Archive for the 'Reflections' Category

Caught Between two Paradigms

In the very near future, clinics like ours will be paid according to how well our patients do medically, or at least according to how consistently we provide certain medical tests and interventions.

This includes frequency of diabetic blood tests, foot exams, eye exams, prescriptions for heart and kidney protective medications, achievement of pre-set targets for blood pressure, body mass index and immunization rates, and other measurable “quality indicators”.

But paychecks for medical providers as well as short term financial viability of clinics like my Federally Qualified Health Center depends, besides Federal grants for being open in the first place, almost entirely on the fixed revenue we receive from every face to face encounter we have with patients.

If I spend an extra ten minutes with a diabetic to help him quit smoking and avoid a heart attack ten years from now, I don’t bring in any more money than if I send him out the door with a pat on the back and “see you next time”. But if I cut his visit short and see his grandson for a sore throat, I generate as much income for us as I would have done for a lengthy visit with his newly diagnosed diabetic wife. Any face to face encounter generates the same revenue, no matter how short.

My productivity target clashes with my quality targets. I am constantly balancing between them. And so are physicians everywhere, even if non-FQHCs get paid per Relative Value Unit (RVU), which rewards them to a degree when patient visits are longer and more complex.

In the old paradigm, a physician is only working when he or she is face to face with a patient. The new paradigm claims the importance of reading and being aware of incoming reports from hospitals and specialists, conferences with nurses and care managers, review of population health data and planning future interventions.

But right now, those are money losing activities. How many organizations have the courage, and the deep pockets, to do right now what will hopefully be paid for some time in the coming years?

So, in reality, doctors skim over their incoming reports or sign them off unread. Nurses and care managers read them and enter diagnostic details and new medications prescribed by hospitalists and consultants in each patient’s EMR, but the busy providers don’t have enough time to talk in depth with the care managers whose chart entries take as long to read as the outside reports would have taken in the first place.

We struggle to find the time to talk to our patients, and rely on others to communicate with them. When we work that way, information can get lost or distorted, so we risk making tangential or inappropriate clinical decisions. A patient calls back reporting to the medical assistant or receptionist that they are not better from their antibiotic and the physician prescribes another one, when the real message may have been that they are only 75% better and most likely will be fine in another day or two. So resources are wasted, unnecessary treatments are prescribed, and opportunity for patient education is lost. All because we are too busy to gather the clinical information that we have the training and experience to collect.

It is obvious that this incongruence between paradigms is a setup for physician burnout, but on a bigger scale it also makes me wonder about organizations. Can they experience burnout too?

I read somewhere about the causes of burnout:

“Maslach, Schaufeli and Leiter identified six risk factors for burnout: mismatch in workload, mismatch in control, lack of appropriate awards, loss of a sense of positive connection with others in the workplace, perceived lack of fairness, and conflict between values.”

All of today’s healthcare seems to fit this description. We must go forward, or even back, but we can’t stay too long where we are right now.

The Dunning-Kruger Effect

“The fool doth think he is wise, but the wise man knows himself to be a fool.”
– Willam Shakespeare

I learned about the Dunning-Kruger effect at a medical conference recently. It certainly seems to apply in medicine. So often, a novice thinks he or she has mastered a new skill or achieved full understanding of something complicated, but as time goes on, we all begin to see how little we actually know. Over time, we may regain some or most of our initial confidence, but never all of it. Experience brings at least a measure of humility.

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Just the other day I finished a manuscript for an article in a Swedish medical journal with the statement that, 38 years after my medical school graduation, I’m starting to “get warm in my clothes”, as we say in Swedish.

I think the Dunning-Kruger effect applies not only to people who are in the beginning of a career in medicine, but also to people who learn about it for purposes of judging its quality or efficiency or of regulating or managing it from a governmental or administrative point of view.

I think many people outside medicine think “how hard can it be” and then proceed to imagine ways to change how trained medical professionals do their work.

But the Dunning-Kruger effect is also a particular problem in rural primary care. Newly trained physicians, PA’s and Nurse Practitioners are asked to work in relative professional isolation with full responsibility for sizeable patient populations. Unlike the hospital environment, primary care practices seldom have time earmarked for teaching and supervision, and there is little feedback given to such new providers. There is also very seldom collaboration and communication about specific patients or cases. We probably get more feedback from our specialist consultants than we do from the providers in our own clinics, because we are all busy with our own patients.

So, how does a new clinician avoid the newbie hubris Dunning and Kruger describe? Seek out potential mentors and ask them to be yours, start a case conference at your clinic, read the leading journals, NEJM, JAMA, BMJ, The Lancet and ones like them, and read about the history of medicine and the old masters.

And consider honestly how often a brand new driver should expect to instantly do better than the person who taught them, parent or driving instructor.

