Archive for the 'Reflections' Category

Be the Doctor Each Patient Needs

Doctors need to be true to themselves but at the same time they must be chameleons.

A doctor fills certain roles in the lives and stories of patients. It is a two-way relationship that looks different to each person we serve throughout every workday and even in the most casual interactions we have.

Some patients need us to take charge for a while because they’re exhausted, others need us to listen quietly while they vent or process something out loud.

Some patients need reassurance and empathy, others thirst for detailed information. Some patients thrive on viewing us as equals and friends, yet others need some distance because what they need to share with us is something they couldn’t even tell their best friend – only a priest, rabbi or doctor without the familiarity of a friend.

I may be naturally analytical, intuitive, reserved or outgoing, but I must get a sense of my patient and the situation he or she is in and understand how I can fit into that situation.

This is not acting or being dishonest. I don’t dress the same way for a day in the office as I do for a day in the barnyard or a night at Chateau Frontenac. Neither do I conduct myself the same way in every situation in my life. It would be selfish and inconsiderate of me to act exactly the same way with every patient – “take it or leave it”.

I work at being chatty and cheerful, but that is no more dishonest than practicing another language. I may know the perfect word for something in Swedish but that doesn’t do my English speaking patient any good.

The roles we play in people’s lives are necessary for them in those moments, in their personal journey. Many people need someone in an archetypal role to carry them to the next level or the next chapter in their lives by saying or doing something they cannot do themselves.

Doctors are performers, not only when we perform procedures, but also when we deliver a diagnosis or some guidance. This is the premise of an audiobook I listened to a while ago during my commute between my two clinics: Dr. Bob Baker, retired physician and an accomplished magician, draws parallels between the two professions in “The Performance of Medicine”.

I have done a lot more thinking lately about these two P-words: The Practice of Medicine and The Performance of Medicine. Both words, both concepts, point out that what we do in this job is much bigger than we ourselves are, something that transcends time and place. We have to continually work at it and it takes place in the energy field of two people in a therapeutic encounter.

Quoting Dr. Baker: “The magic of medicine begins with the doctor/patient connection.”

That connection requires us to be what we Swedes call “lyhörd”. There is no single word I know of in the English language that conveys the same notion. Literally, it means “of keen hearing”. Google Translate suggests three words: responsive, keen and sharp.

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”.

Fundamentals of Medicine: Diagnosis and Guidance (Not Just Treatment)

Non-clinicians skip over some of the most necessary underpinnings of Doctoring and speak too much about housekeeping issues: Blood Pressure targets, aspirin use, mass screenings, immunization rates and so on.

People without medical degrees could do those things. But there are steps that must be taken before we worry about the measurables. These are the essence of being a physician, what people ask for when they come to see us. Most people don’t come in and say “I need you to regulate my blood pressure” or “Help me lower my cholesterol”. They come in saying “I don’t feel good” or “Help me stay healthy”.

DIAGNOSIS

More than anything, people come to us to find out what’s wrong with them. They come with rashes, aches, fevers, coughs, “bunches” (the Maine word for lumps and bumps on their bodies) and concerns like fatigue, which could be a symptom of almost anything.

In that scenario, not to be melodramatic, making a correct diagnosis could be a matter of life or death, or at least wasteful spending of thousands of dollars and valuable time.

We don’t get enough credit by outside observers, like health care administrators, insurers and “consumers” for the value of our diagnostic acumen. It is the first fundamental of health care. Different diseases have different treatments and the success of medical care hinges on treating the right diagnosis.

A trivial example is a patient I heard of just recently with sudden agitation and high blood pressure presenting to the emergency room. Many hours and many tests after arrival – blood tests, EKG, CT scans and so on, he turned out to have urinary obstruction. A Foley catheter relieved the obstruction and cured his high blood pressure as well as his agitation.

A young woman came to see me a few days before graduation for a mild rash on her legs. Not only was she about to graduate; she was also planning a long trip afterward. The bloodwork I ordered STAT on our first encounter showed that she had acute leukemia. She was allowed a temporary leave from the cancer clinic to attend the ceremonies and then went back to continue her treatment. Today, she is the proud mother of a soon-to-graduate teenager. What if I, as she later said, had glanced casually at her skin and sent her off on a faraway trip with a prescription for a cream?

GUIDANCE

“Treatment”, the second part of the traditional duad, is too simplistic a notion, only useful for lancing boils and prescribing penicillin for strep throat. Most diseases are multifaceted and most patients have several health and disease considerations. Most diseases are also chronic, even ones we thought of as rapidly terminal earlier in our own lifetime, like HIV and an increasing number of cancers.

The physician’s role is not a knee jerk intervention, it is informing and educating the patient and helping each patient choose a plan of action that is right for them.

Primary Care does what Google can’t, it applies knowledge of the patient and of the relative importance of medical facts and factoids and offers guidance in the sense of ranking options.

Even when the treatment requires specialized care we have a role as guides. We help patients choose specialists depending on each patient’s particular medical problems and personal preferences – referral to a particular subspecialty and to a take-charge doctor or a collaborative one, for example.

As guides, we follow patients along on their journey, sometimes actively by showing what to do, sometimes only watching from a distance, ready to intervene if they stumble. We don’t just prescribe, we anticipate – we warn patients and their families of things that may come up at the next turn. It takes experience and expertise do that well, not just handing out mass produced information to meet “meaningful use” mandates.

Sometimes our Guide role requires us to talk about a different journey – not one back to health and function, but one of decline and death. We must be comfortable with that role as well as the cheerleader’s.

