A Motherless Child Without a Father

The young man with chest pains, shortness of breath and heart palpitations had come back for his followup visit.

His thyroid test and blood count were well within the normal range, his EKG was normal and his chest X-ray was declared normal by the radiologist.

We talked some more about his anxiety and poor sleeping habits. We talked about his late shift at work, and we talked about his late gaming habits on the computer and how he sleeps until ten and misses out on mornings with his young daughter. He had been setting his alarm and getting up two hours earlier than he used to. That had made him more tired and less inclined to stay up past one o’clock in the morning.

We talked about how many years it had been since his mother died, and the emptiness he had felt ever since then. We talked about how he has had to mother himself in some ways ever since then.

We talked about how he had now gone from being a motherless child to a young father, and I asked him what kind of father he wanted to be for his little girl.

That’s when he said, “I wish my dad would act more like a father”.

“Do you wish he would give you some more guidance?” I left it open ended.

“Yeah, I feel insecure, like I’ll mess up with the baby.”

“Have you asked him?”

“Not in so many words. But, he doesn’t seem that interested. He’ll take me out to lunch and we eat without saying all that much and here he is, fifty years old, texting his girlfriend like some teenager instead of talking with me. I’m scared, I don’t know exactly what I’m supposed to do or be like, and he is no role model at all.”

“So if your father acted exactly the way you need him to, what would that look like?” I asked.

He thought for a while, and then, with words that flowed on a river of silent tears, he painted a touching picture of a a young father and a still young grandfather talking about what it takes to be a man.

“See, you have a pretty good idea of the kind of advice you would get, then”, I said. “And your wife and daughter, what kind of man do you imagine they wish you will turn into as you mature and continue to evolve? Do you think you know that?”

He nodded.

“I understand that you wish your father could help you more, but for whatever reason, he isn’t able to give you what you need right now, but it sounds like you already know what kind of man you want to be like.”

He nodded again.

“Be the kind of man you wish he was, be the father you want your little girl to have. She will teach you, just watch her and listen. And talk, really talk, with your wife.”

With the image still in my mind of the fifty year old man texting his girlfriend while his son pined for his love and attention, I added:

“Maturity and age don’t always move along at the same speed. I think you’re growing up faster than many people your age.”

He shook my hand, very firmly, and said:

“Thanks, Doc.”

A Failed Transition of Care

Alvion Barr had a four month delay in his diagnosis.

He is technically a patient of my colleague, Dr. Laura McDonald. But he had drifted between two of our regular doctors and a locum tenens physician we hired to work during March, when both Laura and Dr. Wilford Brown were on vacation.

I saw him late Thursday afternoon for a rash, but he also asked what he could do about his heartburn.

“Tell me more about your heartburn”, I said.

What followed was a near classic description of angina pectoris. He had been getting progressively more short of breath with exertion since Christmas, and if he didn’t slow down when he started to get winded, he would get a dull pain in the middle of his chest that gradually spread to his jaw.

Alvion’s problem list read like a Who’s Who of vascular diseases and interventions: Coronary artery disease with a prior bypass operation and two stents a couple of years later, surgical repair of an abdominal aortic aneurysm, bilateral carotid bruits and mild intermittent claudication. He is also a diabetic and he quit smoking only two years ago.

“I have an appointment with the lung doctor next week to go over all the testing he just put me through”, Alvion said.

I checked his peak flow. It was 550, same as mine.

“When was your last stress test”, I asked him.

It became evident that he wasn’t the best historian.

“Just a month or two ago, and it was okay.”

“Do you remember who ordered it?”

“Dr. McDonald, I think.”

Our EMR had no stress test result, not even an order for a stress test.

Health InfoNet, the statewide Internet repository of test results and hospital records, did have a nuclear stress test report from March 21 of this year, done at Cityside hospital.

My eyes scanned their way down the report and as I read the conclusion, I could feel the hair on the back of my neck rising:

“Large, reversible anterolateral defect….”

“March 21”, I said out loud as I scanned the Health InfoNet site. “Here it is: Hospital discharge, March 21″. We did have that document in our own record also. I continued reading out loud:

“Final diagnosis: Non-Cardiac chest pain.”

