MPH, assistant professor of clinical medicine at Keck School of Medicine of the University of Southern California, says as an academic gastroenterologist and hepatologist, he sees a wide range of patients with HCV-from those asymptomatic to those that need lifesaving transplants.
	
	“Now that we have effective treatments that can eradicate the virus, there is an opportunity for people to advance their health and prevent long-term complications,” he says. “It doesn’t make sense that people aren’t being screened.”
	
	Primary care physicians can be a solution to this problem and take action at their practices.
	
	“They can make inquiries by asking qualifying questions to patients during new patient visits, annual exams or wellness visits,” Gaffney says. “They could also give a questionnaire to patients asking if they meet any of the criteria. A single yes means a patient needs to be screened. The test can be ordered alone or with other routine blood work.”
	
	The criteria checklist includes those who currently or in the past have shared needles for intravenous drug use or straws for intranasal drug use; have received tattoos or body piercings from an unlicensed facility; were treated for a blood clotting disorder such as hemophilia before 1987; received a blood or blood product transfusion or organ transplant before July 1992; are on long-term hemodialysis treatment; have abnormal liver function tests or liver disease; or work in healthcare or law enforcement and were exposed to blood through a sharp object, injury, or bite.
	
	Mark Shaffer, MD, a family physician and clinical assistant professor of family & preventive medicine at the University of South Carolina, says the simplest approach to set up hep C screening in the primary care office is to integrate it in the same ordering and tracking mechanism used for mammograms, colonoscopies and other preventive care services at the adult health maintenance exam. 
	
	“Most electronic medical records have a mechanism for this,” he says. “One challenge, however, is that many providers seeing patients feel too far removed from the people actually programming their EHR, especially in large systems, to drive effective changes. Another challenge is that many patients do not attend an annual health maintenance exam, which is currently the only dedicated moment for a provider to review their record and preventive care needs.”
	
	This has led to a lot of direct to patient advertising for other preventive care measures, like mammograms, and Shaffer suspects the same is needed to improve hep C screening as well.
	
	


	
	Gaffney says providers need to inform Baby Boomers that they account for three out of four patients infected with HCV, explaining that they received healthcare before universal precautions became standard for medical care.
	
	This is not always as easy as it sounds, however.
	
	“Sometimes physicians do not want to risk making patients feel ‘judged’ by them, so they may not ask appropriate questions to assess for hep C risk,” she says. “They also may not understand that patients can be asymptomatic and have a normal exam and lab analysis and still have hepatitis C infection.”
	
	Additionally, patients will sometimes decline tests when they do not understand their risk factors for a disease process, especially a transmissible infection.
	
	“It’s a challenge for many due to busy hectic lifestyles and the misunderstanding that, ‘It can’t happen to me,’” Nesheiwat says. “Well, all it takes is one encounter to acquire hep C.”
	
	Aaron Eli Glatt, MD, chair of medicine at South Nassau Communities Hospital in Oceanside, N.Y., and a spokesperson for the Infectious Disease Society of America, says while screening is essential for Baby Boomers, hepatitis C can impact all sorts of different populations, especially those younger generations that were involved in substance abuse. He says physicians should be talking about the dangers of HCV with all of their patients.
	
	He explains that often the virus will go unrecognized until there are symptoms, and while it can still be cured easily, some complications that develop might not be so easily fixed, which is why screening needs to be done before the virus kicks in.
	
	Glatt believes the reason more people don’t get screened comes down to apathy.
	
	“For most people, and I think this is especially true of the Baby Boomer population, if they aren’t sick, they feel they don’t have the time to be screened and it’s not a priority,” Glatt says. “PCPs just need to stress the importance of this screening and their patients have to agree to have the screening done. That could solve so many problems.”
	
	Glatt says that a simple blood test can be an indicator if screening is necessary and no patients should be scared off from that.
	
	“There’s a 98 percent cure rate, and there are very few diseases with those kind of numbers,” he says. “It’s expensive, but insurance usually covers it. A simple pill once a day for eight weeks can cure it. If someone is in the Baby Boomer range, it makes all the sense in the world to be screened.”

Why primary care physicians should be setting up a screening program.

