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Guidelines: When Satan Reads the Bible

Clinical guidelines are a mixed blessing. Wise clinicians know that they offer a general pattern of doing things that usually results in favorable outcomes. They also know there are lots of situations when guidelines can’t be applied because of unique patient characteristics.

Guidelines can be dangerous if we apply them indiscriminately. Education and experience teaches us when and when not to follow them.

The problem with guidelines is that people without our knowledge or experience have placed themselves in positions where they judge physicians by whether we follow a particular guideline or not. Never mind that there are competing guidelines, and that the web repository of them shut down a month ago.

That reminds me of a colorful Swedish analogy my grandmother often used, “som fan läser Bibeln”, translated “like Satan reads the Bible”.

One of many American Christian authors writes about it this way:

“What makes Satan happy is when he can get Christians to believe that Proverbs 15:6 justifies the accumulation of wealth in a world of hunger; that 2 Thessalonians 3:10 abolishes charity; that Romans 9:16 makes evangelism superfluous; that 1 Timothy 2:4 means God is not sovereign in conversion; that John 10:28 means a “Christian” can do whatever he wants and still be saved; that Hebrews 6:4–6 means there is no security and assurance for God’s elect.”

If Satan can pick and choose Bible phrases to confuse, tempt or mislead earnest and well meaning Christians, imagine what someone with ill will or authority without wisdom can make out of clinical guidelines.

That is the reality of today’s Quality Quagmire in health care.

We sometimes get judged if we don’t have diabetics on ACE inhibitors, even if they don’t have microalbuminuria. According to UpToDate, there is insufficient evidence for this practice.

Regarding statins, the American College of Cardiology writes: “Five major North American and European guidelines on statin use in primary prevention have been published since 2013. Guidance on use in the growing elderly population (age >65 years) differs markedly…The main goal of primary prevention with statins is to achieve net-benefit from treatment. Potential harm(s) is a crucial part of appropriate decision making. As frailty, comorbidity, and polypharmacy may increase the risk for adverse statin-associated symptoms, the “risk-benefit” balance in the elderly could theoretically tip in favor of withholding statin therapy if such conditions are present.” So much for following guidelines there.

Another striking example of how crazy this system is:

A doctor sees a patient with bronchitis. Guidelines discourage antibiotics. That is a Quality indicator. On the way out of the office, empty handed, so to speak, with no antibiotic but a lengthy diatribe about the uselessness of antibiotics and the looming threat of multi resistant superbugs, the patient is asked to rate his physician. Such ratings are an increasingly large part of provider evaluations and even compensation formulas. Will that patient give the doctor a favorable rating?

This what I do: Some patients, like those with chronic lung disease, get antibiotics right away. Others get a thorough explanation of why I’m not prescribing them. And a few get a “backup prescription”: “If this, this or this happens, fill it”.

Guidelines and doctor ratings shouldn’t tie our hands. We are the professionals here. We must apply our knowledge to every clinical situation we encounter. In some cases, the people who dangle guidelines or popularity ratings over our heads are simply being ignorant bullies.

Be the Guide, Not the Hero

The Family Doctor used to be almost the only source of medical information patients had access to. Now, few people need us to bring them the latest news. It’s there for everyone to see. There’s even too much of it.

Today, our role is to help make sense of it all. In order to do that, we must possess and project authority, but we have no reason to put ourselves on any kind of pedestal.

In our culture, evidenced by the stories we read, the movies we watch and many of the ways we interact with the world, people see themselves as heroes of their own lives, the main actors in their own narratives. Most Westerners aspire to reach higher levels of skill, status, health or wealth. We, deep down, generally don’t connect well with heroes who are flawless and obviously much better than we are, and we identify the deepest with products, companies and professionals who help us move toward our personal goals.

Today’s business literature urges entrepreneurs and business leaders to take on a supportive role rather than flaunt their achievements or expertise. “Be the Guide, Not the Hero” is a quote from Donald Miller of StoryBrand.

The dominating narratives present a flawed, insecure hero, who faces challenges while also reaching a higher level of insight, and he or she is supported by a guide who is older or wiser (Obi-Wan Kenobi or Yoda) but in no way competing with the fledging hero. These characters have been there, done that, and have nothing to prove. They are portrayed in ways that indicate they are supremely competent and yet almost self effacing. It is not their turn to shine.

