A Country Doctor Reads: May 19, 2019

“The physician–patient encounter is health care’s choke point” -NEJM

This week’s Journal has a very profound article about why healthcare has not evolved through its technology the way other sectors of society have.

My take, and extrapolation, is that there are three reasons why healthcare has failed to evolve in usefulness of both our product (the care we deliver) and our technology (our EMRs), our customer centeredness and the value/cost relationship of the services we provide.

1) Healthcare is not at all customer centered. Even the required operational framework for Patient Centered Medical Home recognition is completely top-down. We are being crushed by mandated screenings for everything from obesity to domestic abuse (see my postBrief is Good”). The whole notion of Quality is arbitrary and paternalistic. Cash practices are appearing and evolving to meet patients’ needs without the mandates of Medicare and the private insurance industry, but are in essence duplicating cost and effort because of Obamacare’s insurance mandate.

2) Our technology was not created with the purpose of speeding up or simplifying documentation so that clinicians can deliver better care. Instead, there was a dual focus of maximizing billing and controlling the “Quality” in clinician performance. Since we basically don’t have a clue, let alone agreement, about what Quality really is (see my 2009 postQuality or Conformity?”), any effort to promote or require Quality through templates and “hard stops” becomes cumbersome and potentially meaningless.

3) Healthcare is still practiced as if we were all solo practitioners without technology, seeing one patient at a time, in person, in the office, which is marginally more efficient than housecalls. So far, we have no incentives to do anything different. A silly example: A patient with perfect blood pressure at home on their internet connected sphygmomanometer doesn’t help my Quality ratings one iota, since my “grade” for the year is the last blood pressure recorded in the office for the calendar year (see my postDon’t Do Chronic Care in December”). And, as the NEJM article points out, there are no financial incentives to have nurses or other non-providers manage routine problems like hypertension in our current system.

Here is an eloquent section of the article by Asch, Nicholson and Berger:

“Information technology is changing medicine, but electronic health records (EHRs) are mostly demonized by clinicians, and the promised customer efficiencies seen in the retail, financial, entertainment, and travel industries have been largely absent in health care.

These approaches will improve with time. It’s worth noting, however, that the transformations seen in other industries have followed a different path. In these cases, aligned financial incentives, better customer centricity, and technology have been motivating and enabling forces for change, but the transformations themselves came from operational changes that enhanced productivity — mostly by finding ways to use fewer people.

The movement from bank tellers to automated teller machines to cashless digital transactions has reduced effort all around. Because of easy-to-use software, fewer people now use travel agents. Yet despite increased use of EHRs by clinicians and smartphones and wireless technology by patients, the fundamental approaches to managing hypertension, diabetes, and chronic lung disease have remained the same for 50 years. The drugs are better, but the way patients engage with doctors during office visits and hospital stays is unchanged.

The physician–patient encounter is health care’s choke point. So long as we continue to think of health care as a service that happens when patients connect with doctors, we shackle ourselves to a system in which increased patient needs must be met with more doctors. Other industries overcame similar constraints in various ways — McDonald’s pioneered a production-line approach to fast food, for example — but more recent transformations have come from facilitated self-service. Taxpayers abandoned tax preparers when TurboTax created a new pathway to what they wanted. Until we invent the TurboTax of health care, we won’t achieve the kind of productivity gains needed for transformative change in quality, access, or cost.”

https://www.nejm.org/doi/full/10.1056/NEJMp1817104

The Folly of Self Referral

A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.

This “system” often doesn’t work, because of the way medical specialties are divided up.

If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does ERCPs, and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from an ovarian cancer, best treated by a GYN-oncology surgeon, which anywhere in Maine means a drive down to Portland.

The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and another unrelated operation for a fracture in Bangor a few years ago. Then, after a non surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for EMG testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.

The man, who has traditional Medicare and thus the right to see any specialist who accepts Medicare, wanted me to get him in touch with the brilliant Boston hand surgeon. The man told me he wanted a diagnosis and a cure, and not just a bunch of pills, which is what his family doctor had offered him.

“I won’t take gabapentin, I mean, with all those side effects”, the man said emphatically.

“Did anybody suggest the diagnosis of Reflex Sympathetic Dystrophy or Regional Complex Pain Syndrome?” I asked.

“No, is that the name for what I’ve got?”

“I think so”, I told him. “And I don’t think even the most brilliant hand surgeon can help you. Around here, this is a problem that physiatrists, rehabilitation specialists, handle. I think you should see Dr. Paul DeBeck.”

“What would he do?”

“Confirm the diagnosis and probably offer you medication to start.”

The man frowned.

