“I Hate Coming Here”

It’s another Monday morning at the substance abuse clinic. It is my turn as the doctor in the black swivel chair in the corner office overlooking a half-vacant strip mall.

Today’s first inductee is a pregnant 22-year old with track marks on her forearms. Her obstetrician and caseworker at the Department of Human Services made her come. It is obvious she is less than thrilled.

“How long have you been doing opiates”, I ask with my fingers hovering over the keyboard. She tells her story, first in monosyllabic monotone, but as we move through the questions and she realizes I am not there to lecture her on anything, she warms up a little.

Because she is pregnant, she didn’t arrive here in withdrawal out of concern for the fetus. Her last use was the night before. I explain how to place the Subutex tablets under the tongue and avoid swallowing, so the medication is fully absorbed through the mucous membranes of her mouth. Then I fill out the prior authorization form for Medicaid. I make sure to put her due date on the form, so she will be approved until she delivers. Then I write the prescription, sign it and spell out my name and my special DEA number for opiate replacement prescriptions.

My next inductee is in a cold sweat. He is the same age as my own son. He snorted some Oxys and Ritalins Friday night. Today he has the shakes and the runs. He has no job, is in trouble with the law, and he has been here before, but was discharged because of repeated failed urine drug screens.

I document his COWS score, the degree of physical withdrawal he is in. He had been doing high doses, so I prescribe him 16 mg of Suboxone daily. I explain that since last time he was here, we have switched from tablets to strips that melt under your tongue the same way. He knows; he knows everything about opiates. Is he here again because of his circumstances, I wonder, more than from a deep desire to quit right now? His counselor’s notes in the computer record have a hint of skepticism in them.

“I hate coming here”, says my third patient for the morning. He is a foreman at a nearby factory, logging week number 178 in the program. He is on 2 mg per day. Going from 3 to 2 mg, he had a terrible time with both physical symptoms and cravings.

“I wish I didn’t have to be on this stuff. I want to be over this. I sit in the waiting room with these people who trade stories about what they have done, and I don’t want to hear it. I have a job, a family, and I hate having to come here for my lousy prescription, but I know I can’t keep my life together without it.”

Fourth up is a woman in her forties I haven’t seen before. She transferred in a week ago when Dr. Feiner sat in this chair. I recognize the woman’s name. She is a physician, who just lost her license a few months ago. She is stable on her dose. I write the prescription and she leaves quietly.

The next patient is a mother of two, who just had surgery for ovarian cancer. She is in obvious pain. We had talked last time about how Suboxone does help with pain, but it is not all that potent. She had told me then that she was more afraid of falling back into addiction than being in pain.

This time, she is tearful. Her cancer has already metastasized, and she speaks of what will happen to her two girls if she can’t be cured. She winces with pain, and I ask her again if she is sure she wants to stay in the program. Her husband already manages the Suboxone strips for her, and he could manage pain medications for her as well. But she knows that the naloxone in her Suboxone strips keeps her from feeling the same high that other opiates give.

“I am so grateful for what this program has done for me, that I don’t want to risk that, even for this”, she says and points to her abdomen. “Whatever time I have left..” She chokes, tears streaming down her cheeks, and blows her nose with tissue from the box on the corner of my desk. “Whatever time I have left, I want to be sober, and I want to be all there for my girls and for my husband. I don’t want to be strung out.”

“I hear you”, I say. But you are in pain, I can see that.” She nods.

“I’m going to increase your dose back up to our maximum. That will make some difference. But you may be helped by something like a fentanyl patch, that stays on for three days at a time…”

“Thanks, but this is fine”, she says as she takes her new prescription and strains to rise from the visitors’ chair by the window.

I rise and open the door for her. Then I close it and sit down quietly in my black swivel chair for a few minutes as I look out over the boarded-up windows of the empty storefronts across the parking lot.

I don’t hate coming here, as some of the patients do. It is sobering to think back on the ones who are forced to come here, the ones who come here when they can’t afford their drugs of choice, the ones who fight valiantly to get their lives back in order and the ones who have lost, or are about to lose, everything.

Let Doctors be Doctors

It’s a strange business we are in.

Doctors are spending less time seeing patients, and the nation declares a doctor shortage, best remedied by having more non-physicians delivering patient care while doctors do more and more non-doctor work.

Usually, in cases of limited resources, we start talking about conservation: Make cars more fuel efficient, reduce waste in manufacturing, etc.

Funny, then, that in health care there seems to be so little discussion about how a limited supply of doctors can best serve the needs of their patients.

