A Country Doctor Writes:

Archive Page 155

It’s Time We Talk: Why Should Doctors Treat the Well and Nurses the Sick? – Part One

Published November 18, 2014 "It's Time We Talk..." 7 Comments

THREE PROVIDERS IN MAINE

Mary Hunt is a busy family physician with a full caseload. A twenty-five year veteran with an Ivy League medical degree and a residency training at an eastern seaboard tertiary care center, she has seen a lot, but she never jumps to conclusions or takes shortcuts. This makes her run late sometimes, but her patients don’t mind; they know she provides top-notch medical care.

Mary’s schedule is filled weeks in advance, and she seldom sees patients for acute illnesses. The bulk of her work is chronic disease management. Her EMR inbox is filled with prescription requests, results of standing lab orders, consultant reports, records from the emergency room, inpatient hospitalist service and the local walk-in clinic. Her office visits the past several years have become more and more scripted with checklists for the different quality measures from her Medicare Accountable Care Organization, NCQA and all the other agencies that measure her performance.

Almost every night after supper, Mary logs on to her EMR from home to finish office notes, go through results and answer “medical calls” from her medical assistant and her office case managers.

Megan Brown has been a nurse practitioner for two and a half years. She considers herself lucky to have Mary Hunt as her supervising physician. For the first two years after her graduation from her Masters program at the local branch of her state university, Dr. Hunt co-signed her chart notes and had weekly tutoring sessions, but now she is only available if Megan feels she needs help.

Megan has a small panel of patients of her own, but mostly she sees “acutes” down the hall from Dr. Hunt. She hates to interrupt the doctor because she sees how busy she is, but never feels put down for needing help managing a case. She often sees presentations that are unlike anything she has encountered in the four and a half years since she started nurse practitioner school. Before then, as a nurse, she was never exposed to the diagnostic process; she was more focused on assessing patients for comfort versus discomfort and for carrying out existing treatment plans.

Rhonda Smart has been a nurse practitioner for a decade. Before that, she was an emergency room nurse, which helped prepare her for a career as an independent frontline clinician. She has worked at a shopping mall urgent care center for three years now. She sees a fairly interesting variety of patients, but is starting to feel a little stale, because she rarely gets to hear how her patients make out. She sends her reports to the local primary care physician offices, but they never give her any feedback or updates. She does her shift and goes home and rarely spends much time with the other nurse practitioners who work at her clinic. She has no mentors and no peer group to share difficult cases or career conundrums with.

THREE QUESTIONS:

Is Mary Hunt doing what we want doctors to be doing in a way that is sustainable for her and her patients?

Is Megan Brown our best choice for first responder for undifferentiated medical symptoms and conditions?

Is Rhonda Smart growing in her profession or will her medical acumen shrink as she continues to work in the isolation of her storefront clinic?

Nailing the Diagnosis, Failing the Patient

Published November 14, 2014 Progress Notes Leave a Comment

Andy was new to me. He told me he had seen several doctors over the past few years for various pains in his right arm.

Some months ago, he had right shoulder pain that went away on its own, but for the past few weeks, he had pain in the middle of his upper arm. Last year he had tennis elbow and forearm pain for many months.

A slender, middle aged man, he had no unusual hobbies and denied injuries or neck symptoms. He was visibly uncomfortable as we talked and kept his left hand tightly gripping his right upper arm, held close to his chest.

He had full movement of his neck and normal sensation to touch of both arms and hands. His intrinsic hand muscles were not atrophied. In fact, his grip was stronger than mine.

I asked him to abduct his shoulder forward and to the side, which he did without pain, even when I resisted his movements – a sign of an intact rotator cuff.

When I asked him to place his right arm over his head, he volunteered that he sometimes slept with his arm in that position as it offered some relief from his otherwise unrelenting pain.

I excused myself with the words “let me get my wiring diagram”. Returning with my tattered paperback copy of Mumenthaler’s pocket neurology textbook from the early seventies, I showed him its picture of the cervical dermatomes.