“The list of side effects is only a list of possibilities. It’s published for legal purposes, so you can’t sue the drug company for not warning you”, I explained. “I mean, would you drive a Jeep, or any car, on a public road if you read a document that said your gas tank could explode if you got rear ended, you could hit a moose, you could roll over if you went through a curve too fast, you could slide into a ditch on an icy road or you could get impaled if you drive too close behind a logging truck…”

“Anyway”, I continued, “I think your problem is not surgical, so going all the way to Boston would probably be a big waste of your time. I suggest you ask your doctor for a referral to Dr. DeBeck, right in Bangor. Then he could guide you from there, even if he doesn’t think it is what I think you have. He sees a lot of that type of problem, so he’ll know.”

The same day, I saw a woman with “hip pain”, which turned out to be on the lateral, outer side, of her hip and a little toward the back side. That spelled sciatica from lumbar disc disease. She had wanted an orthopedic referral. But in the northern half of Maine, almost none of the orthopedic surgeons deal with back problems, so an orthopedic referral would have been a terrible waste of time for her.

I sometimes wonder why it is that medical specialties are divided up the way they are; you need to know the diagnosis before knowing what specialist to see. I mean, why isn’t there a belly pain speciality? But, that is why it makes sense to see a generalist first. Plus, we are qualified to treat most cases of the majority of diseases people run into.

A Country Doctor Reads: May 11, 2019

Soulful Medical Writings

This morning I read a touching essay in The New York Times by an ENT resident at Harvard, Alessandra Colaianni:

https://www.nytimes.com/2019/05/10/well/live/skin-medical-ethics.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

Looking for more of her writings I found a Canadian Journal I will now be checking out on a regular basis:

Ars Medica is a literary journal that explores the interface between the arts and healing, and examines what makes medicine an art.
— Read on ars-medica.ca/index.php/journal/issue/view/29

And then, of course, there is Bellevue Literary Review, edited by a frequent NYT contributor, Danielle Ofri , MD:

Read on blr.med.nyu.edu/content/editors-picks

The Guardian once published a thoughtful piece on the importance of doctors writing about not just diseases but about the human beings who are affected by them:

In the heyday of modernism, doctors lionised specialisation, but patients have now turned to holistic approaches that combine oncology, psychiatry, cardiology, neurology and a variety of alternative treatments. After a long period when we focused primarily on depth of knowledge, we have returned to the importance of breadth of knowledge. In telling the stories of illness, we need to tell the stories of the lives within which illness is embedded. Neither humanism nor medicine can explain much without the other.

A rising literature attempts to reconcile these modes of thought. Voltaire complained, “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.” But a new run of books attempts to address the last clause of Voltaire’s challenge. Such writings may not be remarkable as either medical information or writing, but they rightly insist that coherence sits at the intersection of science and art.

https://www.theguardian.com/books/2016/apr/22/literature-about-medicine-may-be-all-that-can-save-us

Brief is Good

How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain?

So why is the typical “cycle time”, the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour?

Answer: Mandated screening activities that could actually be done in different ways and not even necessarily in person or in real time!

Guess how many emergency room or urgent care center visits could be avoided and handled in the primary care office if we were able to provide only the services patients thought they needed? Well over 50% and probably more like 75%.

Primary Care clinics like mine are penalized if a patient with an ankle sprain comes in late in the year and has a high blood pressure because they are in pain and that becomes the final blood pressure recording for the year. (One more uncontrolled hypertensive patient.)

We also get penalized if we see an infrequent visitor only once in a given year and don’t screen and provide interventions for depression, alcohol use, smoking and a host of other conditions unrelated to what the patient came to us for.

So we can’t afford to have quick visits since anything less than comprehensive makes us look bad.

Imagine if you pull up to an ATM for $40 in cash and the machine insists on going over your annual budget with you. That’s what primary care feels like sometimes.

Of course I will look one or two steps beyond the chief complaint. If a smoker has bronchitis, I’ll talk about smoking. And if an alcoholic falls down his front steps, I will take the opportunity…

But I can’t do everything for everybody in every visit. I can be comprehensive, over time, if I am not penalized for squeezing In patients with simple problems for quick visits. I think that is more comprehensive than declining to provide rapid access and thereby forcing patients to fragment their care between multiple unrelated providers.

Here is my simple prayer:

Dear Overlords of CMS and all you other Healthcare Policymakers and Deities,

Let us judge how to best meet our patients’ needs when they come to our clinics. Admit that sometimes a sore throat is just a sore throat.

A Country Doctor Reads: May 4, 2019

Delays in B-12 deficiency diagnosis -WSJ

This was interesting. The Wall Street Journal ran an article about the difficulties and delays in getting diagnosed with B-12 deficiency. It often takes years:

www.wsj.com/articles/vitamin-b-12-deficiency-the-serious-health-problem-thats-easy-to-miss-11556589900

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Review article: metoclopramide and tardive dyskinesia – RAO – 2010 – Alimentary Pharmacology & Therapeutics – Wiley Online Library

All of a sudden, I am reading a lot about tardive dyskinesia. I’ve been thinking about it in the context of being a side effect of metoclopramide.

