Wasted Education

I saw a young woman the other day with severe and longstanding hidradenitis suppurativa. She knew very little about her disease. I logged in to UpToDate and printed out “The Basics”, a two page summary for patients, and the 18 page article for medical professionals. I showed her the pictures of what Hurley Stage II and III look like and we agreed she is probably a stage III. She had had one lesion lanced a few years ago and she had tried one topical agent. I suggested chlorhexidine, prescribed doxycycline and ordered a dermatology consultation to see if she is a candidate for more advanced medications and to help her learn more about her disease. I encouraged her to read the article and to ask the dermatologist lots of questions.

She seemed encouraged as we wrapped up our visit.

Back in my office, I clicked on the “Patient Education” icon and printed out the information that comes with every certified EMR. It was two thirds of a page long, in a large font with one and a half line spacing, and it said very little about her disease. I did what I often do – dropped it in the recycling box next to the printer.

Why print it if I was going to throw it away? Because we get Meaningful Use credit ONLY for patient education that is printed from the EMR. But since the handouts are so embarrassingly rudimentary, I click for credit and give my patients the real stuff from my personal UpToDate account.

This is how a lot of things work in today’s healthcare: Meeting some arbitrary requirement and then making sure the patients get what they really need.

A Blackmail Attempt

Ellen Boulder filed a complaint against Dr. Kim and it was my job to handle it.

Her previous physician had retired and she had been reassigned to see Dr. Kim, who was trying very hard to limit his opioid prescribing.

Ms. Boulder had been on moderate doses of hydrocodone for years for osteoarthritis, lumbar disc disease and chronic sciatica after a failed back surgery. She had also been diagnosed with fibromyalgia.

Dr. Kim explained to her, and documented everything impeccably thoroughly in the medical record, that long term opioids have been shown to be less effective and carry greater risk for debility and death than non-opioid pain medications. He also explained that hydrocodone can cause a fibromyalgia-like condition called opioid induced hyperalgesia, which can be more debilitating than the condition the opioids were prescribed for in the first place.

He outlined a slow tapering schedule that he printed out for her and he prescribed a starting dose of gabapentin. A few days later, she had called and reported severe drowsiness, generalized swelling and tingling all over from the gabapentin. She refused to take any more of it, but wouldn’t come in to document her swelling and talk about what to do next because her car was in the shop. Dr. Kim prescribed 10 mg of amitriptyline at bedtime until her next appointment and didn’t hear from her until one week before her hydrocodone, at the lower dose, would have been due for a refill.

When she called and left a message that she needed a refill, Dr. Kim sent the message back to his medical assistant with the reply “not due until next week”.

That’s when the barrage of noisy phone calls started, back to the medical assistant, to the on-call doctor that evening, to our nursing supervisor and care coordinator the next morning and to our Chief Operating Officer just after lunch.

By 4:30 it was my turn. My COO sent me an urgent message to review the situation and deal with the patient’s concern. Ms. Boulder wanted to fire Dr. Kim and get a different provider.

On the phone with me, she spoke softly. She described how she had struggled to remain functional with her chronic pain and never mismanaged her hydrocodone. Then she proceeded to tell me that her brother had been taken off his pain medications a few years before and had turned to heroin. Maybe she had no other choice herself if she couldn’t stay on the hydrocodone. And Dr. Kim had given her no warning that she was supposed to come off it this quickly.

I told her I had read the detailed instructions Dr. Kim had printed out for her about how to reduce her hydrocodone.

“But I had to take more than he wanted me to because of my pain being out of control, I went from a “5” to a “10” with just two pills less per day.”

I answered: “Well, you’ve been through our pain program, you know that our pain experience is influenced by our frame of mind, you’ve been upset about the taper and may have expected to hurt more….”

“My pain is real”, she interrupted. “And if I can’t have my hydros, I may have to turn to heroin, just like my brother. He got into trouble when he was on heroin, lost his job and his family. Then he went to rehab and was clean for a year but his pain was unbearable. Then they prescribed amitriptyline for him, just like Dr. Kim did for me, but I won’t take it, because – you know what happened? He killed himself with it, it’s more dangerous than a few measly hydros every day ever was. I refuse to take that kind of medicine.”

I answered: “I know Dr. Kim is more than willing to work with you at finding other ways to manage your pain.”

“But you’re the Medical Director, you can tell him not to cut me down.”

“No, I can’t, and you know that this is something every doctor is doing now as we see what the long term risks and consequences of opioids are.”

“But Dr. Kim doesn’t listen to me. You do, would you see me instead? I’m afraid of the kinds of medicines he wanted to give me, and I don’t want to end up on heroin, like Johnny.”