Alvion’s troponins had been negative and the EKG portion of his stress test had been normal. There was no report from the nuclear images, but there was a comment, indicating that the images were of poor technical quality and that a final report would not be forthcoming for that reason.

He was prescribed pantoprazole for acid reflux, and here he was in my office after five o’clock on a Thursday afternoon four months later with classic, frequent although not crescendo angina and a highly abnormal stress test.

He had had a hospital followup with the locum tenens doctor, a Transition of Care visit as we now call them. We have created a template to meet the Medicare criteria for the new transition of care codes 99495 and 99496. One of the items is “Pending results at discharge:”. In Alvion’s case the word after the colon was “None”.

I started Alvion on isosorbide mononitrate, a long acting nitroglycerin. He was already on a beta blocker, a statin and a blood thinner. I made sure he had more sublingual nitroglycerin and told him not to push himself and to call 911 if he had chest pain that didn’t go away after two nitroglycerins.

The next morning I called the cardiology office and happened to get to talk to the doctor who had read the nuclear images after the patient had already left the hospital. He took no responsibility for the confusion. All he had to say was “I thought the hospitalist would contact the patient in a case like this”.

“If he was on duty when the report came in”, I thought, adding to myself “and if he read through the whole thing, since you had already told him it was uninterpretable”.

“Just in Time” Information – Lessons from Manufacturing

One of the things that can cause physician burnout is the arcane way information flows in medical offices. In essence, due to EMRs we are the recipients of increasing amounts of unfiltered data without context.

Pre-EMR, team members sorted incoming data, which allowed us to deal with it more efficiently. We would have piles of things that needed a signature just as a formality, other piles for normal reports, smaller piles for abnormal reports, or whatever system worked best for us and our practices.

Because EMRs were created by people who never imagined that doctors themselves knew anything about how to maximize their own efficiency, results and reports now fill our inboxes in random order and demand our attention and our electronic signatures more or less immediately.

There is a better way. It is standard practice in manufacturing. They call it “Just in Time”.

First, let me describe the way it works now:

I saw Mrs. Keller three months ago for her diabetes. Next week, she will be back for her three month followup appointment. In the next few days, I will get her blood test results, each requiring my electronic signature. This time that might be her HbA1c and her annual urine microalbumin and a chemistry profile. I might also have received an eye doctor report from last week and a progress report from her podiatrist, neither one of which requires any action on my part. That means I must “steal” time from this week’s patients to peruse and electronically sign off five items, which I will have to review again when I see her next week. I also have to remember to flag the eye doctor report for my medical assistant to enter in the flowsheet so we can keep up our quality reports.

In my mind, I multiply Mrs. Keller’s five sign-offs by the number of followup visits I have every week. Even CT scans, MRIs and other imaging could be reviewed and signed off at the time of the followup visit; the radiology departments at all my area hospitals have routines in place to flag critical results.

Why should I look at everything twice? Why are physicians, the highest paid members of the health care team, essentially opening and sorting the mail?

I imagine how my day would flow if none of those five items cluttered my inbox, but popped up when I sat down with Mrs. Keller to talk about her diabetes or with Bill Watterson to talk about his partially torn meniscus.

In the lean, “Just in Time” manufacturing paradigm, factories don’t store parts and raw materials needed for production. They save space, time and money by planning for what they will need and having these supplies arrive just before they are needed.

In medicine, information like test results and outside reports are the parts we need in order to produce treatment plans, which is the output in our “industry “.

Most of the time today, we get paid only for face-to-face visits, and not for “managing” patients’ care. Even in the future, when Medicare starts paying us for outcomes, efficient information flow is essential. Imagine getting important information in random order versus delivered in context, when it is time to assess a patient’s or an entire population’s health status.

Between the skill and experience of our team members and the vast untapped potential of the expensive information systems we have, we could get to where we touch most incoming information only once, just when we need it. Imagine how much time, energy, frustration and money that could save us all.

No Better

“No better” was the message I got last week about a sore toe, a stubborn cough and a case of C. Difficile diarrhea. All three messages were false alarms, misleading missives, inadequate information or whatever you want to call it.