Gastroparesis is frustrating to treat. Metoclopramide has been around since 1979, and I have certainly prescribed it often. But now there are all these warnings about Tardive Dyskinesia. Erythromycin is an option, not always well tolerated, and now the price of it has gone from $4 to $600 per month. Over the years, one motility drug after another has entered the market and been withdrawn due to side effects. There has also been Domperidone, not available in this country but in Canada (I have a Border License), but now I hear that it isn’t available there either.

So I wanted to get a handle on how prevalent Tardive Dykinesia from metoclopramide really is. I found a ten year old piece that said 1-15%. Guess how many cases I have seen over the years. Answer: Not a single one.

In the past 5 years, guidelines from two national organizations on the treatment of gastroparesis suggested that the frequency of TD with metoclopramide use is 1–15%.3, 4 However, clinical experience suggests that the risk of TD is much less. There are several potential explanations for the discrepancy between the stated prevalence and clinical experience: First, TD may not be encountered by gastroenterologists because it is actually rarer than the minimum 1% frequency. Second, gastroenterologists may miss the complication. Third, the patient may seek advice from another physician such as a neurologist.

— Read on onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2009.04189.x

————-

The Empty Promise of Suicide Prevention – The New York Times

Last Sunday’s NYT had a thought provoking piece by Dr. Amy Barnhorst at UC Davis. She suggests that real suicide prevention would be bettering people’s social circumstances and decreasing access to lethal means. She also quotes statistics that 50% of suicides are impulsive actions and 25% of people who kill themselves contemplate their decision for less than five minutes.

According to a 2016 study, almost half of people who try to kill themselves do so impulsively. One 2001 study that interviewed survivors of near-lethal attempts (defined as any attempt that would have been fatal without emergent medical intervention, or any attempt involving a gun) found that roughly a quarter considered their actions for less than five minutes. This doesn’t give anyone much time to notice something is wrong and step in.

Nonetheless, mental health providers perpetuate the narrative that suicide is preventable, if patients and family members just follow the right steps. Suicide prevention campaigns encourage people to overcome stigma, tell someone or call a hotline. The implication is that the help is there, just waiting to be sought out.

But it is not that easy. Good outpatient psychiatric care is hard to find, hard to get into and hard to pay for. Inpatient care is reserved for the most extreme cases, and even for them, there are not enough beds. Initiatives like crisis hotlines and anti-stigma campaigns focus on opening more portals into mental health services, but this is like cutting doorways into an empty building.

And yet there are things we can do to prevent suicide. One of the few tried-and-true strategies is reducing people’s access to lethal tools, so that if they do sink into hopelessness, any attempt they make most likely won’t be fatal. If my first patient had had a gun in her house, she wouldn’t have made it to me. If my second patient had grabbed acetaminophen instead of ibuprofen, she might not have either. Averting death in that impulsive moment of despair is crucial to reducing suicide rates. Contrary to popular opinion, only a small fraction of people who survive one serious suicide attempt go on to die by another.

www.nytimes.com/2019/04/26/opinion/sunday/suicide-prevention.html

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Am I Smarter than Geisinger and The Harvard Business Review?

I subscribe to HBR, even though many issues don’t apply a whole lot to what I do. But the March issue seemed irresistible: Transforming Health Care…

A big article about Geisinger looked especially promising:

But, their physician interim CEO is another one of those HUDDLE HIJACKERS who thinks that mucking up primary care providers’ fifteen minute visits with spotting care gaps is going to be the solution for improving health care. He, like many other pundits, must never have heard of computer reminders, Constant Contact and Mailchimp.

Another article looked interesting:

But it only depressed me. What kind of system is Employer Provided Health Care when it only provides for half the population? Seems like a no-brainer to me (a Swede who left that country’s version of Socialized Medicine, mind you) that this system has got to go away.

I think we need to really reinvent health insurance in this country. My recent experience with Martins Point and other managed Medicare plans is echoing in my mind (and now the CMO of Martins Point wants to talk to me….I wonder what that is all about).

The American health insurance system is perverse, that’s all there is to it. If you are insured by your employer, your plan offers a free physical (deemed a worthless thing to do by most clinical experts) and free random bloodwork ordered as part of that physical, but if you feel a lump in your breast or testicle, copays and deductibles apply. If you have Managed Medicare, you get free gym memberships and other flashy extras but God help you if you need a CT or MRI to look for cancer.

Today’s Doctors: Colleagues or Free Agents?

My first job after residency was in a small mill town in central Maine. I joined two fifty something family doctors, one of whom was the son of the former town doctor. I felt like I was Dr. Kiley on “Marcus Welby, MD.” I didn’t have a motorcycle, but I did have a snazzy SAAB 900.