“All the doctors here have agreed not to go against a colleague’s tapering of opioids, because that is the road all doctors are on now, there are only some small differences in how fast we are going.”

“So are you saying I have to become a heroin addict?”

“No, I’m saying…”

“None of you doctors is taking responsibility for my pain, and it is your job to do that”, she interrupted.

“Actually, our first responsibility is to do no harm”, I answered. “Pain relief that is risky or dangerous doesn’t always help, it can hurt and we know that now.”

There was a long pause.

“I’ll just have to find another doctor”, she finally said.

“I’m afraid you’ll hear the same words everywhere you go these days”, I answered. “Times have changed.”

After another pause, she said “thank you for at least calling me back”, and hung up.

The Codes that Disappeared

I take pride in my dermatological diagnostic prowess. The medical establishment seems not to.

Recently I saw three patients in just a few days with concerns about similar skin lesions that were all dermatofibromas. I couldn’t help notice that my EMR Diagnosis search came up blank. I had to pull out my iPhone and google the code. This happens often enough that I don’t have time to think much about it, but making the same search almost three days in a row, I registered some frustration.

Dermatofibromas are now bundled together with several other dermatological diagnoses that used to be pearls of pride in primary care, such as halo nevus, dysplastic nevus, histiocytoma and neurofibroma.

I grumbled internally because I knew that there was an ICD 10 code for much more specific and esoteric diagnoses, like drowning while diving for pearls.

Here are some examples of these phenomena:

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I understand why: Medical coding doesn’t serve primary care clinicians anymore. Instead, it is the foundation for research into the epidemiology of infectious diseases, cancers and accidents. There’s simply no money and little interest in diagnostic accuracy for non lethal and non litigable medical conditions.

Too Early or Timely Diagnosis

I went to a thought provoking series of talks about dementia the other day.

One of the first PowerPoint slides listed “Early Diagnosis” as being important.

Having watched my father in his final days of end stage Alzheimer’s disease seven years ago, I have no sympathy for screening the general population for this gruesome disease. Why would anybody in their right mind want to know that such is the fate that awaits them?

If you have no symptoms, and if you are enjoying your family, career, community and intellect, could you still appreciate whatever time you have left on this planet if someone told you that you are doomed to die emaciated, nonverbal, incontinent, immobile and contracted?

Screening for incurable and essentially untreatable conditions is only cruel and meaningless, I challenged the speaker.

She clarified her viewpoint by saying that she didn’t mean to make the diagnosis as early as possible, but rather in a timely way so that patients and families can start making decisions.

Thinking back to my own practice, I know that I have perhaps not always called a spade a spade by spelling out the diagnosis of dementia and putting it on the problem list until late in the course of the disease. I can see that it is my obligation to do that when symptoms are only beginning to threaten a person’s judgment and abilities. Making sure Advance Directives are in place is important, and a couple with one spouse showing signs of mild dementia probably shouldn’t buy a two story home far away from public transportation. The speaker also advised estate planning and considering options to pay or qualify for aid for long term care.

Another topic was driving, a situation where I certainly have been the non-family bearer of bad news many times (see my post “A Very Careful Driver”).

So, I did mellow in my resistance to labeling patients with dementia before they become debilitated.

In the same vein, what keeps me from putting other emotionally loaded labels on the problem list, such as:

F10.20 – Alcohol dependence, uncomplicated
Z72.53 – High risk bisexual behavior
F52.22 – Disorder of sexual arousal, female
N52.9 – Erectile dysfunction

One thing is the patient’s overall perception of privacy when the (mandatory) visit summary contains a loaded diagnosis. Specifically, in a very small community, there is the possible concern that staff members without direct clinical involvement (front desk staff) may see such diagnoses. And, perhaps most importantly, with health care law changes in our country’s future, concerns about future uninsurability.

Because making a diagnosis isn’t just a matter between me and my patient anymore.

How to Write Like a Dockter

Many physicians have become world famous writers and in Greek mythology, Apollo was the god of both poetry and medicine.

I can personally think of many prominent physician writers I have come across in my reading over the years:

There was the 12th century rabbi Maimonides, Copernicus in the 15th century and the poet John Keats in the 1700’s.

In the late 1800’s to early 1900’s there were Anton Chekhov, Sir Arthur Conan Doyle and William Somerset Maugham.

Examples from our time (or at least mine) are A J Cronin (Dr Finlay) Robin Cook (Coma), Viktor Frankl (Man’s search for meaning), Michael Chrichton (Jurassic Park), the Polish science fiction writer Stanislav Lem, M Scott Peck (The Road less traveled), Oliver Sacks, Frank Slaughter, Sherwin Nuland, Walker Percy and more recently, Mainer Tess Gerritsen.

But you wouldn’t think doctoring and literature are even remotely connected after reading what my colleagues and I are producing every day in our electronic medical records.

