Archive for the 'Reflections' Category

Remembering the Inpatient Workup: All the Tests to the Patient’s Bedside

The most high powered rotation in my medical school was Endocrinology. There, you got to see things most doctors never come close to diagnosing themselves. Uppsala University’s Akademiska Hospital served as a referral center for the Swedish population north of Uppsala, an area the size and shape of California.

Back in the seventies, laboratory testing wasn’t as sophisticated as it is now, we didn’t have CT scanners even at the major hospitals, and MRIs weren’t in use yet.

The Endocrinology ward accepted referrals from northern Sweden for evaluation of suspected pheochromocytomas, Cushing’s Disease, Wilson’s Disease and other exotic conditions. The Chief, Professor Boström, had established the most appropriate workup, or “utredning” (investigation), for each type of problem, and patients would undergo these tests in rapid succession with almost real-time interpretation. Within two or three days, they would be on their way home with a diagnosis and treatment recommendations for their local doctors or followup appointments with Uppsala specialists.

The other feature of the Endocrinology ward was that every day, the Chief or his deputy would do rounds with the junior doctors and doctors in training who carried out the testing protocols. Each patient’s progress was presented to the Chief, who would suggest modifications or additional interventions. That way, each patient had the benefit of having the Professor of Medicine oversee their care. This is the way hospital rounds are done everywhere in Sweden; the head of the clinic directly supervises every patient’s care.

Two differences in how health care is delivered in American hospitals stand out:

First, Patients seldom get admitted for testing here. People end up having serial imaging tests as outpatients. Someone with vague upper abdominal pain may go for an ultrasound that shows a normal gall bladder and borderline dilatation of the common bile duct and slightly irregular texture of the liver, followed a week or two later by a CT which shows only a harmless fatty liver but confirms bile duct dilatation. Next, they might have an MRI that suggests a blockage of the bile flow somewhere in the head of the pancreas where there appears to be a tumor. By that time the patient is feeling worse and is suddenly jaundiced and finally gets admitted for an ERCP that provides a tissue diagnosis of pancreatic cancer.

Second, the quality of care you receive depends on the hospitalist(s) in charge of your care. They work as a team, but many of them are young or temporary hires who practice without the day to day involvement of hospital clinical leadership. I see patients admitted for the same thing to the same hospital being handled completely differently because somebody else was on duty when they came in.

In Sweden, it seems that even today, bed-nights are relatively inexpensive, and patients are sometimes kept simply for “observation”. Here, bed-nights seem to be a rare and exclusive commodity that cannot be wasted. So we make the patient with chest pain that went away come back on Monday for his stress test if it happens to be Friday. And we get paid the same whether we discharge someone early or end up keeping them a little longer because of the bundled payments of DRGs.

And, oh, here we have to justify “medical necessity” for every admission. So we make an older woman take her laxatives at home and have her grandson drive her 50 or 100 miles to the hospital in the predawn hours for her early morning diagnostic colonoscopy.

In the Socialized system in Sweden, there always was the freedom to admit someone because it was the right thing to do, even if you had to use the diagnosis “Causa Socialis” (social reasons).

I hear there’s even now a diagnosis code for that (ICD-10): Z60.9. I remember using it during my early years in practice there.

Sometimes you need to do what’s right for the patient. Actually, we should always do what’s right for the patient.

EMRs Should Be Like Rental Cars

When a new doctor joined our clinic, she spent a week learning our electronic medical record. She had used two other systems before, so she was no stranger to EMRs, but that’s how different they can be.

That’s crazy.

EMRs should be like cars, which range from the likes of Smart to Mercedes Maybach from Daimler, Mini to Rolls Royce from BMW or Skoda to Porsche from the Volkswagen group of companies. They range from simple to sophisticated, from nimble city cars to opulent highway cruisers.

There are occasional differences like type of fuel, battery, ethanol or gasoline powered, steering wheel shift paddles or voice controlled entertainment systems, and the driving experience varies wildly between marques but you could probably pick up just about any car as a rental vehicle, learn the basics and safely be on the road within just a few minutes.

For example, one country doctor, who shall remain unnamed, worked for over a year with an EMR which he explained to his patients wouldn’t tell him if any new reports had come in since they were in last. One day, by accident, he discovered a tab on the right hand panel of the computer screen, labeled DRTLA, that does just that – Diagnostic imaging, Referrals, Telephone calls, Labs and Actions, plus other incoming documents, neatly arranged. Somehow the implementation process skipped over that feature. That is just one of many functionalities of my particular EMR a new user wouldn’t be able to figure out very easily on their own.