Will was a John Deere man, wore a flannel shirt and listened to A Prairie Home Companion. He was kind and methodical. Joe didn’t seem quite as rural, moved quicker and wore more formal clothes. I never could read his handwriting.

They each had their own patients, but covered seamlessly for each other. They were like a pair of spouses in the sense that they answered to each other as much as to their patients. They had to make everything work for the benefit of their shared practice, their shared livelihood. Their mutual loyalty was essential and obvious, although allowing for their differences in temperament and personalities.

Invited to stay on and enter into a partnership, I hesitated. How did I fit in? Could I follow in their footsteps and become an equal partner, covering for them and doing things similarly enough to fit in for the long haul?

In the end I declined and became an employed physician in the clinic I have been the Medical Director of, with some side forays, for decades.

Here, we are all employees, strangers brought here by chance, held together more loosely. We are all choosing to get along, but there isn’t the marriage-like commitment that Will and Joe had. We don’t arbitrate our differences in the same way; we, as a larger group, have the option of “doing our own thing” to a greater degree.

We do feel a strong loyalty to our growing but still small organization. Incoming providers paint a picture of what it is like to work for practices owned by much larger organizations, and in those it seems less obvious that doctors feel a deep commitment to their corporate mission.

Answering to the administration as much as, or more than, our colleagues makes it possible for us not to be team players. It also sets the stage for possible professional isolation. We must consciously cultivate clinical interchange and a collegial atmosphere.

In spite of all the talk about team based care, medical providers today are terribly isolated. There is no doctors lounge anywhere anymore. We are all collaborating with other staff categories, but not so much with each other.

There are virtual options for camaraderie and professional sharing, but with long clinic days and “pajama time” work from home, do we feel we have the time and energy for that?

I think we need to find ways to interact with each other at work. I seriously believe that this would be an investment with potentially huge return. Instead of working and eating at our desks or holing up to stare at our smartphones, and instead of giving up our lunches for structured meetings, we could eat lunch together and talk about tough cases, new things we’d like to try and challenges we face as modern medical providers.

If we talk more with each other, we can also develop a more shared vision of what we want out of our jobs for ourselves and our patients.

I’m talking about bringing back the Doctors Lounge…

The ABCs of Beginning a Clinical Encounter

You’re running late and many things didn’t go right today. You knock on the door and enter the exam room with an apology. If you’re like me, you have a few papers and an iPad or a laptop in your hand. You sit down and open the patient’s chart in your device or perhaps on the big desktop, eyes not exactly locked on the patient.

Only after getting to where you need to be in the computer do you really look the patient in the eyes. Your body language has been one of hurry and distraction. Now you try to repair the damage of that, so you try to show you’re settling down now, at least for a few moments. You might sigh, move your arms in a gesture of relaxation and say something to get the history taking underway.

So far, you’re failing. I do that often, too.

Here’s what we all know we need to do, but often don’t; we should follow these ABCs:

A – Attention:

Clear your mind. It doesn’t matter what happened in the other room with the other patient, or on the phone with the insurance company or the smug specialist or ER doc who pointed out the diagnosis you missed. Open the door (I always knock first) and immediately look at the patient. Make eye contact and observe them. Pay attention to how they look, what they are signaling. The computer can wait; a few moments of focused attention will usually save you time in the end. After all, red or teary eyes, a leg cast, a big bruise or change in grooming can make the visit go in a direction you wouldn’t have expected from he listed chief complaint. How many times have we heard a patient comment about another doctor: He didn’t pay attention to me. Do we always do that ourselves if we’re rushed or preoccupied?

B – Behavior:

Behave like a doctor. I keep saying that. But the clinical encounter is like a dance, where either one of us can lead, and we lead a little too often. Behave in a way that signals respect, interest and both confidence and humility. Behave like someone who serves, guides and helps the patient heal. Behave in a way that behooves a doctor. You have paid attention to the patient. What did you see? What does he or she need, or need you to be like, in this moment?

C – Connection:

The goal of contemplating how a good clinical encounter should begin is to establish connection. Learning about someone, counseling someone, treating someone, comforting someone all require having a connection with that person. They tell you that strangers you meet like you better if you invite them to talk about themselves. Making connections with patients requires showing genuine interest, inviting disclosure and reciprocating just enough to show that you are a real person, but not so much that you seem too fallible or self absorbed. It is better to talk about your interests than about yourself. Sharing about pets, children and hobbies that don’t portray you as uppety is safest.

In the fast paced, high pressure day to day work we do, I sometimes catch myself not engaging quite enough with my patients. Even after forty years of doing this, I need to remind myself to start every patient encounter off in a way that sets the stage for making clinical and interpersonal progress. My demeanor builds relationship equity over time so that if I sometimes don’t live up to my ambition and miss one of my ABCs, my patients are a little more likely to overlook it.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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