Archive for the 'Reflections' Category

Upselling in Medicine: Would You Like a Pap Smear with that Ankle Brace, Ma’am?

For many years, I’ve held a brief huddle with my team every morning to make sure we are ready for the day: Anybody with complex problems coming in today? Anybody who’s been in the ER? How is Mrs. Jones’ husband over at the nursing home, is she worried about his condition? Where can we squeeze in more add-on’s?

Now other people have tried to hijack the word “huddle” for a completely different purpose. They want to use it to slow us down instead of helping get us get through the avalanche of issues we’re already expecting. In my other office they call it pre-visit planning. It’s not about having the MRI result available or the recent ER note, but more about who is behind on some aspect of their health maintenance and (unsuspectingly) expecting just a sore throat visit, but consistently avoiding their diabetes followup visits?

My veterinarian colleagues handle this differently. They just send a post card at random times, or hand me a paper, usually part of my exit statement, as I recall, that says which critter is due for what. But in that case I’m already safely close to the door and nobody is expecting me to act on it in that instant.

In human medicine, our quality ratings, and soon our paycheck, will depend on how effectively we convince patients to get caught up on their proscribed health maintenance.

In the retail world, they call that upselling. When I stop at a 24 hour gas station and buy some coffee for my long trip between my two offices, they always ask if I want some donuts or chips with that, maybe a banana or whatever. Same thing at the hardware store, if I buy a flashlight, they ask if I need spare batteries, and so on.

How fair is that to our patients?

I remember seeing a video about the hijacked kind of huddle, where the doctor and medical assistant almost gleefully talk about how to convince a noncompliant female patient to have her overdue Pap smear when she is only expecting something much less involved.

And all the while we are supposed to be patient centered and respect each patient’s own agenda. Too bad not everyone else has to…

Brilinta or Clopidogrel, Maximum Benefit or Social Responsibility?

Brilinta, at $6.50 per pill, twice a day, reduces cardiovascular events more than generic Plavix, which costs 50 cents per pill, once a day. But only a little – 20% relative or 2% absolute risk reduction. The event risk was 10% with the more expensive drug and 12% with the one that costs 82% less.

Put differently, if 100 patients were treated with Brilinta for a year, at a cost of $4,680 for each patient, 10 patients would still have an event. With clopidogrel, 100 patients, each one at a cost of $180, 12 events would occur. That means two fewer events would happen per 100 patients on Brilinta at an extra cost of $450,000, or $225,000 per avoided cardiovascular emergency (Number Needed to Treat, NNT=50).

This is described in a New York Times article as a profound ethical dilemma in medicine today:

“Some of us believed that a doctor’s job is to deliver the best possible care, period. Others argued that doctors should aim to find some balance between medical benefit, financial cost and social responsibility. It’s the kind of question that we aren’t really trained to solve. Are costs something that an individual doctor should do something about? What is a doctor supposed to do?”

As a Swedish born and trained physician, even though I now work in the United States, I guess I would claim that I was trained to solve this kind of question. Therein lies the fundamental dilemma of American medicine.

The American ethic of wanting to do absolutely everything possible for each patient has its roots in a different era from the one we live in now. It is a relic of a time when diagnostic tests, surgical interventions or medicines for everyday diseases didn’t cost multiples of average people’s annual incomes. It also came about in he era before the Government (Medicare and Medicaid) or risk pools of ordinary people (insurance companies, in stewardship of employers’ and wage earners’ premiums) became the payers of health care expenses. Back then, patients paid for their own health care, or it was offered as more or less charity care.

Americans don’t like to use the term Socialized Medicine, but that is what it works like when someone else pays for our care. We may use different words, like Socially Responsible Medicine. But “social” is part of it.

If I had just survived a heart attack and had a choice between clopidogrel and Brilinta, would my choice be different if I had to pay an extra $4,500 per year myself than if I could have someone else pay for it?

Would the latter choice possibly deprive other people of medicines, surgeries or vaccines they needed because of the vast number of people making the same choice at their fellow citizens’ expense?

Would my choice indirectly be someone else’s death sentence? All for a jump from an 88% chance of me being okay to a 90% chance? I could get the more expensive drug and make bad dietary choices, or forget a dose here and there and the nuance in efficacy between the two drugs might be moot – but certainly not the cost differential.

The operative word here, in English, is stewardship. I can’t even remember what it is in Swedish: Spending resources wisely, especially when those resources belong to all of us.

My Suboxone License is Capped at 100 Patients, Should My Opioid License Also Be?

I can prescribe Suboxone for 100 patients in opioid addiction treatment. You start with 30 and can upgrade after two years. Some Suboxone prescribing doctors have a waiting list; only when a patient “graduates” or gets dismissed from the practice can a new one enter.

In the State of Maine, there are now limits on the doses of opioids we can prescribe, and as a result of the efforts to reduce, some patients have come off pain killers completely. But providers regularly get emails from the Prescription Monitoring Program telling us whether we have more opioid patients or prescribe higher doses than our colleagues.