One hair-brained novel idea making its way through the blogs and journals right now is to have pharmacists treat high blood pressure. That would have to mean sending them back to school to learn physical exam skills and enough physiology and pathology about heart disease and kidney disease, which are often interrelated with hypertension. Not only would this cause fragmentation of care, but it would probably soon take up enough of our pharmacists’ time that we would end up with a serious shortage of pharmacists.

Within medical offices there are many more staff members who interact with patients about their health issues: case managers, health coaches, accountable care organization nurses, medical assistants and many others are assuming more responsibilities. We call this “working to the top of their license”.

Doctors, on the other hand, are spending more time on data entry than thirty years ago, as servants of the Big Data funnels that the Government and insurance companies put in our offices to better control where “their” money (which we all paid them) ultimately goes.

In primary care we are also spending more time on public health issues, even though this has shown little success and is quite costly. We are treating patients one at a time for lifestyle-related conditions affecting large subgroups of the population: obesity, prediabetes, prehypertension and smoking, to name a few that would be more suitable for non-physician management than hard-core hypertension.

It is high time we have a serious national debate, not yet about how many doctors we need, but what we need our doctors to do. Only then can we talk numbers.

The Illusion of Electronic Prescribing

The other day Bigtown Pharmacy sent an angry fax addressed to me. It was a printout of an electronic prescription I had sent the night before. Scribbled at the bottom were the words: “Unit field can’t say unspecified. Please correct”.

I looked at the printout, which was actually a fax they had received from the prescription clearinghouse that connects doctors and pharmacies. Even though I enter prescriptions in my Electronic Medical Record, that pharmacy receives it from the clearing house via fax.

My prescription was for lancets for a 72-year old diabetic to check her blood sugar once a day. But it didn’t say “lancet”. It said “lancer”. My first thought was that my two-fingered typing had offended the Bigtown pharmacist.

The way electronic prescribing works, at least in my EMR, is by having every medication available in this country already programmed into the prescription module, so there can’t be any misspellings or ambiguities of which drug I want my patient to have. But medical supplies like glucometer strips and lancets are not in the system, so they have to be entered manually, which means my computer program doesn’t know at all what I am prescribing; it’s just a bunch of letters to it. The same thing happens when I prescribe a Canadian medication, not available in this country, for patients who cross the river for their prescriptions; the computer can’t check for allergies or interactions because the drug had to be “manually entered” instead of picked from its list.

As I hastily had entered “lancer” instead of “lancet” in the box for “unit” in my EMR, I assumed at first that the angry pharmacist didn’t tolerate any typos, but as I looked closer at the fax, I realized that there was more to this.

The layout of the form didn’t look anything like the layout of my prescription screen. There was a field titled “unit”, and it said “unspecified”. The misspelled word appeared in a free-text window a little below, so the context seemed obvious, even if the spelling was off.

I called Bigtown. The pharmacist explained that Medicare will not pay for my patient’s strips if any of the boxes, particularly the “unit” box, is not specific enough. This is apparently a new requirement. That sounded similar to the “meaningful use” criteria medical practices have to meet in order to get paid under the new health law. One of those requirements is to reach a certain percentage of prescriptions done via the computer instead of on paper prescriptions or sent via fax.

As I was talking with the pharmacist, I pulled up my patient’s prescription log and there was my misspelled “lancer” just where it belonged in the “unit” box on my screen, even though it was missing on the pharmacy’s fax.

“Lost in translation at the middleman”, I mumbled to myself. I asked the pharmacist:

“It is entered correctly, except the spelling, at my end. What can I do?”

“You can free-text ’Unit: Lancet’ anywhere, and we can accept it.”

“Will do”, I said and typed it into the comment field. Then I moved the cursor up to my own “Unit” field and corrected “lancer” to “lancet”. I couldn’t just leave it blank, because if I did that, my EMR wouldn’t send it electronically; I, too, have to fill out all my boxes, even if the receiver can’t see them. After all, I still have to meet my own “meaningful use” requirements.

An Act to Eliminate Constipation

I never contemplated bananas very much until the other day, after I counseled a patient with diarrhea about the BRAT diet, consisting of bananas, rice, applesauce and toast. The next two patients I saw were in their 80′s, on fluid pills and bothered by constipation. Both patients were eating at least one banana per day for fear of low potassium.

Since that day I have informally polled constipated patients about their breakfast habits. My early results suggest that more constipated patients have cereal with milk and banana for breakfast than their non-constipated peers.