A medical license is in no way proof of mastery of the art of medicine, it is only a license to begin practicing, in a very literal sense.

Alarm Fatigue

I missed a drug interaction warning the other day when I prescribed a sulfa antibiotic to Barton, a COPD patient who is also taking dofetilide, an uncommon antiarrhythmic.

The pharmacy called me to question the prescription, and I quickly changed it to a cephalosporin.

The big red warning had popped up on my computer screen, but I x-ed it away with my right thumb on the trackball without reading the warning. Quite honestly, I am so used to getting irrelevant warnings that it has become a reflex to bring the cursor to the spot where I can make the warning go away after a quick glance at it. Even though I have chosen the setting “Pop up drug interaction window only when the interaction is severe”, I get the pop up with almost every prescription.

Today I went back to Barton’s chart and looked at his interaction screen.

With the Bactrim DS no longer there, the first of the red boxes was a major interaction between his 81 mg aspirin and his Pradaxa (dabigatran) – two blood thinners are more likely to make you bleed than one. That is basic knowledge, even common sense.

The next red box was a moderate interaction between his baby aspirin and his lisinopril. Theoretically, higher doses of NSAIDs can interfere with the blood pressure lowering properties of ACE inhibitors. That is very basic knowledge, too.

The third red box, another moderate interaction, was between the aspirin and his steroid-bronchodilator inhaler. Theoretically, steroids and aspirin can increase the risk for stomach irritation and supposedly, the pharmacologic effect of aspirin may be decreased by the inhaler.

After these came several warnings labeled “extreme caution” and some that were “not recommended”. The scrolling seemed endless, so I printed out the warnings instead. They filled eight pages. I counted 61 “extreme caution” warnings, from metoprolol and diabetes to the poor man’s steroid-antifungal cream and his diabetes. Beta blockers can, at least theoretically, decrease the tremors and other warning symptoms of low blood sugar, and oral steroids can raise blood sugars, but a mild steroid cream doesn’t do that.

There were 32 “use cautiously”, many of them quite tangential, like the blessed fungus cream and Barton’s history of hepatitis C.

On the last two pages were the dietary warnings, including not to swallow your atorvastatin with grapefruit juice, or to mix your pain pills with alcohol.

I hate to sound uppity, but no amount of pop-up interaction alerts or other forms of “decision support” can replace basic medical education. In Barton’s case, the only warning I needed was the one about his dofetilide, which he gets from his cardiologist, and the antibiotic I wanted to prescribe. The aspirin-Pradaxa interaction is common sense, and the baby aspirin-Symbicort interaction is nonsense. And if I were to even read through the eight pages worth of precautions and “use with caution”, I would have doubled the 15 minutes it took to assess and document his infection in the first place. Or I could have listened to a tutorial about evaluating lung sounds – how much coaching do the EMR designers think we need?

So, here is my suggestion: Make these warnings behave like some computerized card games – let users decide based on their skill level whether to get all the warnings or only the critical ones that are not generic class effects we all learned in pharmacology class. Because when everything is a red alert, alarm fatigue sets in and all the warnings are wasted.

It reminds me of the story about the boy who cried wolf…

Quality Medicine: Showing the Math

Medicine is a lot like grade school mathematics. The days are long gone when instantly knowing or quickly arriving at the right answer was enough. Now it’s all about showing your calculations. Process is everything. It’s almost like having the right answer doesn’t matter anymore.

If you ask a patient with a given symptom, like tremor, lameness or a skin eruption, only a few questions and then conclude that they have a rare disease you happen to have seen before during your years of training and experience or read about in your diligent study of the leading medical journals, you get paid next to nothing. If, on the other hand, you ask a hundred questions and examine them from head to toe and then decide to refer them on to someone who knows more than you do, you can charge a bigger fee, at least a 99214 instead of a 99213.

We get reimbursed for complexity that is sometimes a result of incompetence. That is one definition of value in health care delivery.

These days, quality in healthcare is also measured in “outcomes”; how many people comply with our recommendations by eating better, quitting smoking or exercising more. Or at least whether we documented that we told them to.

Of course, you could talk about more things in greater depth in your precious fifteen minutes together if you didn’t also have to document everything you touched on in a Byzantine electronic record better suited for billing than patient care. But, if you didn’t document it, it didn’t happen.

Diagnostic accuracy doesn’t figure prominently in the quality literature, only sometimes when it comes to missing heart attacks and cancer, but in my world, primary care, you can still achieve great quality scores from documenting sometimes meaningless housekeeping tasks like annual microalbumen tests for diabetics, even if you don’t manage to decrease the kidney damage.

Good quality measures are ones that are easy to collect and manipulate statistically. But does a good and tidy measure convey better quality?

We are still stuck in the Deming manufacturing mindset. But people are not machines and diseases are not manufacturing processes.