The importance of Hepatitis C screening

More than half of patients diagnosed with cancer have comorbid conditions. Yet once cancer treatment begins, patients sense that they don’t need to see their primary care physician, and that the oncologist should treat everything, says Jacqueline Winfield Fincher, MD, MACP, an internist in Thomson, Ga., and the ACP president-elect. “Everything health-related comes down to this one thing, which is a natural response,” she says. “You don’t want to survive cancer just to have a major stroke or heart attack because you did not continue to address and treat your cardiovascular risk factors.”
	
	Primary care physicians (PCPs) have important roles during cancer care, though not all realize it. Once cancer is diagnosed, there’s a tendency for patients to be transferred to oncology rather than referred there, says Amy E. Shaw, MD, a family  physician specializing in oncology care at St. Joseph Health Medical Group in Santa Rosa, Calif. “I think this is a holdout from the days when most cancer was fatal,” she says.
	
	Instead, oncologists and PCPs need to work together to address all the patient’s medical needs, and therefore PCPs need to stay in touch with the patient during active treatment.
	
	

Communicating with patients during treatment


	
	Often, a PCP is the referring physician for a suspected cancer. Fincher says her office tracks referrals, and follows up if her office hasn’t heard back from the oncologist. The specialist’s consult report makes it easier to identify if a patient has a new cancer, as some patients may not inform the PCP of their diagnosis. Fincher also tells patients with comorbid conditions to return at their regular intervals, and what to look for during active cancer treatment that could impact their health.
	
	The PCP should reach out periodically to patients getting cancer treatment, even if they don’t have other medical issues. “I hear over and over how much patients appreciate it when they got a call from their PCP during their cancer treatment,” says Shaw. She also hears how disappointed patients are when they don’t hear from their PCP, and that the patient may not want to return to their care as a result.
	
	“Patients know you’re not an expert in cancer. When they’re going through something terrible, at least acknowledge what they’re going through,” she says.
	
	Shaw recommends calling the patient to say something like, “I’m sorry you are going through this. Is there anything I can do to help?” The best times to call are at transition points, when the patient is starting or finishing a treatment. “I know doctors have 2,000 patients, and you’re not going to call every time someone breaks a leg or gets a sore throat. But cancer is uniquely terrifying.”
	
	Sometimes the patient may have difficulty getting a specialist appointment, and the PCP can make a phone call to help. Shaw also recommends giving priority to calls from a patient undergoing cancer treatment. “We have this sign posted in our office for staff and doctors: ‘Just because we see it commonly, does not mean it is common for the patient,’” she says.
	
	Shaw sometimes hears from patients that their PCP immediately refers them back to their oncologist when they call the PCP’s office with a medical problem during cancer treatment. Even if the PCP doesn’t have oncology expertise, they should find out a patient’s issue before referring them back to the oncologist.
	
	“If I haven’t personally spoken with the patient to determine that they are having a problem that only the oncologist can address, then I shouldn’t be telling them to go elsewhere for care,” Shaw says.
	
	


	
	Both the PCP and oncologist should encourage patients undergoing cancer treatment to see their PCP for existing health issues, especially as cancer treatment can impact these conditions. “We know that high blood pressure, heart disease, heart failure, and diabetes are profoundly affected by cancer treatment, particularly chemotherapy and steroids that sometimes accompanies chemo,” says Fincher.
	
	For example, she says, she might need to increase a patient’s diabetes medications due to steroid use, or decrease blood pressure medications if they’re losing weight and their blood pressure is dropping, or if they have significant treatment-related fluid losses or gains. Oncology treatment can be delayed if the patient’s glucose levels or blood pressure aren’t controlled.
	
	Shaw has seen many oncologists renew a patient’s blood pressure or diabetes prescription because the patient hasn’t seen their PCP in years. “This is understandable, but renewing a prescription is not the same as managing the condition,” Shaw says.
	
	For patients without comorbid conditions, PCPs can help with treatment decisions, care coordination, and managing treatment side effects. Shaw has helped patients understand each clinician’s role on the team, and get treatment authorizations and referrals. “Not every (oncology practice) has a patient navigator. The primary care doctor sometimes has to help,” Shaw says.
	