That is a useful way for doctors to think of themselves. We must support our patients in their own pursuit of health and happiness. They must find out or choose for themselves. We can not make them do things that they don’t see or feel by themselves. And we have no right to expect that they will always follow our advice.

Our quality metrics can make us feel as if we are the main characters, or heroes in the story analogy, in our interactions with our patients. The results of our efforts can make us feel as if we are experiencing success or failure. This in turn can create job stress and burnout.

By adopting and staying in the role of Guide, physicians can preserve their stamina and enthusiasm for each and every patient encounter. We offer guidance, but every hero is free to choose whether or not to accept our words of wisdom.

Comprehensiveness is Killing Primary Care

In most other human activities there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Healthcare spans from one extreme to the other. Think Code Blue versus diabetes care.

Primary Care was once a place where you treated things like earaches and unexplained weight loss in appointments of different length with documentation of different complexity. By doing both in the same clinic over the lifespan of patients, an aggregate picture of each patient was created and curated.

A patient with an earache used to be in and out in less than five minutes. That doesn’t happen anymore. Not that doctors and clinics wouldn’t love to work that way, but we are severely penalized for providing quick access and focused care for our well established patients.

Why is that?

Our Quality mandates have ended up creating perverse roadblocks and disincentives for taking care of the simplest needs of our patients. Any time we don’t screen for depression, alcohol use, smoking and readiness to quit, obesity, immunization status, blood pressure control and so on, we lose brownie points and, increasingly, money.

This is happening near me:

The primary care practices of Maine Coast Memorial Hospital in Ellsworth Maine have lost many, if not most, of their providers in recent years after some belt tightening due to running the clinics at a loss. They are not able to see new patients for six months or more. BUT the hospital is actively promoting its walk-in urgent care center – and they don’t seem to have trouble staffing it, and don’t appear to be losing very much money on it.

Bangor, Maine, home of a small Catholic Hospital and a 400+ bed hospital with a level 2 trauma designation, cardiac surgery, neurosurgery and many other specialties, has a severe lack of primary care doctors in spite of having a Family Medicine residency. Yet, a private out-of-state company is building a brand new freestanding urgent care center a couple of blocks from the Catholic hospital.

Quick and easy acute care visits visits could generate revenue with positive cash flow for primary care practices, especially for Federally Qualified Health Centers with their flat rate reimbursement, but possibly for all practices if CMS’ new proposal to scrap differentiated Evaluation and Management codes becomes reality. But the requirement to weigh down the simplest visits with all those screening requirements eliminates the incentive to nimbly meet patients’ need for access.

The end result will be that primary care providers will become chronic care providers only, and care will be fragmented so that anything profitable will be siphoned off to freestanding entrepreneurs or hospital owned profit centers. Meanwhile primary care practices risk becoming more and more of a millstone around their hospital owners neck because all their patient visits are more complex and costly than the reimbursement scheme can support.

And more and more providers will be tempted to jump ship for the easier work and greater predictability of a Doc in a Box career.

The only solution is to acknowledge that Family Medicine and all primary care is meant to assess patients over the continuum of time. You don’t have to fix the whole person when all they ask for is some penicillin for their strep throat.

Sometimes you need to be quick and sometimes you need to be slow. Without the freedom to adapt, in a patient centered way, to the situation each patient presents with, primary care risks going under.

Myopic Versus Hyperopic Views on Physicians’ Work

There is a constant tension in medicine between the details and the big picture. Many factors magnify this tension, and they make our work as clinicians harder. We really need to find our own balance between tending to the details and grasping the big picture, or, in optical terms, a myopic or hyperopic view of our work.

A jeweler working on a delicate mechanical watch, with a loupe pinched over his dominant eye, is not well equipped to also watch the front door of his store for shoplifters.

The more pressured I feel from the number and complexity of patient visits in my schedule, and the further behind that schedule I fall, I know that I become increasingly hyper-focused. It is definitely my survival mechanism for days that threaten to spin out of control. I revert to a razor sharp focus on THAT patient in order to make decisions, sometimes in a triage sort of way: What is the WORST thing this could be? What is the NEXT step for this patient? What would make the BIGGEST difference in this situation? If I instead tried to think of how to get the next two or three patient visits to go smoothly, I don’t think I would be much help to the person I am with RIGHT NOW.