After a few more questions, all three patients turned out to actually be doing much better than the messages suggested.

The octogenarian with the sore toe, which looked like gout to me, told me the exquisite pain she had experienced from the lightest touch was gone, the throbbing had subsided, and now there was just a strange itching deep inside her toe. The swelling was almost gone, and she didn’t even flinch when I squeezed her toe. The two days of prednisone I had prescribed really seemed to have helped her. And, her uric acid level had come back elevated.

The man with a cough back in April had actually almost stopped coughing after a ten day course of antibiotics for his cough, sinus congestion and postnatal drip. But his symptoms had gradually started to come back. He hadn’t refilled his prescription as I had told him he could, but decided to give it more time. Now he was almost back at square one. I told him to take another round of the antibiotic and expect to see him do well.

The poor woman with clostridium colitis had improved significantly, but wasn’t quite back to normal. Her probiotic order had stopped when her metronidazole stopped and she turned out to have a fondness for tall glasses of cold milk. I had her restart her lactobacillus and give up the milk, and within two days her stools were formed.

In all three cases, one or two simple followup questions provided information that the prescribed treatments had actually worked fairly well. But in all three scenarios, either the patient or the person who took the message seemed to have an all-or-nothing mindset, almost like a “true or false” quiz, or “complains of/denies” click boxes in our electronic medical record.

This is a problem in healthcare today: Information is expected to be “discrete”, “structured”, or straightforward. But people and diseases are usually more nuanced than that. And without the nuances provided by a real patient narrative, we risk making deleterious treatment decisions.

Medical practice is not usually so algorithmic that simple yes or no answers can guide our treatment decisions. One person’s yes is another person’s no, depending on their expectations and a host of psychological factors.

Our job is to listen to the narrative and, only then, decide whether to follow the “yes” or the “no” arm of whatever algorithm we are trying to apply.

In this era of EMR click boxes and team based care, there is a real danger of seeking simple answers without listening to patients long enough to understand what they are trying to tell us.

We learned this in medical school and residency. EMR people and office staff didn’t. We need to pause and think like doctors before we give knee-jerk responses to seemingly simple messages.

The Intricacies of Antidepressant Interactions

Once upon a time there were jokes circulating about putting Prozac (fluoxetine) in the drinking water.

The idea was that the modern antidepressants were indicated for most people living in today’s society, and that these drugs were completely safe to use.

Now, these same drugs have so many warnings that they have become increasingly difficult to use in treating the common maladies of depression and anxiety.

The earliest scuttlebutt about Prozac causing suicidal thinking never did go away completely. We were assured that the suicide rate itself did not go up, only thinking about it. Some of that was explained by powerful antidepressants potentially unmasking bipolar illness and causing manic episodes. But a few years later, Paxil (paroxetine) was reported to cause suicidality in adolescents.

Just in the past few months, I was reminded several times about the intricacies of prescribing SSRIs.

A middle aged man on the blood thinner warfarin suddenly developed nosebleeds when his INR shot above the therapeutic range. His psychiatrist had doubled his Prozac two weeks earlier.

An anxious and depressed elderly woman wanted to try an antidepressant, and I gave her a low dose of Lexapro (escitalopram). She told me the following week that she felt tired and listless. I ordered some routine blood taste and her sodium level came back precipitously low. We stopped her Lexapro and she felt better again within a week.

A tall, thin elderly man with Parkinson’s disease and depression wanted to try something for his mood. I searched the literature and prescribed the SSRI with the most data on use in his condition. The following week he felt lightheaded. His blood pressure and pulse were both lower than his baseline, and I ended up cutting his beta blocker in half twice before his vital signs normalized; I had never heard or seen this interaction before.

A middle aged woman with a history of pulmonary emboli had been difficult to regulate on warfarin, and during a recent hospitalization, the doctors had changed her over to the novel anticoagulant Eliquis (apixaban), which doesn’t require any monitoring. When it was time to refill her Zoloft (sertraline), my computer flagged me with a bold, red warning that apixaban and sertraline are a dangerous combination resulting in increased risk for bleeding.

The list of warnings for this class of drug goes on, including effects on pregnancy, heart arrhythmias, seizures, glaucoma, liver disease and diabetes.