The handwriting is on the wall: Doctors are continually and systematically shamed into reducing their opioid prescribing. It is an unpleasant situation.

Maybe, since Big Brother is obviously involved here anyway, we should just be issued quotas: Don’t make us guess how many patients on opioids are “too many”, just spell it out. The DEA already does it for Suboxone. That would be cleaner. And it would make it easier for patients to understand:

“Sorry, Jim, I had to cut 35 patients from my opioid roster this year and you turned out to be one of them. Nothing personal…”

The Other Opioid Epidemic

“I made myself a hypodermic injection of a triple dose of morphia and sank down on the couch in my consulting-room….I told her I was all right, all I wanted was twenty-four hours’ sleep, she was not to disturb me unless the house was on fire.”
– Axel Munthe, MD, The Story of San Michele (1929)

When people in this country mention the opioid epidemic, most of the time it is in the context of addiction with its ensuing criminality and social deprivation, and the focus is on opioids’ medical complications like withdrawal, overdose and death.

But that is only one of the opioid epidemics we have. Far greater is the epidemic of largely compliant patients who take their modest three or four daily doses of opiates for pain that was originally described as physical, but which in many cases is at least as much psychological – not imagined, in fact often quite severe, but nevertheless without a physical explanation or available cure.

Stimulation of opioid mu-receptors in the central nervous system induces euphoria more reliably than it reduces pain. In fact low dose opiates have been shown to sometimes lower pain thresholds but at the same time allowing dissociation from the pain experience.

People who smoked opium in antiquity didn’t all have intractable pain to begin with; many had miserable lives, just like many of my countrymen today with health problems, low income, poor education, lacking social supports and limited prospects for even a sustainable future in a job market they cannot even begin to qualify for.

Most physicians have or know of patients who have remained on the same moderate or low doses of opioids for many years and never failed a pill count or a urine test. They show no addictive behaviors, but without their prescriptions they function less well. We are still tapering most of them down or off their pain medications because that is what we do these days in response to the more famous opioid epidemic and in an effort to have fewer opioids, legal ones, that is, in circulation.

Ronald is a 57 year old patient of mine with a bad back, diabetic neuropathy and generalized anxiety disorder. He has been off his 5 mg oxycodone-acetaminophen (paracetamol) pills for two years now, takes pregabalin for his neuropathy and escitalopram for his anxiety with a low dose diazepam as needed. Since he came off his pain pills, his anxiety has been almost paralyzing. Social stressors, like a move to a different neighborhood, sent him into a frenzy. Then he fractured several ribs moving his washer and dryer up the icy front steps of his new home. The emergency room gave him just a couple of days worth of his old pain pills.

“It was amazing”, he explained to me, “I felt a warm wave travel through my body and it was like I was being hugged and everything felt all right, like I didn’t have a single thing to worry about in the whole world, even my nerve pain seemed like it didn’t bother me even though it was still there.”

Next, he asked if he could stay on them, “just three a day”.

I shook my head no.

He has his three other pills that don’t work as well. But at least they’re not opiates.

Routine Physicals, Routine Labs

I still sometimes get messages from patients without known chronic illnesses who want “routine blood work” and “routine physicals”. This terrible set of medical myths just won’t go away. It is even getting promoted by well-meaning but misinformed employee wellness programs.

In spite of all the talk about evidence based medicine, patients and colleagues all around me are clinging to the antiquated misperception that disproven rituals like digital rectal and testicular exams, clinical and self administered breast exams, annual lipid profiles, PSA tests, EKGs and 20-item chemistry profiles have anything to do with good health and longevity.

A dozen years ago I started offering instead an “Annual Health Review”, a brief opportunity to talk about each patient’s individual risk factors, based on family history, personal metrics and lifestyle. I also did a symptom inventory or review of systems. But I did not check their sodium or vitamin D levels, their back molars or the lint between their toes.

That sounds a little like the new Medicare Annual Wellness Visit, but that one rigidly demands that every patient gets screened for exactly the same items (risking non-payment if a single thing is missed). The AWV is cluttered by more or less mandated silly, medically unproven items like baseline EKGs and visual acuity by means of the Norman Rockwell style eye chart (seniors need their intraocular pressures measured; even the DMV checks their acuity, at no extra cost).

The canned Routine Physical, no longer recommended by the US Public Health Service Taskforce on Prevention, is a relic from a bygone era. These days, when people can send out for their own personalized genetic profiles, their family doctors are stubbornly treating everyone according to the same yardsticks and protocols.

This costly ritual consumes more than half of the working hours of some doctors: Thirty minutes per patient times the “ideal” panel size of 1,500-2,000 patients amounts to 750-1,000 hours of a normal 2,000 hour year. Consequently we see our patients go to walk-in care or, worse, the emergency room when they get a cut, a headache, bronchitis or the flu, so we can keep doing all those physicals.

A Christmas Wish

It’s just after six o’clock on a Sunday morning in December. The barn animals have fresh hay and warm water. My wife and the dogs are asleep. The cats are gathered around me as I sit down to write. One of them has jumped up in my lap and is pawing and clawing my jeans.