Many processed grains, particularly wheat, can be constipating. Dairy products are also constipating for many people. But bananas, fruits with lots of fiber, are they also constipating?

Reading what scientific literature I was able to find on the subject of bananas and constipation, I found several mentions of a theory that unripe, starchy, bananas are constipating, whereas ripe bananas promote regularity.

The obvious next phase of my inquiry will be to ask my banana eating patients how they prefer their bananas, ripe or more “al dente”. I know that whenever I look at bananas in the store, too many black spots on the skin makes me think they’re about to go bad, and I prefer the less sweet taste of what might be considered unripe bananas.

When I lived in Sweden, I saw a little less constipation than here, so it was a surprise to me when I read that the Swedes eat more bananas than other westerners. I know for a fact that extra ripe bananas are not preferred there. My theory on why the Swedes aren’t plagued by constipation to match their banana consumption is that they are more physically active, even into old age, than Americans. In my mother’s neighborhood, she and many other octogenarians were always out with their rolling walkers, going to the store, the bus stop or just taking a stroll.

I am beginning to formulate a better, more pragmatic approach to geriatric constipation now that I have become aware of the dichotomy of bananas. Of course, I have to also be more diligent in dispelling the myth that everybody on fluid pills has to eat a banana a day.

Another aspect of adult and geriatric constipation I have become more and more aware of is that many people with constipation get worse by eating high fiber foods. Patients with bulky, hard stools can get even bulkier stools from extra fiber. For such patients, high fiber breakfast cereal with milk and unripe banana is the ultimate insult to regularity, and a habit to be discouraged.

An apple a day may keep the doctor away as whole apples relieve constipation.

A banana a day, on the other hand, may bring about more business for the doctor.

How Should Doctors Get Paid? – Part 2

Hourly Wage, Piecework or Quality?

A long time ago, when I worked in Sweden’s Socialized health care system, there were no incentives to see more patients. In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On-call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.

There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: most clinics took phone calls only for an hour or two in the morning. After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.

As my father always said: “There must be a reward for working”. But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.

A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.

So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.

But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.

The scientific community, for example, knows that elderly diabetics with “ideal” blood sugars are more likely to suffer harm or die than those with sugars that are a little higher. Even though the American Diabetes Association has embraced higher blood sugar targets for older diabetics, many healthcare organizations’ quality assurance programs treat all diabetics the same and penalize doctors who individualize treatment goals in accordance with the scientific evidence or common sense.

In almost every area of medicine there are individual nuances that must be considered if we are to best serve each of our patients. It is ironic and very sad that, right now, those who pay us are looking for simple (or simplistic), universally applicable quality targets just as the explosion in our understanding of genetics is promising to usher in the era of “personalized medicine”.

Up until now, the gold standard of scientific research has been to prove which standardized interventions work best for large groups of patients, even if there are subgroups that aren’t helped at all by them.

Who should define the “quality” measures of our work?

The central question for how doctors might be paid for quality in the future hinges on the priorities of whoever holds the purse strings. Insurance companies, if we overlook profit motives that also exist, prioritize population management. They pay for what works for most people, knowing full well that some patients will not get the best care for their individual situations, for example when certain medications are not covered. Politicians also favor the population view of health care.

If patients pay us directly, they expect us to deliver the care that works for them. If the Government or an insurance company pays us, they expect us to deliver care that meets their standards, because they don’t trust the patients – their constituents and customers – to know what is best for them. And their focus is to have us do what helps most of our patients, even if some are not helped and some, or many, aren’t happy with what they are getting.

With all the political talk about “Patient Centeredness” during the current health care reform, may I suggest that patients need to be given more choice about how their health care dollars are spent. With limited choice and no responsibility, patients tend to feel entitled and deprived at the same time. This creates a toxic environment for delivering health care. I have never met a patient who felt in partnership with his or her insurance company – ever. And I don’t expect to.

In order to maintain what partnership is left today between doctors and patients, we need a cost-quality paradigm that is shared by patients and providers. We also need to foster and maintain a sense of stewardship that is elusive if all that is at stake is someone else’s money.

I think there are ways to achieve this.

(More to come…)

Never Assume – Indeed!

A couple of weeks ago I wrote a post titled “Never Assume” about a handful of patients, whose case histories took an unexpected turn.

Well, as it happened, a few more twists and turns unfolded since then:

Peter Bartley, the man with upper abdominal pain and black stool, not just from the Pepto-Bismol he had taken, had his upper endoscopy. It only showed some mild gastritis without bleeding. Fortunately, the surgeon also did a colonoscopy, which showed an actively bleeding polyp almost the size of a clementine in his transverse colon.