A rental car would be considered dangerous if the shifter didn’t look somewhat like shifters in other cars, or if the windshield washer fluid and coolant caps weren’t easily distinguishable.

Similarly, a car would be considered unsafe and illegal if the windshield was only a few inches wide, and if drivers had to press a button or two in order to see the whole road in front of them. But that is how each lab report, like a Complete Blood Count, shows up on that same EMR.

And, now I know this, of course, but why is the “send” button on my prescription module marked “fax”, with a drop down menu choice of electronic prescription, which is the way we have to send prescriptions to comply with Meaningful Use? To confuse clinicians? I can think of no other reason.

A child, or a middle aged physician, can pick up an iPhone and quickly work the basic features by intuition, and wouldn’t be completely lost if suddenly handed an Android phone instead.

And, truth be known, my iPhone does some things better and faster than my million dollar EMR. And some inexpensive cars are more reliable than high prized exotics.

Doctors Should Be Paid Like Athletes

Think about it, athletes aren’t the ones who document their performance. It’s other people that keep the score. That’s a whole science in itself. People talk for hours after the game or tournament is over about how each athlete did this or that in whatever way they did it and the numbers are in many cases captured by extremely sophisticated electronic equipment.

Physicians work hard to diagnose and treat their patients, and on top of that, we have to do all the work of documenting what we did and how we did it. It isn’t enough that we make a correct diagnosis or provide an incredibly effective treatment. We have to code and document so that accountants, lawyers and the general public can understand what we did.

Our medical charts are now instruments for billing and, sadly, less and less of a tool for us. I suppose it is a bit like if a baseball coach in America had to speak to his/her team so that any Swedes or Martians accidentally present could also understand what was going on. (Baseball is not big in Sweden, or on Mars.)

Now, you might think doctors aren’t worth the millions we pay our professional athletes. I’m not going to argue with you on that one, but I will point out that the medical spending controlled by your average family doctor, through direct care, tests and consultations ordered, emergency room visits and hospitalizations – per capita spending multiplied by the number of patients cared for – is in the ten million dollar ballpark, to borrow a term from America’s favorite sport.

My point is, why do we have to input the data with our own, in my case, two typing fingers, when professional sports doesn’t make athletes keep their own score? The technology is there in other arenas (sorry, the sports terminology keeps popping up), so why not in ours?

The Illusion of “Other People’s Money”

The problem with healthcare, and drug prices, in America isn’t that we spend too much money. The real problem is that we believe we are spending “other people’s money”.

Yes, I was raised in Sweden, but no, I’m not a Socialist. But the irony is that “free” healthcare there is more clearly understood to be directly financed by local(!) taxes that can go up if people in that region consume more healthcare. Here, nobody really knows what anything healthcare related actually costs, or who pays how much, so how can we really care about the cost of healthcare?

Here, most health insurance is financed by employers, and I don’t believe the average American worker is lying awake at night worrying that his family’s medical bills will eat into the corporate profits of his employer. And even if American workers bear some of the costs of their health insurance, the relationship between how much healthcare they consume and how much their portion of the insurance premium will go up is less than obvious, depending on who else is insured in the same risk pool as each particular worker’s employer sponsored insurance.

The Swedes have, in spite of their minimal churchgoing, a set of ethics that relates their personal choices to the impact they have on society as a whole. They recycle batteries instead of throwing them away, they worry about air pollution – so much that it is illegal to idle your car for more than 60 seconds, for example when the bridge over the canal in my home town opens to let a tall ship through. My former countrymen also care deeply about how waste in the healthcare system can affect the availability of healthcare for vulnerable people.

Another thing they are more sensitive about than we are over here is corporate greed. The examples on this side of the Atlantic are so many, and occur so frequently that we soon forget each individual case. What we do retain is the regrettable sense that healthcare is a dirty business where someone is always taking advantage of someone; providers cheat Medicare, insurers cheat patients, drug companies cheat them all.

What we need in this country is a moral wake up call, whether that comes as a crisis or a disruptive innovation. It is obvious that Government regulation and oversight has done relatively little to reduce the “Wild West” behavior and mentality of the big players in our “industry”.

The first thing we need to do is scrap the concept of health insurance, because insurance is when something expensive but unusual and infrequent is paid from a pool of money that a lot more people pay into than withdraw from. In America today, everybody draws from that pool of money, even for things that are completely predictable, like having a baby or even an annual physical (except if you have Medicare, and then you get a Wellness Visit, but that’s another story). That means every single transaction of healthcare in this country becomes a profit center for one or more types of middleman, who most of the time adds little value but draws handsome revenue from what they do.