“You have a pinched nerve in your neck, the fifth cervical nerve, and some of the pains you’ve had before sound like they could have been from the sixth nerve also”, I told him.

His eyes widened. “You know, I did fracture my C-5 twenty seven years ago in a skiing accident, but I’ve never had any issues with my neck since that year”, he said.

We talked about what his options were. Because the pains had come and gone before and had only been severe for a relatively short time, and because his muscle strength was intact, I explained that a short course of steroids might help, at least in the short run. I also offered him pain medication.

“I’ll take the steroids but I’ll pass on the pain relievers. I hate the idea of taking those things”, he said emphatically.

I went over the dosing and side effects of the prednisone and said “if ten days of this doesn’t help, I would go ahead with an MRI”. He nodded agreement and we set up a follow up appointment eleven days later.

Day ten was a Monday. Among the weekend faxes from the hospital that landed on my desk that morning were two emergency room reports about Andy.

The first report, from late Friday night, told of how his pain had escalated steadily since he saw me. They had done plain X-Rays, which showed bone spurs and narrowed disk spaces from C-4 to C-6. They gave him some 5 milligram Percocet, which helped his pain, and sent him home with a prescription for 10 milligrams every 4-6 hours as needed and instructions to keep his follow up appointment with me.

The second ER visit, eighteen hours later, was for nausea and vomiting. The five milligram tablet Andy took in the ER Friday night was just right, but the ten milligram tablets, which he had dutifully taken every four hours, were too strong.

“Did you try breaking the pills in half?” I asked when I saw him back in the office.

“I guess I could have, but I didn’t really think of it”, Andy answered.

“I feel terrible that you ended up going to the ER twice”, I confessed, “because I should have told you that if the prednisone hadn’t done anything after three or four days, it probably wouldn’t work at all. If I had, you would have known before the weekend that you needed to let me know.”

“Ah, that’s all right”, Andy said, but I kept thinking about how the most accurate or clever diagnosis is of little use to a suffering or fearful patient if you aren’t clear enough about what seems like a straightforward plan to you, but not to a patient who never had the experience of being sick or taking medications before. As doctors we assume all patients will make the necessary judgement calls on their own.

I failed Andy and the first emergency room doctor failed him, too. We rattled off our standard instructions without making sure he understood what to do if our treatment plan didn’t work.

That’s the Art that sometimes gets lost in this business.

Checklist or choke list?

Published October 22, 2014 Reflections 5 Comments

Medical errors happen every day. Few make the headlines, but when they do, almost everyone who chimes in to comment offers the same type of solution for avoiding them. Three of the most common are guidelines, decision support and checklists.

From my vantage point as a primary care physician I agree that checklists, in particular, can enhance clinical accuracy, but some of the lists I have to work with in today’s healthcare environment are more likely to bog me down and distract me than focus my attention on the essentials. I call them choke lists.

Re-reading “The Checklist Manifesto” by Atul Gawande, published in 2010, the year before my clinic implemented their first EMR, I am reminded of how much has changed since then. How I work and where my attention is drawn has changed because of the minutia of Meaningful Use, Patient Centered Medical Home, Accountable Care and all the other new philosophies and forces that define primary health care. Each one has their own set of checklists, many only slightly different, and none of these lists actually improve diagnostic accuracy; this is somehow taken for granted, or perhaps not addressed because the creators of these checklists, as non-physicians, simply have nothing to say about that aspect of healthcare.

Gawande writes: “There are good checklists and bad….Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brain off rather than turn them on.”

A very simple way to “turn on” or focus providers’ brains is to adhere to a structured format of clinical assessment, but to avoid unnecessary rigidity after that. After all, in my world we have 15-30 minutes at most with every patient for a fee of $50-150. You can only cram so many prescribed agenda items into that kind of time frame before your time is up.