Given that their effectiveness is reported to be only marginally better than placebo, I have become increasingly more cautious about prescribing them.

Just this year, though, in Molecular Psychiatry, a new analysis of old data suggests that previous studies had used an ineffective rating system for depression, and that SSRIs are more powerful than we thought.

I remain skeptical. Once bitten, twice shy.

A Fifteen Minute Man

“I should be home well before nine o’clock”, I said to my wife on the phone as I steered my eight cylinder SUV quietly down the highway at 75 mph (121 km/h) with more than 100 miles left to go.

“More like eight fifty-five”, I added.

“That’s well before nine?” She sounded both weary and incredulous. I knew what she meant. I am not as obsessive about time as I used to be, but even outside the clinic, I have an awareness of time that is possibly not entirely normal or healthy.

As a physician in America today, I work within a schedule of fifteen minute blocks. Some visits, like physicals or hospital follow-ups are scheduled for thirty minutes, but the bulk of what I do has to average out to fit a fifteen minute slot, or sometimes, when we double-book, half of that.

It takes constant awareness of time to function in that manner, and I work very consciously not to relay that awareness too plainly to my patients.

Whenever I work with new scheduling staff, I have to help them learn how long things take. They don’t usually know much about medicine, but it is essential to have a sense of which things take a lot of time and which don’t.

For example, a person with acute chest pain and shortness of breath, although this may sound serious, only takes a few minutes, because it involves a triage decision – if it’s bad enough we ship them out to the hospital. If it’s not, we order a basic set of tests with relatively few possible outcomes.

On the other hand, an older person with fatigue, depression, nausea, weakness, weight loss or any kind of gynecological or bowel related problem takes a lot more time. Just getting an older person undressed and on the exam table can take half of a fifteen minute slot, let alone taking a good history from someone whose memory, conversation style or medical savvy isn’t in tune with the pace of today’s society.

In the past I remember making lists. An earache takes five minutes, severe headaches up to fifteen, and so on.

I also often say, “if you can’t figure out what they need or if you can’t get off the phone with them, I probably can’t solve their problem in a double booked, seven and a half minute slot.”

Compared to ten or fifteen years ago, I am less emotionally affected by my gains or losses in my daily race against the clock. I tend to make more automatic, subconscious corrections in my pace, depending on how my day is going. And, more importantly, I seldom get frustrated about time.

Managing time is a little like driving, more automatic after more years of practice.

I remember how I completely failed to notice two pedestrians trying to cross the street in one of my early driving lessons. I was stopped at a red light on a hill and getting ready to turn left. I was completely focused on my left foot on the clutch, the ball of my right foot on the brake pedal and my heel on the accelerator, hoping the baby blue Volvo wouldn’t stall on me.

Now, even though I don’t drive a standard very often, I can still do those kind of maneuvers without engaging my conscious mind.

In the clinic, even though I am always aware of where I am, time-wise, I almost always carefully control how I express that awareness. My years of experience often help me get to the heart of things quicker than I did in my youth, and my years of relationship building with my patients give me the credibility to sometimes declare priorities when there is more going on than I can reasonably address in one visit.

At the same time, some of the things I have seen over the years have helped me recognize those times when I have to stop everything and do what needs to be done, no matter how long it takes.

Handling time, like so many other things we do in medicine, is a necessary part of our work, but it isn’t the essence of our work. Time can be a distraction, just like our technology can be too visible.

People who don’t treat patients themselves don’t usually understand the nature of our work. Instead, they focus their attention on things they know: Is the doctor running on time, is the documentation complete, are the billing codes correct, or does the doctor have “huddle” with the scheduler and medical assistant every morning?

Focusing too consciously on any one of such housekeeping issues detracts from the real work that we do, at least when we are new in our careers. For a brand new driver, how you drive is at first more important than where you are going, because of all the components that necessarily go into driving a car safely. For a new healthcare provider, the form of our work tends to dictate the function, especially in today’s hyper-regulated corporate environment.

When we deal with patients, we need to keep the external considerations as invisible as possible. We need to inspire the confidence that we are really paying attention and we need to create an atmosphere that is conducive to healing.