If we are trying to cover everybody for everything, let’s call it what it is, Socialized medicine. But are we ready, today, for a society where we all stop and consider the common good before we ask for that MRI, “just to know what’s going on”, or where drug prices are negotiated between a “single payer” like CMS or each State Health Department and the drug companies?
I believe the citizens of my adopted homeland prefer to have more freedom of choice than a Socialist system usually offers, and I believe that by having both the ability to choose and the responsibility to pay for services, we can make the healthcare value equation come out more even.

And, I’m sorry, but if we reign in the excesses of insurers and drug companies, American patients may act more responsibly, but as long as the gauging, fraud and abuse continue to be rampant in the industry, there will be no loyalty between patients and “the system”.

Then, our only hope will be a post-apocalyptic Direct Primary Caree model, which is just as American as the corporate model. Come to think of it, maybe even more so…

Don’t Ask Me to Work for the Other Side

As a physician with a strong sense of calling, I always see myself working for each patient, regardless of who pays the bill. Following in the footsteps of role models like Hippocrates and Osler, how could I do anything else?

Ted Ross has been my patient for decades. He can’t seem to lose weight.

John Jackson has admitted he doesn’t know how long he can keep doing the kind of work that has supported his family until now.

Ted is a long distance truck driver. He needs a DOT physical. Because of the new requirements, he will probably need a sleep study to rule out sleep apnea. If he fails, he could lose his job, because we all want to feel safe on our highways.

John came in with back pain the other day. As I filled out the Workers Comp M-1 form, he sighed “this may be it for me”.

John told me his back started hurting when he lifted a washing machine at work. As long as his employer’s Workers Comp carrier doesn’t challenge the claim, he’s covered for medical costs, rehabilitation and disability income, possibly even for life. If it had happened at home, on his own time, he would not be entitled to anywhere near the same benefits.

Medicine is a very personal business. A trusted provider hears more than a stranger and his or her words have more impact. Our patients assume we are there to help them. But sometimes we are put in a position of working for someone else, against our own patients.

In Ted’s case, I won’t be the one to tell him that his job is on the line because of his obesity. When the new requirements and certifications for performing physicals for the Department of Transportation went into effect, I simply didn’t pursue them.

In John’s case, as the treating physician, I have to file regular reports with his employer’s insurance company, and every test or referral I want to make has to be approved by them. If I keep him out of work longer than they expect or prescribe more pain medication than the average situation requires, I get a call from an insurance company nurse whose job it is to bring my treatment in line with their expectations.

It is impossible to overlook the fact that his employers Comp carrier is trying to direct John’s care; they are the ones who pay me for each one of his visits.

If other life circumstances come into being while I am treating him for his back injury, I have to be very careful not to spend too much time talking about them, and I certainly can’t put any of it in his record, since every Comp visit goes to the insurance company for review. I have to constantly remind patients that a Comp visit is a legal document, to be used in what amounts to a case of litigation.

If I could help it, I wouldn’t treat Workers Compensation cases for the same reason I don’t do DOT physicals: I never want to represent an authority or institution that can be seen as the opponent of patients I need to have a therapeutic relationship with.

If John’s Comp carrier were to claim that since he went to the Cityside Hospital emergency room with low back pain after a minor car accident ten years ago, he had a preexisting back problem, his medical expenses could bankrupt him. He has a high deductible health insurance. If he can’t go back to work, he will have 26 weeks of reduced-pay short term disability benefits. After that, he’d have to apply for Social Security Disability, which could take several years.

If Ted loses his DOT certificate, how can I be effective as his personal physician with my signature on the document that cost him his career? And if he were to commit suicide, as some middle aged men who lose their jobs do, could I counsel and care for his wife and daughter?

I often think about my native Sweden in cases like these. I saw many things that frustrated me when I worked there after graduating from medical school, but they didn’t have one level of health and disability benefits for injured workers and little or no help for people who got hurt on their own time. That is a pretty arbitrary and inhumane way of stratifying health care.

If you’re hurt, you’re hurt, regardless of whose fault it is. (I’ll tell you about Sweden’s no-fault medical malpractice payments some other time.) And if you seek help from a doctor, you expect the doctor to be working with your best interest in mind. And if the society you live in doesn’t take good care of people who are sick or injured, you may have trouble accepting that your doctor is putting the good of “society” or “the system” before your most urgent needs to put food on your family’s table.

