A Country Doctor Writes:

Archive Page 137

All or Nothing

Published April 8, 2017 Progress Notes Leave a Comment

The other day, as I was wrapping up my visit with Mrs. Brown, she said:

“Harry is no better, he is coughing and spitting something wicked.”

Her husband, silent during the visit, was unshaven and looked a little tired.

“How long have you been sick?” I turned to him.

“Going on two weeks now. The cough medicine I got last week hasn’t helped.”

I opened his chart in the computer. He had been in six days earlier. A colleague had noted that his lungs were clear and diagnosed him with a viral illness.

“Let me listen to you”, I said.

He had scattered rhonchi and a few wheezes, and at the bottom of his right lung I heard faint crackles.

“You need an antibiotic”, I said, and made sure he didn’t have a fever and that he wasn’t too short of breath.

I created a “new telephone encounter”, documented my findings and e-prescribed an antibiotic for him.

“Be sure to come back if things don’t turn around quickly”, I said.

There’s no way I could charge him for a brief visit. And that’s got nothing to do with whether I wanted to increase my productivity numbers or our clinic revenue.

In this day and age, there is no such thing as a quick visit to make sure someone is okay or to avert clinical deterioration or disaster.

In order to meet all our quality requirements for being a patient centered medical home and all the other ways we are judged and measured, a visit note has to include, even if the patient was seen just one single day before, a complete medication reconciliation, updated past medical and surgical history, social history and specific questions about any other care the patient has received since last seen. In our EMR it would be impossible to get around all these clicks by building a note template that says nothing has changed since last time; the computer tracks the actual clicks we make in the EMR.

So in cases like Harry Brown’s, I have these choices: Treat him for free right then and there, make him come back some other time when we have time for all the extras, or send him to walk-in care in the big city.

My choice is clear, but I can’t help wondering if the people who created the requirements for overambitious repetitive inquiries into the past history of people we already know quite well really understood that instead of becoming more patient centered, we would start giving free care or turn away patients and thereby fragmenting their care.

Stop Excessive Measurement

Published April 6, 2017 Progress Notes 2 Comments

“Stop Excessive Measurement.”

Those three little words were music to my ears. The fact that they were spoken by Don Berwick, creator of the Institute for Healthcare Improvement and former head of Medicare, made them even more significant.

I was in our state capital today for a regularly occurring conference by Maine Quality Counts. The theme was “Achieving Excellent Patient & Provider Experience”. There was a lot of talk about provider burnout. Dr. Berwick spoke of the central role of the provider-patient relationship and the failures of the current quality movement.

He told a touching vignette about his brother, who is a patient in a rehabilitation facility. All his brother wants right now is to go outside for a few minutes and experience spring, but the rehabilitation hospital is so focused on keeping their falls statistics down that they haven’t been able or willing to work with him to see how he can safely meet his goal.

Berwick more or less said that if you serve your patient well and keep his or her needs in sharp focus, quality will improve, waste will decrease and provider burnout will diminish. How refreshing.

His remarks were originally made at the IHI and published in JAMA a year ago today, during a time when I fell behind in my journal reading.

He describes three eras in medicine.

The first era was the autonomous physician, serving a calling and belonging to a self-regulating profession. Science exposed variation and inconsistencies in the healthcare of the first era, and a second era was born.

That second era, which we now live in, is the era of accountability, measurements and incentives.

The ideals of those two eras are incompatible, but they point the way to a possible third era, which he calls the moral era, where providers are subject to fewer measurements because organizations trust their commitment to their patients and to the principles of quality.

I need to hear things like that now and then.

Watch Don Berwick speak about the third era:

Why Can’t We Speak Our Own Language?

Published March 23, 2017 Opinions 2 Comments

My voice recognition software insists on typing “when needed” when I say “PRN”, and the other day I saw an orthopedic note that said “before meals joint”. I was sure that the straight-laced orthopedic surgeon was not intending to tell the world anything about anybody’s cannabis use. Instead, it was obvious he had spoken the words “AC joint”, meaning acromioclavicular (on top of the shoulder). But AC can also mean “before meals”, (ante cibum).

Hospitals and health care credentialing bodies make us use plain English instead of medical terms and abbreviations. They say it is to avoid confusion. I think it often creates confusion when doctors are forced to speak as if we didn’t know medicine.

Why are we singled out for this dumbing down? Why are we robbed of the language of our own craft?

How would it be if the tech industry couldn’t use abbreviations like LCD, LED and HDTV?

What if Wall Street outlawed terms like hedge, spread and spot market?

What if military jargon was verboten in the war rooms of the Pentagon?

What if coaches weren’t allowed to scream any technical terms to their teams from the sidelines?

Do we really think a jargon free, plain speaking world will move with greater accuracy and with anywhere near acceptable speed if we remove the majority of the new language our progress was built on?

Remembering the Inpatient Workup: All the Tests to the Patient’s Bedside

Published March 19, 2017 Reflections 2 Comments

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.

Medicine is a Love that Finds Us

Published March 14, 2017 Progress Notes Leave a Comment

Medicine is a love that finds us wherever we happen to be.

It snatched me, a quiet four year old boy, almost sixty years ago. I don’t know how it happened. I remember being in the hospital and having stomach X-rays and I have also been told we had a family doctor who made house calls. I couldn’t have seen doctors on TV, because television was only introduced in Sweden when I was three and I saw my first program at age 5, a show about an infantile doll named “Andy Pandy”.

At age four I simply announced that I was going to become a doctor and I never hesitated after that. It seems everything I did from that moment on prepared me for what I do now: Being a Boy scout who made do with what I had on hand; learning discipline as a military recruit in basic training; working as a substitute teacher for fifth to ninth grade students; spending a summer as the pastor’s assistant with confirmation students and in his parish, and traveling the world to interview people from other cultures.

In my day to day work I always look for the story behind each patient’s symptom and even behind their laboratory values. I often find myself circling around the concept of Narrative Medicine.

The other day I happened to read the Swedish journal for general medicine (Allmän Medicin). A doctor, who seemed to be about my age, had written about his experiences with Narrative Medicine and the tension he used to feel between it and today’s Evidence Based Medicine.

The writer’s name was Christer Petersson, and he looked and wrote as if he was someone I had known from High School. I Googled his name and found another article he had written, in 2009, in the Swedish Medical Journal, Läkartidningen.

That article was titled “I worked as a Doctor for 20 Years. Then I Became a Doctor”.

I did a quick double take and continued to read, finding exactly what the title suggested: He had studied medicine because the science interested him and it seemed like a good thing to do. He was a young man with big thoughts and big ideas. But he felt uninspired by learning about the digestive system and was uncomfortable with the notion of treating mundane things like bleeding, boils and open wounds.

He writes:

“It took about 10 years and quite a bit of agonizing before I discovered that I was exactly where I was supposed to be, and it took another 10 years to understand that I actually was a doctor and didn’t just work as one. During that time I learned that man is more than his digestive system and the most important events in life often happen in the seemingly uninteresting space where blood flows, boils burst and wounds heal.”

And then, he paraphrases Hippocrates’ first aphorism:

“And I saw that it is equal parts suffering and joy to deal with all this as a doctor: to cure sometimes, treat more often and comfort the best you can.

It doesn’t get any better than that, does it?”

Different journeys to the same destination.

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