When I talked to my wife from the car the other night, I should have dropped my instinctive thoughts of that five minute margin, just like I didn’t give her a blow by blow account of which way I was turning the steering wheel, whether I was using cruise control or not, or whether I had switched on my high beams.

I should have just said, “I’ll see you at nine”.

EMRs, PCMH and OCD are Limiting Access to Care

We have a problem in our clinic.

Between our EMR implementation a few years ago and our PCMH recognition shortly after that, our office visit documentation has become bloated and our cycle time has almost doubled.

There are no brief visits anymore, since every visit entails screening for multiple psychosocial conditions and consideration of various immunization and health maintenance reminders.

Nobody sees over thirty patients a day anymore; we’re lucky to exceed twenty.

That means patients today are actually more likely to go to walk-in clinics or emergency rooms than they were a few decades ago. We’re still okay with PCMH as long as we have a single open access slot at the beginning of every day, and we don’t actually get any credit for squeezing in, or double booking, acutes.

It also means patients with chronic illnesses get seen a little less often than they used to. Sure, we have RN case managers who can stay in touch with them, but the communication between them and the medical providers is hampered by the new busyness of checking our electronic inboxes, which takes seconds longer for each item than the old paper reports used to take, and which is done “in between patients” in our already tight schedules or after hours, staying late at the clinic or logging in from home.

It wasn’t supposed to be this way.

Here is what we hoped and were led to believe would happen:

1) EMRs were supposed to make documentation lightning fast.
2) EMRs were supposed to make data review and retrieval faster than paper systems.
3) PCMH would have us transform into physician driven, super-efficient, yet warm-and-fuzzy places filled with patient friendly personal touches.

Instead, medical practices have evolved into bigger bureaucracies with OCD afflicted doctors who don’t lead practice transformation, but who feel personally responsible to compensate for all the shortcomings of their hastily implemented, immature technology.

OCD may be the most significant and destructive acronym in today’s healthcare environment. And we have all been cultivating it, medical practices and providers alike.

The old school expression of OCD, in Marcus Welby’s era, was extremely high physician productivity and unwavering personal commitment to patients.

The new manifestation of OCD is trying to follow overly ambitious, often conflicting Federal edicts and mind-melding ourselves with our computers to the point of losing touch with our patients’ real needs.

Why else did we end up with a working environment where we allow ourselves to be distracted by health maintenance discussions when somebody comes into see us for what should be a ten minute visit for a simple sore throat, or when they are in pain from an injury?

(A ten minute oil change for your car is not the same as a 100,000 mile service, is it? Why is health care any different?)

Why else do we think that it is appropriate to do depression, alcohol, smoking, domestic and drug abuse screenings on new patients the minute they walk through the door to size us up as their chosen new health care provider?

(How did it become patient centered not to spend the first visit, or even the first few minutes of a new therapeutic relationship, listening to the concerns of a new patient?)

Why else, if not because of our personal and organizational OCD, are we sending our own patients to the walk-in clinic instead of fitting them into our own schedules? Isn’t it because of our obsessive fear that we might document such a quick visit without the required Federal accoutrements and end up scoring poorly on some arbitrary quality scale?

(Do we really think the walk-in clinic will do a better medication reconciliation than we do if we squeeze a 45 year old hypertensive diabetic in for quick look at an ankle sprain?)

Pardon my comparison to veterinary medicine, but in my veterinarian’s cash practice, they manage their health maintenance reminders by simply printing them automatically on the receipt. If I bring a pet in for something simple, they don’t bloat the visit up by talking about things I didn’t come in for; they stay on schedule and I can read the printed reminders at my leisure.

Somehow, in the new vision of primary care, we went from taking care of our patients over a continuum of time to doing everything all at once, as if there were never going to be other visits. That kind of OCD is anathema to real primary care.

And somewhere along the path to more patient-centeredness, we got sidetracked by the paternalistic ambitions of our biggest payer, Medicare, into hammering our customers with Federally imposed public health agendas that have little to do which their personal vision of why they need a doctor.

To quote a new patient who came in to size me up a few years ago:

“I need a doctor when I’m sick.”

Access, in other words.

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