Primary Care Has a Dirty Little Secret

We are like restaurants that charge handsomely for sit down dinners but give away food for free at the takeout window. And we pay our providers only for serving the dining room guests. If traffic gets backed up at the drive-through, we hold our providers responsible, even though we never planned for our ever increasing demand for takeout.

In simpler times, patients went to the doctor when they felt unwell, and doctors didn’t claim responsibility for what patients did on their own time between visits.

Now, doctors are working just as hard taking care of patients in the office, but they are also expected to, on their own time, handle all sorts of ongoing hand-holding between visits. This happens through phone calls, electronic messaging and reading and commenting on endless streams of reports from case managers, specialists, hospitals, emergency rooms, walk-in clinics, pharmacy benefit managers, insurance companies and medical supply companies.

There is talk about how all this extra work will some day generate income streams from cost savings and improved outcomes, but today, the very foundation of how doctors get paid is how many patients they see in the office on a daily basis. Few health care organizations have the cash on hand to schedule provider time for what isn’t going to bring money in during the present budget year.

The dirty little secret we all deal with in primary care is that we make our doctors, PA’s and NP’s see as many patients as they possibly can, with ever increasing demands on the complexity of care they deliver, and on the comprehensiveness of their documentation and quality reporting, and then we quietly assume they will be able to do all this extra, unscheduled and uncompensated work without falling behind, making medical mistakes or simply burning out.

Imagine a CEO who spent all day in meetings and never had any time to himself or herself available to think, plan or write.

Imagine an average office worker, who is said to spend 25% of their time on business related email, suddenly being told that all company emails from now on have to be done outside working hours.

Imagine a judge, presiding over case after case at the bench from 8 am to 5 pm, without any scheduled time to read briefs or write judgements.

Imagine a TV anchor, broadcasting 8 hours a day, never taking any time to study the issues of the day or to speak with colleagues or newsmakers.

Imagine an orchestra, constantly performing, never practicing, never studying the sheet music.

And we are now offering resilience training to our medical providers to help them not burn out…

Today’s Medicine has no Credibility

This week’s issue of The New England Journal of Medicine once again questions two practices that used to be almost the backbone of primary care.

One article is about the low likelihood that prostate cancer detected through PSA screening will shorten a man’s life, even if he chooses just to keep an eye on it.

The other article is about how repeated mammography screening mostly leads to the diagnosis of small and not very aggressive tumors, just like PSA screening.

These two common health screening issues, along with the disappearance of all scientific rationale for cholesterol targets, baseline EKGs, digital rectal exams, testicle exams and “routine” lab work, not to mention routine physical exams, have essentially forced primary care doctors to rethink how they spend their days.

CMS has plenty of other things for us to do, although they still want us to do some of the things the evidence has debunked, and much of their vision for doctors falls within the Public Health domain.

As a result of these changes, physicians today face a serious credibility problem. The more dogmatic we have been before about following the guidelines that are now relegated to the history books, the more ridiculous we look to our patients as we more or less enthusiastically make our required 180 degree course corrections.

Thank goodness I always spoke of the guidelines as just that, current expert opinion, not something carved on stone tablets, handed down to us from Mount Sinai. As my father used to say, “view everything a little von Oben”. That’s the German expression for “from above”. The full phrase is von Oben heraus”, which rings of superiority and can even mean snooty.

As a physician, I am not putting myself above the expert opinion of the day, but I see myself as a humble servant and disciple, not of the current guidelines but of the principles of my forbears, from Hippocrates to Osler. If I take them seriously, and always speak of today’s guidelines as something likely to be temporary, I don’t seem to have to feel embarrassed when the guidelines change, which they inevitably do.

I think this attitude requires knowing your caft and its science well enough to be able to tell why the guideline looks the way it looks. Without the proper depth of knowledge you can’t be “above it all”.

Seriously, whether we are making guideline related u-turns without explaining why suddenly our practice is changing, or reciting all the possible side effects of a medication we are about to prescribe, we are making ourselves look bad compared to other practitioners, whose research isn’t double blinded and who aren’t mandated to badmouth their own treatments the way we are.

With guidelines coming and going, promising new drugs suddenly disappearing from the market, and with so many of our favorite prescriptions barely more effective than placebos, we need to go back to the source for the physicians of yesterday and those of the future:

Know your science, view today’s guidelines from a historical perspective and don’t be completely immersed in today. Because the present is just the razor sharp boundary between the past and the future.


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