	Especially in rural communities, PCPs can take control of drains and manage general side effects. It’s best when the oncologist communicates this with the PCP, which isn’t always done well, says Eben Rosenthal, MD, director of Stanford Cancer Center in Palo Alto, Calif.
	
	As a PCP in a rural town, Fincher says her patients are usually at least 45 minutes away from their oncologists. Patients come to her for issues that develop between chemotherapy treatments. And while not all PCPs have oncology expertise, patients still may want their opinion on recommended treatments.
	
	“There’s a level of trust,” Fincher says. The patient often has an ongoing relationship with the PCP, while only seeing the cancer specialist for a short time. “Our patients come back to us and say, ‘this is what the doctor recommended, what do you think?’” That’s common. A 2016 study in the Journal of Clinical Oncology showed that 35.4 percent of women with newly diagnosed breast cancer consulted their PCPs about treatment options.
	
	Shaw says she’s talked with patients who didn’t want a recommended treatment because of the side effects. She discusses the patient’s personal goals, how potential side effects would be treated, and why it was recommended to give a more thorough perspective for making a decision.


	
	While experts say that it’s the specialist’s responsibility to share updates with the PCPs, the PCP plays a role as well.
	
	PCPs often complain that oncologists don’t send their notes, says Shaw, but PCPs also don’t always send their notes to the oncologist, forcing patients to act as the messengers between various doctors. Giving the patient access to their notes via a patient portal makes communication easier.
	
	“Cancer providers should be reminded to send office notes to PCPs at a minimum, or better yet, have the EHR automatically route office notes to the PCP,” says G van Londen, MD, a medical oncologist at UPMC Hillman Cancer Center, and director of the Women’s Cancer LiveWell Survivorship Center at UPMC’s Magee-Womens Hospital in Pittsburgh.
	
	Developing relationships with specialists helps as well. Shaw says that when she was a family practitioner-she now practices primary care oncology-she sometimes accompanied her patients to the oncologist. “I learned so much, and the oncologists got to know me,” she says.
	
	Of course this isn’t practical for most PCPs, but there are other ways to develop relationships. Stanford’s Rosenthal recommends that PCPs attend courses about oncology care, and visit facilities where they refer patients.
	
	This can help PCPs understand which cancer treatment-related symptoms to expect, screen for, and manage. Communication also helps eliminate duplication of efforts, says van Londen, and decreases the risk of the bystander effect, where everyone thinks someone else is tackling the problem.
	
	“We travel and have dinners (with PCPs), do grand rounds at community hospitals about treatments, and talk about what to expect,” Rosenthal says. “It’s old fashioned communication.”
	
	Ideally, specialists would also refer patients back to their PCP to manage quality of life issues such as anxiety, depression, sleep disturbances, and treatment-related pain, Fincher says, adding that primary care physicians are in a better position to treat patients’ pain.
	
	Given the problems caused by opioid addiction, PCPs knowing the patients and the community give better context to treatment options, and PCPs also treat the patient holistically, rather than treating just the cancer.
	
	For example, Fincher recalls one patient who had intense pain from bone metastases, and the oncologist was not responsive to the patient or Fincher when approached about the issue several times. The patient maxed out on her pain medication but was still in severe pain. Fincher referred the patient to a radiation oncologist, who began radiating the area. Within a week, the patient’s pain decreased, she was sleeping  and feeling better.
	
	Patients expect that PCPs will be available to help them when there’s a serious medical issue, including cancer, says Shaw.
	“We stay closely involved when there are other medical crises like a CVA, car accident, myocardial infarction, Parkinson’s, or dementia. But for partly historical reasons, we treat a cancer diagnosis differently,” Shaw says. “Most of our patients now survive their cancer and these patients will return to our practices, so it’s best to stay in contact with them so a gap doesn’t open up.”

Regular contact with patients is vital for successful treatment.

Primary care’s role in cancer care

If bad handwriting was the only problem we had to deal with, medicine would be in a much better place.

October 10, 2019 edition

Your voice: Why medical leaders must pay attention to physician frustration, dissatisfaction

How physicians should tackle their toughest money decisions

Coding for hospital observation

The importance of Hepatitis C screening

Primary care’s role in cancer care

Medical Economics Cartoon: Pining for the days of bad handwriting