The almost pastoral duty we have is to instill and preserve hope. Although this is often for a cure involving certain obstacles or challenges, sometimes the hope we can offer is only the hope of feeling better and sometimes it is just of relief from suffering.

We live in an era of tweets, sound bites and intellectual shortcuts. Medicine doesn’t fit into that kind of mindset very often. Contrary to what some outsiders think, ours is a deeply cognitive profession of careful consideration and deeply personal counsel.

“Treatment” is simply a misnomer for what we do. Even when there is no cure, there is care.

Medicare Knows Everything About My Patients, But Hopes I Will Forget

My clinic belongs to an Accountable Care Organization. My job is to keep my patients medical costs down, in my clinic as well as in the hospital and specialist offices, without sacrificing quality. Of course, I have about zero control over costs generated outside my office.

So, since I can’t do very much about what Cityside Hospital and all the specialists they employ charge for their work, my only chance of getting any “shared savings” is to make my patients look real bad.

That is what some of the Medicare Advantage plans (Federally subsidized for profit contractors who manage Medicare subpopulations that get extra benefits, like glasses and gym memberships, in exchange for Prior Authorizations and other forms of rationing). I used to puzzle over why they paid us $150 just to update/verify my patients problem lists until I got caught up in the same situation through no fault of my own. Now I also know why these lists sometimes contained outrageously erroneous diagnoses such as paraplegia.

The baseline cost, from which any savings (shared savings for my clinic) or the dreaded opposite is calculated, is predicated on complex actuarial formulas, summarized in what Medicare calls Hierarchical Condition Categories.

This is how that works:

Even through Medicare paid for patient X’s medical care in previous years, and received bills with all of his terrible diagnoses listed, they calculate my base “cost” only counting the diagnoses submitted recently. If they don’t see anything that looks expensive, they budget about $8,000 for the coming year for that patient. Never mind that he is a quadriplegic amputee (which I might not include as a reason for any particular visit, although I might treat and code for his bedsores). Of course, since he may need a new power wheelchair anytime, I wouldn’t want that cost to drag down my “performance”, so I’d better put “quadriplegia” and “below-the-knee amputation” on at least one superbill every year.

It seems obvious they hope I’ll forget to “take credit” for how sick Mr. X really is, so that his multiple hospitalizations and new power chair will hurt my clinic’s bottom line.

In other cases, it is more a matter of word choice: If somebody has fairly stable heart disease and takes nitroglycerin two or three times per year, “coronary artery disease” gets me no points, whereas “angina pectoris” jacks up my baseline a little.

Obesity is an interesting problem. If a patient is morbidly obese, that gives me more of this HCC “play money” to work with. Once they lose the weight, I will of course lose those dollars. But there are quality bonuses to be gained from treating obesity. However, Medicare will REJECT any and all claims for office visits conducted solely for the purpose of treating obesity.

There is obviously more money to be made, at least for the next several years, from aggressive coding than from looking over the shoulders of hospitalists and specialists. I can’t even tell from the hospital reports exactly what they did and why they did it. So how and why could I gain more from that than from becoming a Hierarchical Condition Category Coding expert?

This is what I not so fondly call Metamedicine.

(See also https://acountrydoctorwrites.wordpress.com/2014/07/24/medicine-is-easy-but-metamedicine-is-hard/. The diagnosis codes in that post are the old ICD-9 ones, but the principles still apply.)

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.

What is Healthcare and Who Deserves it?

Today’s news if full of commentary about work requirements for Medicaid. Is work a prerequisite for healthcare or is health a prerequisite for work?

Not to complicate things, but can we even agree on what healthcare is? I don’t think we can, and it largely falls back on what we want to share in paying for.

A patient with an ugly skin lesion can have it removed if it might be cancer or if it bleeds or causes pain. If it is just ugly, it’s considered cosmetic, and insurance won’t pay for it.

A man wants a vasectomy, while another one regrets having one and wants it reversed. Is one procedure more medically necessary than the other and more deserving of societal cost sharing?

Even the most esoteric medical procedures, like freezing embryos or cloning children, could be called healthcare, but may not have society’s support when it comes to being necessary or desirable.

And, even as we speak, what about abortions? Are they healthcare or not?

In many ways, I think life was simpler practicing medicine in Socialized Sweden. The Government paid and the Government made the rules. Here, the Government makes some rules, the insurance industry makes others; the Government pays for some people’s care and the insurance industry pays for others. And the insurance companies all have different rules.

Since healthcare costs twice as much in this country as anywhere else in the world, it seems painfully obvious that we need to talk about what the purpose of healthcare is and, from a moral perspective, what we have a right to expect our fellow countrymen/women (if not citizens) to pay for.

It is remarkable that such an enormous slice of our budget and our life so much lacks definition and almost seems to be taboo to openly try to debate.

If we look at other aspects of cost sharing in our society, can we draw any useful parallels?

If a high school senior wants to repeat his senior year because he had so much fun, should he be able to do it for free? (Just a hypothetical example, I don’t know if anyone would really want to.)

If a child calls the fire department every time she smells smoke from the family barbecue, should the town charge the family or stop sending a fire truck?

If an amateur sailor capsizes every weekend and always calls Marine Patrol, should they keep responding?

In social policy terms, the word entitlement is used to define programs like Medicare and Medicaid. I think that is an unfortunate and very loaded word. Contrast that with another word that I personally keep coming back to: Stewardship.

It is time for a serious conversation about balancing stewardship and entitlement in healthcare. At least as long as it is not all self-pay: Taxes or insurance premiums both imply we want someone else to pay for some or much of what we think of as our personal healthcare.

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…


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