Today’s checklists would have me ask every patient, apart from figuring out what is wrong with them, if they are homeless, home bound, safe from domestic abuse, if they have scatter rugs, firearms in the house (not a legal question in Florida, however), if they are a caregiver and several more things I can’t remember. I am sure the architects of these templates meant well, but the end result of long lists like this is that physicians risk not paying attention to the forest because of all the trees. A more appropriate checklist could summarize all these items in one question: “Have you considered the patient’s home environment?”

One item I haven’t found in my new EMR is what we in Sweden always used to include in our medical histories, “Epidemiology”. This simple word prompted the question “Do you know anybody else with the same symptoms as yours?” It is a question I overlooked at least once that I will always remember:

I was fresh out of residency, working in a small town in Maine. A middle aged man came to see me about nausea, loss of appetite and abdominal pain of more than a week’s duration. I didn’t know what was wrong with him, so I ordered some labs and an upper GI series. His CBC was mildly abnormal and while I was waiting for his x-ray to get done, my partner and employer ran into him in the grocery store one Saturday. Doctor Joe approached me the following Monday and told me not to bother with the x-Ray: “Mr. Billings’ dog was just diagnosed with lead poisoning. You might want to check a lead level on him”.

Talking to Mr. Billings, he had been scraping paint off his old farmhouse with his Golden Retriever faithfully waiting at the bottom of the ladder, inhaling the dust from the dried and cracked paint. It never occurred to me to ask about “epidemiology” the way I had been taught, because I had dismissed infectious causes of Mr. Billings’ symptoms almost subconsciously and never considered environmental exposure, which also falls under the “epidemiology” heading.

A similar but more dramatic incidence in “The Checklist Manifesto” involved a surgeon who thought he had all kinds of time to get ready to explore and repair a small stab wound inflicted at a Halloween party. Suddenly the patient’s blood pressure bottomed out and as the surgeon hurriedly entered the abdominal cavity and found it filled with blood, he remembered he had neglected to ask about the weapon that had caused the stab wound. He later found out it was a bayonet, which turned out to have lacerated the abdominal aorta – he had only assumed it must have been a pocket knife.

Obviously, no check list can be complete enough to include questions about scraping lead paint for every person with abdominal pain and asking about having been stabbed by a bayonet in every laceration – only more general and somewhat open-ended questions will get you all the answers in a reasonable amount of time.

Quoting Gawande again, “The checklist cannot be lengthy. A rule of thumb some use is to keep it between five and nine items, which is the limit of working memory.”

As I contemplate how to continually improve the care I deliver while also addressing the increasing demands for fulfilling and documenting the Government’s requirements, I think I can use my computer and my EMR to streamline the way I meet all the requirements. But I think it’ll be up to me to create my own clinical checklists, because the Government issue doesn’t seem to be my size, which reminds me of another set of Swedish experiences I had – boot camp, blisters and learning to march in formation and follow orders without complaining.

Hopefully, the “official” checklists will evolve over time as people have a chance to assess their impact. Again, quoting Dr. Gawande:

“…no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart….and one needs to study how, make changes, and keep testing until the checklist works consistently.”

Welcome to the real world, any time you wish to see what it’s like, Mr. President, Ms. Congresswoman, Mr. Insurance Executive, Ms. EMR vendor!

Requests Denied

Published October 11, 2014 Progress Notes 3 Comments

In my mind I was debating whether the woman in front of me was my second-ever case of a brain abscess or if perhaps during one of her recent falls, she might have suffered an intracranial bleed. She was taking warfarin for atrial fibrillation and her frontal headaches and nausea with vomiting had been getting worse over a four week period. My own father almost died in his fifties from a chronic subdural hematoma. This woman looked like something between my brain abscess patient and my father just before he was diagnosed.

Gwen Garfield was congested and blamed her nausea and vomiting on her purulent post nasal drip. She was clearly not a complainer; she split her own firewood and walked with a severe limp from childhood polio. Her regular physician, Dr. Landry, is out this week, but his nurse has been helping Autumn out, and she told me that Gwen wasn’t her usual self at all. She had even asked a friend to drive her in because of how poorly she felt.