I don’t verbalize or claim this nearly enough: If my team wants me to handle THIS MANY patients in THIS LITTLE time, they need to watch the flow for me; there is no way I can do both. I can’t get enough from them of things like:

“I put out the instruments you might need if you decide to lance this.”

“I got a urinalysis/EKG and a copy of the last culture/tracing…”

“You need to look at this ankle ahead of your next patient, because x-ray is leaving in twenty minutes…”

My other persona, the Medical Director, zooms effortlessly between the two focal distances. Unfettered by a near-superhero clinic schedule, I can zero in when consulted by a new nurse practitioner on a clinical case, and the next minute I can watch the clinic flow and sense the energy of a dozen coworkers as they go about their day, or I can glance at lists of data and get the “big picture” or spot incongruences.

The difference is that pressure, which is so insidious that you can’t really understand it until it is gone: When the last patient has left, the phones are off, most people have left the clinic and the sounds of air conditioners and office equipment have eased off, you realize there had been a pressure on your mind and even your body, coming from every angle as if you were a deep sea diver far below the surface.

Suddenly, the air feels lighter, I am aware of my surroundings and not just striving to tune them out. I didn’t feel the pressure building, but when it eases off this suddenly, it is a very physical sensation.

I throw the word “pressure cooker” around now and then. My mother had one back in the early sixties. Long before microwaves and convection ovens, we cooked things faster by using airtight lids on heavy pots. Without that extra pressure, dinner would be late. Without that extra pressure, clinic would run longer and overtime costs would mushroom. Without that extra pressure, revenue would drop. But like kitchen technology, aren’t there more elegant ways of doing this? The heavy iron lids and the steam escaping through their rattling top vents evoke yet more images – steam locomotives of a bygone early industrial era.

Oh well, I’m just letting off some steam…

The Art of the Message

Sometimes I wonder if I am wired differently from other doctors, in terms of what I remember on my own and what I need some help with.

The other day I got a “medical call” that simply said, “Mr Brown called to report his blood pressure is 120/80”.

With more than fifty calls in my inbox and no memory of what the issue was with Mr Brown’s current blood pressure, I replied “seems like a random fact, is there a back story?” I never heard back.

Seeing up to thirty patients a day and receiving at least fifty each of EMR “documents”, messages and lab results, my mind doesn’t retain the details of each clinical plate swerving in the air above my head. Mr. Brown could have stopped his blood pressure pill because he was lightheaded with a low blood pressure, or he might have stopped his valsartan because he was caught up in the fears of cancer causing ingredients in Chinese generics, or he could have had an abnormal potassium and stopped the medicine that could influence potassium levels. Or, perhaps he got a home blood pressure cuff to prove that he has white coat hypertension.

In my world view, in light of the productivity requirements in primary care, messages need to be anchored in a clinical scenario so that the provider can make a decision without doing several minutes of research during time stolen from scheduled patient visits, lunch, bathroom breaks or life in general.

“Tell me why you were asked to call in your readings” would have been the way to handle that call, but I have a vague suspicion that the medical assistant who took the call felt pressured by the list of other calls that needed attention, for example the mandatory ER Followup calls that are a quality indicator for us. The quality of clinical calls doesn’t count, so they might be a lower priority. Everyone in the medical office has their own hoops to jump through and sometimes we are tempted or have no choice but to do the minimum and pass the buck just to get through our day.

I had hoped, naively as many readers commented back then, that the Patient Centered Medical Home concept would foster a reengineering and a clearer focus on what really matters. Like so many other quality enhancements in medicine, it has created another layer of superficial check-offs that has made it harder to see the patient and the clinical issues at hand.

I still wonder what the deal was with Mr. Brown, which is not his real name; I forgot the name the instant I hit “reply” and got the incoherent message off my already full plate.

Too Many Chest Pains

There are at least 50 words in the Eskimo languages for snow, 25 in mainstream Swedish, and supposedly 180 or so in the Sami language of the nomadic inhabitants of the northernmost parts of Norway, Sweden and Finland.

But there are even more words than that for “chest pain” among my patients, many of whom do not consistently or fully comprehend the English phrase “If you have chest pain, call 911 or go to the nearest emergency room”.