Do we ask how a teacher managed to inspire a young student to become a great scientist? Do we demand an explanation of how a priest brought a distraught parishioner from the brink of suicidal despair? Do we ask how Da Vinci held his paint brush when he painted Mona Lisa’s smile? Do we value an athlete with “good” technique more than one with good scores?

I think our health care quality debate has a myopic view. We are often ignoring the big picture and the real purpose of caring for the sick. That’s because healthcare is a business now…

EMRs: It’s the Interface, Stupid*

The reason we all struggle with our EMRs is simple: It’s not so much the underpinnings we object to, but the “User Interface”. And the User Interfaces of EMRs are awkward, to say the least.

UI is the look and functionality of the screen.

For example, if I have an imaging report in my inbox and want to do something about the result, say look at the previous scan the patient had six months ago, let the patient know it was okay, add a new diagnosis to the problem list, arrange or check the date of the followup visit, send a copy with a question or comment to a specialist, look back at what the blood work showed, prescribe or stop a medication, or check a reference website like UpToDate what the best treatment is for what the scan shows – how many clicks does it take to do any of those things, and can I still see or at least get back to the report I just received as I do any of those things? Why don’t I have every single option for what to do with the result right there on the same screen as the result itself?

That’s the essence of our frustration.

Even more basic, and I have lamented about this before, can I read the scan, lab report, consultation note or whatever it is, in one view without scrolling, enlarging, clicking or standing on my head?

If you have only fifty reports to go through every day, and each one takes even just over a minute instead of fifteen seconds to go through, like a paper report used to require, it may not sound like a big deal, but that means about 40 minutes more per day, hardly ever built into your clinic schedule, for that task alone.

Documenting a physical exam with abnormal findings in a structured way, not free texting or speaking, can involve innumerable clicks to get to the findings you need.

For example, click on ENT, then EAR, then scroll down to TUNING FORKS, then scroll to WEBER, scroll to LATERALIZED LEFT, go back to RINNE, and scroll down to POSITIVE or NEGATIVE LEFT and try to remember if bone conduction greater than air conduction is positive or negative because that’s not the terminology you use.

What if the physical exam could be documented by pinching your fingers to zoom in on a touch screen with a body and just pointing to the body part in question and having all the options literally at your fingertips?

If video games can do it, why can’t EMRs?

Just look at these two pictures, courtesy of Bangor ER physician Dr. Jonnathan Busko, and imagine…

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https://www.linkedin.com/pulse/dont-let-your-ehr-tail-wag-patient-care-dog-jonnathan-busko

*(It’s) “The Economy, stupid”, is an American idiom from the 1992 Clinton-Bush presidential campaign, a phrase coined by Bill Clinton’s campaign manager James Carville to keep the candidate focused on the most important issue(s).

Imagining a Doctor Shortage

Now, I’m just a country doctor, but I have to say I find it very hard to understand why folks in this country on one hand keep talking about a doctor shortage in primary care and on the other hand keep piling sillywork on those of us who are still here. The net effect is that the doctor shortage is going to be a whole lot worse than it has to be.

But it may just be a relative or imaginary shortage because of how this country defines the duties of doctors.

Public Health agendas have infiltrated health care to a degree that threatens to paralyze it. Physicians are increasingly told their primary concern should be their “population” and not their individual patients. We are charged with preventing disease rather than treat it.

But…

Public Health clinics regularly provide travelers with necessary immunizations. Pharmacists are now giving pneumonia and shingles shots on prescription and flu shots without. States are mandating immunizations for children, and penalizing physician practices with low immunization rates. There are whole departments within every level of Government trying to get people tho behave in healthier ways.

Why should we take the heat for something you don’t need a medical license to do?

A physician’s duty is first and foremost to serve each patient’s needs in treating actual disease. Isn’t that what people worry about when they imagine how a physician shortage would affect them?

Let’s think:

Who would worry that with a physician shortage, they wouldn’t get their flu shot?

Who would worry that there would be nobody to tell them to lose weight, stop smoking and eat less junk food?

Who would worry that there would be nobody to screen them for alcohol misuse or domestic abuse?

Who would worry that they’d be at risk for tripping on their scatter rug because there is no doctor to talk with them about their fall risk?

On the other hand:

You’ve had a cough for a month, and you’re short of breath. Who will diagnose your symptoms?

You have a nosebleed that won’t stop by itself. Who will cauterize it for you?

You have diabetes and can’t control your blood sugar with diet alone. Who will prescribe the right medicine for you?

You’ve become increasingly depressed and are at risk of losing your job because of your symptoms. Your therapist suggests you consider medication. Who will prescribe it for you?

America, the choice is yours: What is the best use of your primary care physicians’ time if there aren’t enough of us to be everything for everyone?

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.


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