Both her maxillary sinuses were tender and she had nasal congestion and her forehead was wrinkled over lowered eyebrows in a static gesture of concern. Her neurological exam had no specific abnormalities, but she seemed just a little vague for a woman with her reputation. She fumbled with her keys and reading glasses and dropped them on the floor, but her finger-nose coordination was surprisingly normal.

I prescribed her some cefuroxime for her presumed sinusitis but also told her I felt she needed a CT scan of her brain before the three day weekend, especially since she lives alone far from town and “off the (electric power) grid”. “We have to rule out a bleed and an abscess”, I told her.

Because her insurance, Aetna, requires prior authorizations, I typed and clicked my office note and put the CT request in as quickly as possible and had Autumn call the referral coordinator to get the prior authorization request going.

I sent Gwen and her friend to the pharmacy and told them to check back with us in a little bit. By 1 pm we got word that her CT scan was denied. I felt concerned enough and it was already late enough in the day that I wasn’t going to risk wasting more time with an appeal with the long weekend coming up. Besides, I was the only doctor covering our whole clinic with an overbooked schedule and also responsible for the large nursing home in town; I know how long the insurance companies can keep you on the phone when you try to appeal a denial.

I told Gwen and her friend to drive down the road to the emergency room, because they don’t need prior authorizations for CT scans. Then I called Jim Anderson, the ER doctor on duty, and told him I hated to dump on him but my patient needed a scan that her insurance wouldn’t pay for.

“Well, they will pay for it now”, he said laconically after I painted my thumbnail sketch of Gwen’s history and exam.

Two hours later we got a fax saying that, after further review, Gwen’s CT scan was approved. By that time Autumn was able to get the results from the hospital computer – no bleed, no sign of an abscess. Jim added a steroid nasal spray to my antibiotic for her sinuses. Aetna ended up paying for my office visit, the CT scan and an emergency room visit I would have wanted to avoid.

The afternoon flew by. Everybody was patient with me for running behind. The nursing home did call a few times to make sure we had received the faxes they had sent us between 2 and 4 pm. As I worked my way through lab results and requests for decisions about coughs, fevers, urinary tract infections, hallucinations and other odds and ends, I gasped internally when I came to the last one.

It was actually a stack of pages, all about the same thing: A dying man had been prescribed subcutaneous injections of morphine and lorazepam placed under his tongue, two staple drugs of “comfort kits” used by hospitals, Hospice agencies and nursing homes all over the world to ease the discomfort of dying patients. The patient’s Medicare D plan, WellCare, had already denied coverage for these two generic drugs. Another provider doing rounds at the nursing home yesterday had filed an appeal, and this appeal, too, had been denied.

The nursing home asked me to write a note to WellCare to appeal.

I usually manage to retain a fair amount of what Sir William Osler referred to as aquanamitas, the seasoned physician’s unflappability, but at 4:30 this afternoon I had already had enough of arbitrary and insensitive insurance companies lacking common sense and human decency. I wrote:

“In my thirty years as a family physician, I have never seen such cruelty as denying a dying man the relief of his final agony with basic, generic drugs like morphine and lorazepam.”

I don’t know yet if that did any good. The nursing home has a supply of these drugs on hand, so for now the patient has been getting what he needs, but to me, this struck at the core of what we all have the right to expect our insurance companies to cover.

Osler, the father of modern medicine, said: “To prevent disease, relieve suffering and to heal the sick – this is our work.”

This is unfortunately not quite the work of the insurance companies.

It’s Time We Talk About Who Should Do What in Healthcare Teams

Published September 30, 2014 "It's Time We Talk..." 5 Comments

“Team based care” is one of today’s buzzwords without real substance, because unless the payment systems change, only the physician members of the “team” can bill for their work.

Few people seem to be concerned with the simple but essential question of how physicians spend their time and how medical offices are paid. As a primary care physician who doesn't do any major procedures, and who in 2014 is essentially paid fee for service, I should bill around $400 per hour – $7 per minute, to put it bluntly – for my employer to stay afloat and for me and our support staff to stay employed.