This Saturday I had three serious cases of chest pain, but of course they all used different words, like “empty feeling”, “tightness” and “pressure”.

“The medical term is PAIN”, I patiently explained to all three. They all had normal EKGs. “Thirty years ago that would have been more reassuring than it is today”, I told each one of them. “But today we have blood tests that can show heart muscle damage that doesn’t ever show up on an EKG. So today’s standard of care is that you get to the emergency room where they can do these blood tests.”

One patient got pain free after a “GI cocktail”, which numbed his irritated esophagus, so I agreed to leave it at that, with a caution that new pains might require urgent reevaluation. Another agreed to go to he ER, declined the ambulance and seemed to understand my concern that his wife could find herself transporting a medical emergency patient singlehandedly on a winding road with sketchy cell phone reception. His wife also understood. The third patient accepted the ambulance, and left the building accompanied by the attendants, only to part company with them in the parking lot.

My compliance officer, after I told her we’ve got to figure out how to discourage Walk-in chest pains with our Saturday skeleton crew, asked about legal risk when the two most recent cases declined the ambulance. I wasn’t worried; the first one I counseled thoroughly, and the second one left the building in the company of EMS. Once EMS takes over, my responsibility ends, that’s well established, no matter what qualifications the doctor in the field has.

We have posters, pamphlets, mailings and all kinds of communications that encourage coming to see us for nonemergent medical problems like coughs, sparing, earaches, rashes and the like but to quickly get ER care for chest pain, severe shortness of breath and the like.

Every month at our Quality Assurance meeting we look at how many ER visits in our patient population could likely have been handled in the office instead. I don’t have statistics on how many people delay care for a serious cardiopulmonary condition by insisting to be seen by us first, but it sure happens.

We definitely need to do more training with front desk staff about this, but I know many patients will not admit to the receptionist that what they have is chest pain; they will try some of the other words instead.

So before Saturday, I think I’ll have to come up with some new, catchier posters about the fact that they all mean the same thing: PAIN.

And that in turn means: NOT HERE.

The Art of Covering

I was a little taken aback when Dr. C. changed my patient from warfarin to one of the “Novel Anticoagulants”, and one I seldom use, at that.

I have only worked with her for about three years, and we seem to come from the same mold, seasoned family docs with a penchant for teaching and patient empowerment. I had not imagined she would step in and completely change my treatment plan when she was just covering for one day.

As far as which is safer, warfarin with variable therapeutic effect and fluctuating INRs or Novel Anticoagulants, which have hardly been studied at all in patients on dialysis, you won’t see test results that may worry you, but the unknowns are still there.

It was a judgment call, and she took it upon herself to change my treatment. She may never see that particular patient again, but that brief doctor-patient relationship has changed my patient’s risk of stroke, to the better or to the worse, I don’t know which way.

As we are now adding a couple of new providers to our clinic, I think back to discussions we had 20-25 years ago, when we had another major influx of providers.

We met back then to talk about what we all wanted from each other when “covering”, and we were all pretty clear that, even though we might feel tempted to tweak blood pressure medications, diabetic regimens or other things while treating an acute problem, we wouldn’t necessarily appreciate if someone did that to our patient and our treatment plan.

So we had a truce: We would deal with the problem at hand and suggest that the patient talk to their PCP about adjusting their treatment. As far as the acute situation, we agreed to emulate each other’s style a little. Dr. Z often gave very explicit advise on over the counter and alternative treatments for more or less self limited illnesses, while I have always been inclined to say, “those things won’t make this go away any faster, they just keep you busy while you wait”. I did a lot more handholding when I covered for Dr. Z. and I think she was less adamant about my patients spending money at the health food store.

Doctors aren’t all the same, and patients usually gravitate to providers who meet their needs. And, I hope this doesn’t surprise anybody, there are many different ways to treat the same problem. Trained “abroad” and old enough to have seen medical “facts” come and go, it has been obvious to me for a long time.

I think there is a balance here. A patient who seems dissatisfied with the status of their condition or its treatment deserves to hear that there are options, and a covering provider can point that out, but to offer such advise unsolicited can do more harm than good. We shouldn’t try to look smart at the expense of our colleagues. It may be better to approach that colleague privately and say, “do you still prefer warfarin over Xarelto in dialysis patients?”

I’m still thinking about that one.


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