Black stool is generally thought to be from the stomach or duodenum, located above the ligament of Treitz. It has been said that it takes the digestive juices 14 hours to change the color of our hemoglobin into black melena. Peter’s intestinal transit time must have been slower than most people’s for this to happen with a bleeding polyp in his colon.

Norma Daigle, who had received another patient’s trazodone and Lexapro, called the other day and told Autumn she wanted some trazodone of her own, because it had made her sleep so well.

Beatrice Nash, whose hip pain seemed to come from a mass in her left pelvis, had her CT scan. It showed a very large probable lipoma, a harmless fatty tumor. She has seen the surgeon, who wrote in his not that she described the pain as sharp and coming directly from the hip, and not at all from somewhere higher up than that. He didn’t think the lipoma had anything to do with the hip pain, and recommended she see an orthopedic surgeon.

As it happened, a few days later she had a follow up visit with her orthopedist for a cortisone shot to her arthritic knee. I eagerly read through his note to see if he thought her pain was from the hip joint or not, but there was no mention at all of her hip pain!

Diane Fehrer, who never seemed to remember to take her thyroid medication, accepted the pharmacy’s offer to put her pills in monthly calendar bubble packs. I am keeping my fingers crossed that she will remember to look at the bubble pack every day, and I keep wondering: If she does take her levothyroxine every day, will my prescribed dose be too high and cause her tremors, palpitations or even atrial fibrillation?

Finally, Matt Wikert, the physical therapist with high blood pressure and chest pains, showed up at the hospital for his stress test as planned. Earlier that morning he had a 45 minute episode of chest pain. His EKG showed some subtle changes from the one I had done, so the stress test was cancelled and he was admitted for observation. He ruled out for myocardial infarction and was discharged with plans for a rescheduled stress test. We still don’t have a date for it.

Every day, just like that day a few weeks ago, I see patients whose stories don’t quite fit the expected pattern. In the words of Sir William Osler:

“Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.”

How Should Doctors Get Paid? – Part 1

It’s a strange business we are in.

I can freeze a couple of warts in less than a minute and send a bill to a patient’s commercial insurance for much more money than for a fifteen minute visit to change their blood pressure medication.

I can see a Medicaid or Medicare patient for five minutes or forty-five, and up until now, because I work for a Federally Qualified Health Center, the payment we actually receive is the same.

I can chat briefly with a patient who comes in for a dressing change done by my nurse, quickly make sure the wound and the dressing look okay and charge for an office visit. But I cannot bill anything for spending a half hour on the phone with a distraught patient who just developed terrible side effects from his new medication and whose X-ray results suggest he needs more testing.

As a primary care physician I get dozens of reports every day, from specialists, emergency rooms, the local Veterans’ clinic and so on, and everybody expects me to go over all these reports with a fine-toothed comb.

A specialist will write “I recommend an angiogram”, and we have to call his office to make sure if that means he ordered it, or that he wants us to order it.

An emergency room doctor orders a CT scan to rule out a blood clot in someone’s lung and gets a verbal reading by the radiologist that there is no clot. But the final CT report, dictated after the emergency room doctor’s shift has ended, suggests a possible small lung cancer. Did anyone at the ER deal with this, or is it up to me to contact the patient and arrange for followup testing? All of this takes time, but we cannot bill for it.

Most people are aware these days that procedures are reimbursed at a higher rate than “cognitive work”, but many patients are shocked to hear that doctors essentially cannot bill for any work that isn’t done face to face with a patient. This fact, not technophobia, is probably the biggest reason why doctors and patients aren’t emailing, for example.

Just lately, there is a new trickle of money flowing into medical offices for the type of between-visit oversight that goes with the new Patient-Centered Medical Home model of care, but it is not enough money to substantially change how doctors’ time is scheduled.

Taking a primary care physician away from direct patient care for just an hour can cost the employer somewhere around $400 in lost revenue. In today’s economic climate, few health care organizations can afford to fully embrace the notion of all the different indirect care activities others think physicians should engage in besides seeing patients one by one for a fee.

Of the three professions, physicians probably have the most confusing payment arrangement: Members of the clergy tend to make a straight salary regardless of how busy they are, lawyers bill for their time whether spent with the client or without, but we only get paid if someone is watching us.

If a tree falls in the forest, does it still make a noise?

If a doctor isn’t face to face with a patient, is he still a doctor? Is he still doctoring?

I say yes, but, then, how should we get paid?

(To be continued…)

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