In journalism school and writing classes they tell you how to capture the reader’s attention and make your point effectively. They teach how to make the readers feel like they are witnessing real events and experiencing the emotions of the characters of the writing.

In medical charting class, and when using EMRs, the priority is to prominently list the items that are required for payment and compliance purposes.

Evaluation and Management (E&M) reimbursement codes are built around how many aspects of a symptom or a physical exam are documented. Sometimes called “bullets”, each one is usually a separate sentence in the “printout” display of a medical record whereas to the documenting physician they may be a click box. Looking at the computer screen, they are sometimes quick to review, much like the paper forms I used to create for upper respiratory infections, urinary tract infections and physicals etcetera in the days of paper records. But when our computer programs turn these checkboxes into sentences, they look more like “See Spot run” grade-school English than an expert clinician’s narrative.

Here are two screen shots from a clinic a couple of towns north of here:

Writer’s view:

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Reader’s view:

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Anybody who tries to quickly read such notes would probably just as soon see the original clickboxes, instead of the stilted English produced by the EMR.

Back to the real writers among us – here is how Abraham Verghese explains the deep connection between doctoring and writing:

“I’m really struck by how much of what I learned in medical school has helped me to be a writer, and how much of what I learn as a writer helps my thinking as a physician. They are very parallel disciplines. When you take a patient’s clinical history, what is that but a story? What makes a good doctor is that he or she takes the story down well, sees the links and makes the connections toward a diagnosis. That’s also what writing is about.”

I guess that’s why, after a long day with my patients and my highly structured EMR, I like to sit down in my den next to the horse stalls with a completely blank screen in front of me and just tell stories.

Give Specialist Doctors a Break!

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As I scrolled toward the end of a consultation report from Cityside Pain Management the other day, I gasped internally. The pain clinic listed all kinds of mandated “quality” items, by number, that they have no chance of knowing.

Nor should they.

Since our EMRs don’t talk to each other, they have no way of knowing whether I ever ordered a bone density or pneumonia shot for my patient. And if they went ahead and did something preventative, how would I find out about it? Don’t assume I have a realistic opportunity to look for the occasional pearl in the massive number of outside computer printouts I get as PDFs in my electronic inbox.

No specialist should be jealous of my task of trying to stay on top of all my patients’ health maintenance. I send my patients to a specialist so they can spend 45-60 minutes on the single problem that is the main focus of their practice. Why would I want them to spend a significant portion of their valuable time on something that very plainly is my job?

The answer to my rhetorical question is:

Because CMS, the powerful agency behind Medicare, says so – that’s why. It makes no sense to me, but I’m just a country doctor, what do I know?

A Boomerang Patient

It is not unusual to see a patient for a timely “Transition Of Care” visit after a hospital admission and within a minute of entering the exam room know with all the bones in your body that this person needs to go back into the hospital.

The funny thing is that when that happens, if the patient has Medicare, we may indirectly suffer financially from such “avoidable readmissions”. We belong to an ACO, an Accountable Care Organization, which is one of the recent schemes Medicare created to save money. The hospital most of our patients go to, Cityside, is not part of our ACO, but we are at financial risk while we have absolutely no control over the hospital’s charges or readmission rates.

I mean, what else could I have done with Allan Beck?

He had rolled his tractor and broken half a dozen ribs a little while ago. Commendably, he didn’t want to go to the emergency room for nothing, so he had called and argued with the triage nurse about coming here instead. She thought she had him convinced, but half an hour later he showed up at the check-in window.

“Triage to the front desk” was announced and Dr. Kim ended up seeing him briefly and ordering ambulance transport to Cityside.

When I walked into the exam room a week and a half later, the muscular could-have-been-a-movie-star farmer was so pale and frail looking that he seemed to blend in with the faintly blue wall paint.

As the story unfolded between his laconic answers to my questions and my speed reading of the hospital discharge papers, it became evident that the day before discharge, he had substantial atelectases and possibly an evolving infiltrate of his left lung, but that his collapsed lung remained expanded with his chest tube gone.

“Yeah, I’ve been coughing up yellow crud since my first day in the hospital”, he told me.

He had almost no breath sounds in his left lung, his white blood count was up and his reds were the same as when he was discharged, one third down from his baseline. His X-ray showed what I had heard, a massive consolidation of much of his left lung – a nasty pneumonia or even empyema, pure pus.

The ER doc sighed. “OK, send him up.”

The irony is that there is a new scoring system that’s supposed to predict a person’s risk of readmission. Allan’s score was low. Everybody loves to use mathematical models, but when it comes down to it, clinical judgment and anticipating “the worst” would have been more valuable in the very moment that his last hospital X-ray was done.


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