Physician review and oversight of the team’s efforts, which is a medical and medicolegal necessity, is an unreimbursed activity. So, how much enthusiasm do the healthcare experts really expect to see for schemes that have computers, apps and non-physicians gather information for physicians to act on without seeing the patient – and thus, without the clinic collecting a fee?

But also, taking a medical history, for example, is not necessarily a simple task that can or should be delegated to team members with little or no training for it. Just like employers who interview prospective new employees themselves, or at least have a seasoned Human Resource professional do the job, doctors do more than just ask questions and record the answers. They pay attention to the person’s posture, attitude, facial expressions and willingness to provide the information.

Would a journalist have someone else interview a politician and then feel he could write a credible feature article based on the other person’s notes?

How truthful and accurate are the answers our patients give in the mandated depression screenings our medical assistants administer in our clinics? How many patients just barely even tell their doctor their innermost feelings and thoughts?

The reality in medicine is that the licensed professionals need to do the bulk of patient interacting and decision making, because that is what they are trained to do. Other team members need to be part of the process by preparing for visits, facilitating the plan that is outlined in the medical record, fielding questions and carrying out standing orders. I don't advocate for less involvement by support staff, but actually more. For example, I feel the front desk staff needs to know which patients and which types of symptoms require more time and which ones require less, in order to be able to schedule appointments intelligently and make the best use of physicians’ time. I also think each provider’s primary nurse or medical assistant should read all office notes after they are completed, so that if a patient calls back with a problem the medical assistant has an immediate awareness of how this patient can best be helped.

Similarly, if a patient is fit into the day’s schedule, a team member who reads the chart in order to make sure pending reports are available and who scans the phone messages and other things that have happened since the last visit can help the physician “hit the ground running”. Also, making sure at check-in that the patient doesn't have an immediate and different concern that may change the plan for the day avoids wasting everybody’s time in the visit.

Team members in a primary care office who know the patient and know what usually happens in typical situations are invaluable. Most primary care offices don't have team members with professional licenses that allow them to make clinical judgements, but just by being facilitators and advocates, they can easily double a physician’s productivity.

Which team effort moves the care forward most efficiently? Having medical assistants give depression screenings and smoking cessation counseling or making sure everything needed for the visit is available? Patients with urinary symptoms need to have a urine test, wound care visits must have all necessary supplies at hand and hospital follow-ups must have not only the discharge summary but also the consultations and all test results available, or the practice loses $7 for every minute of wasted physician time. It may seem mundane to today’s healthcare visionaries, but such efforts keep the doors open.

There is a strange cliché in use here, “working to the top of your license”. This has been used to justify letting support staff take over screening and education duties. It has not been applied to freeing physicians from clerical tasks like entering data that used to be done by transcriptionists.

I am not afraid to clean exam rooms after my visits are done, or anything else that keeps the office flow going. But I get a little frustrated when non-medical people opine that taking histories, doing physical assessments and counseling patients is so easy that anyone can do it. Sure, I can wire a three-way light switch and solder a copper pipe, but electricians and plumbers do it better, faster and neater. That isn't something for me to be embarrassed about – they have more experience doing it, just like I have more experience taking medical histories than nurses and medical assistants, because it is what I do for a living.

I do support making use of special talents; we once had a medical assistant who was a natural motivator. She took courses in motivational interviewing and became our smoking cessation counselor. But a blindly applied “working to the top of your license” is also known as “the Peter principle” – push everyone to their limit, where they can no longer do what is asked of them.

I don't know if I am just less aware of this in other “industries”, or if this is something unique to non-medical policymakers’ vision of medicine: There is less and less respect for professional training, skill and experience. If this were declared as a social experiment or an “equalization” effort, I would understand (after all, I grew up and trained in a Socialist country), but that is not quite what I hear.

My next topic in this series will be doctors, nurses and nurse practitioners – who should do what?

« Previous Page — Next Page »