The fire is roaring in the wood stove but the 1790 room is still cold. I have read the morning news on my iPad. Our house is quiet, always; we don’t have a television or a radio. We have more time to think that way.

I do a lot of thinking these days, even though I put in long hours at work. During my commute to and from the clinic and during the long winter evenings I have plenty of time to think about my role as a doctor at this age, in this place and in these times.

I never wanted to do anything else, and I never want it to end. I cringe when I hear things like the commenter on my blog who wrote “I am sick of it and intend to retire as soon as I am able”. What a shame, what a waste. Kings, Presidents, Supreme Court Justices, Popes and Archbishops don’t usually retire “as soon as they are able”.

In some fields, age and wisdom are valued, especially the combination of the two. In many areas of medicine, at least in this country, doctors aren’t feeling valued at any age or skill level. Many feel like pawns or cogs in big, corporate schemes.

We have allowed ourselves to be devalued, and we as a profession have lost our clarity of vision, our sense of calling. Because of how unappreciated and squeezed we feel, we are at risk of losing our love for mankind, without which we will completely lose our professional purpose. We are thinking too much about production and quality metrics and losing sight of our apostolic and archetypal role in the lives of the patients we serve.

We are too distracted these days; we are practicing medicine with our minds, but not always with our hearts. We need to remember why we are in this profession and we need to stop feeling sorry for ourselves.

Victims of psychological domestic abuse undervalue themselves, overestimate the power of their tormentors and underestimate their own options. They stay in abusive situations sometimes because they don’t see clearly what is happening to them. They become physically isolated and feel shame, isolation and loneliness.

Professional burnout has many similarities with these facets of domestic abuse. But doctors are not really as tortured and trapped as abused spouses. Some of us just feel and act that way. We have one of the most meaningful jobs in the world. What a shame that so many of us want to get out of it while they are still able to do it.

Others have thought and written many wise words, not so often spoken today, about finding meaning in work:

“No man needs sympathy because he has to work, because he has a burden to carry. Far and away the best prize that life offers is the chance to work hard at work worth doing.”
― Theodore Roosevelt

“He who works with his hands is a laborer.
He who works with his hands and his head is a craftsman.
He who works with his hands and his head and his heart is an artist.”
― Francis of Assisi

“The purpose of life is not to be happy. It is to be useful, to be honorable, to be compassionate, to have it make some difference that you have lived and lived well.”
― Ralph Waldo Emerson

A small taste of these ideas is what I wish for those of my colleagues who are unhappy this Christmas.

Between Patients: The Myth of Multitasking

Primary care doctors don’t usually have scheduled blocks of time to read incoming reports, refill prescriptions, answer messages or, what we are told the future will entail, manage their chronic disease populations. Instead, we are generally expected to do all those things “between patients”.

This involves doing a little bit of all those things in the invisible space between each fifteen minute visit, provided we can complete those visits, their documentation and any other work generated in those visits, in less than he fifteen minutes they were slotted for.

If we can’t capture (steal, really) enough time from our scheduled visits, we are still expected to somehow get that work done, but then on our own time. This results in most primary care doctors logging in to their EMRs from home after supper and on the weekends. Mismatched workloads and work schedule are a major source of professional burnout.

Compare this with air safety. Are airplanes scheduled to be in the air all the time, with refueling and maintenance squeezed in only if they happen to land ahead of schedule?

Quickly reviewing a couple of messages, a few lab results and some imaging reports, and then rushing in to see the next patient is an extremely inefficient and sometimes unsafe way of working.

I have likened this to jumping back and forth between baking a cake, balancing your checkbook and mowing the lawn. Normal people don’t work that way. Why do we expect doctors to?

Neuroscience teaches us that there is no such thing as multitasking. We really only do one thing at a time, and every time we switch from one task to another, we expend mental energy and brain glucose. Switching rapidly between tasks reportedly reduces usable IQ by ten points. Maybe doctors in general have IQ points to spare, but why organize our work that way on purpose?

MIT neuroscientist Earl Miller points out that juggling multiple plates floods the brain with cortisol (the stress hormone) and adrenalin (the fight or flight hormone), which prevents clear thought.

And those are the chemicals involved in burnout. In moderate doses, they are known to boost performance, but constant, low levels of them are the biochemical basis for burnout. We all know that.

My ideal way to work would be “protected” time for Results Review and Care Planning, and then, while another doctor does that, give me two medical assistants and double my number of exam rooms for efficient visits where I have already studied the charts and know better what I’m supposed to accomplish.

And, let me do slow visits grouped together, like physicals and wellness visits, and quick visits together, like sore throats, earches, rashes and knee pains. Slow and fast visits require different mindsets and skill sets. Again, comparing with everybody’s personal life, playing ping-pong or whack-a-mole interspersed with practicing or teaching yoga is very unintuitive an inefficient, at least as far as the yoga part goes.

Kind of like scheduled refueling and maintenance for aircraft…


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