A Country Doctor Writes:

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I Have a Strong Relationship with my Bank but I Almost Never Go There. How Could this Translate to Primary Care?

Published September 9, 2019 Progress Notes 10 Comments

Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch – and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.

Of course that’s not how banks operate. There are small ongoing charges (or margins off the interest they pay you) for keeping your money and for making it possible to do almost everything from your iPhone these days. Yes, there may be additional charges for things that can’t be done without the bank’s personalized assistance, but those things happen at your request, not by the bank’s insistence.

Compare that with primary care. The bulk of our income is “patient revenue”, what patients and their insurance companies pay us for services we provide “face to face”. We may also have grants if we are Federally Qualified Health Centers, mostly meant to cover sliding fee discounts and what we call “enabling services” – care coordination, loosely speaking.

Only a small fraction of our income comes from meeting quality or compliance “targets”, and those monies only come to us after we have reached those goals – they don’t help us create the needed infrastructure to get there.

Then look at how medical providers are scheduled and paid. We all have productivity targets, RVUs (Relative Value Units – number and complexity of visits combined) if our employer is paid that way and usually just straight visit counts in FQHCs (because all visits are reimbursed at the same rate there). Sometimes we have quality bonuses or incentives, which truthfully may be the combined result of both our own AND other staff members’ efforts.

As we are now starting to think of how to make the transition to a system that pays medical offices not for the number of visits but for the overall health of our patients (as defined by our quality metrics), we should ideally free up doctors’ time to review and act on health data that comes to us in more ways than face to face visits – but there’s a catch: We don’t think we can afford to have our docs see fewer face to face visits, because right now there is no money in what in the future will compare to the bank’s cash flow that their customers generate when they use online banking, ATMs and so on.

If a patient sends me a list of blood pressures or blood sugars, there is a cost for us to review and act on them – lost lunch breaks, unreimbursed overtime (”provider pajama time”) OR lowered productivity targets (for face to face work in an organizational leap of faith that these efforts will actually result in incentive payments some time down the road).

Most medical offices are quaintly or hopelessly old fashioned in our approach to the changing demands and desires of our payers and our patients. It is hard to make the transition to something new: We are being asked to start working differently and potentially making less or spending more without knowing for sure if it will pay off.

(The Banking business analogy can only go so far. After all, healthcare is still a humanitarian endeavor: More and more payers want us to “take risk”. I bet. Your patients cost more to care for, not just in the office but in hospitals you have no control over. Result: You lose money. But when the bank takes risk, they charge accordingly and if you’re a terrible credit risk, they’ll turn you down. Doctors can’t turn away patients because they are too sick and a bad financial risk. We can only view what we do as a business up to a point. Banks and insurance companies have actuaries and people like that whose entire careers involve projecting costs and calculating risk. Even big medical practices don’t have that. So while I think we can emulate banks in our interactions with patients, I don’t think it’s fair to ask us to behave like banks in every aspect of what we do.)

A Country Doctor Reads: September 7, 2019 – Workarounds in Healthcare, Empathy in he Age of the EMR, US vs Swedish Postoperative Pain Management

Published September 7, 2019 A Country Doctor Reads 2 Comments

The American Medical System is One Giant Workaround – NYT

The nurses were hiding drugs above a ceiling tile in the hospital — not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn’t want patients to have to wait.

So begins an article in Friday’s New York Times. How many times have I used or thought of the word “workaround” recently? Lots, certainly in my personal life, with an older house, an older car, in far northern Maine. But as a descriptor of our country’s entire healthcare system? Well, to be honest, there’s a lot to that notion…

The United States spends more per person on health care than any other industrialized country, yet our health outcomes, including overall life expectancy, are worse. And interventions like bar code scanning are a drop in the bucket when it comes to preventable medical mistakes, which are now the third-leading cause of death in the country. Our health care nonsystem is literally killing us.

As the workarounds accumulate, they reveal how fully dysfunctional American health care is. Scribes are workarounds for electronic medical records, and bar code scanning is a workaround for our failure to put patient safety anywhere near the top of the health care priority list.

www.nytimes.com/2019/09/05/opinion/hospital-workaround-health-care.html

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Empathy in the Age of the EMR – Danielle Ofri, MD

Danielle Ofri has another article on the plights of today’s physician, this time in The Lancet. I had offered some feedback on her article “The Business of Healthcare Depends on exploiting Doctors and Nurses” in The New York Times some months ago, and I ended up joining her mailing list. This just arrived in my inbox and it certainly resonates:

Many of us physicians muddle through our clinical encounters in this manner. We’re half-listening, half-typing, half-processing what tests we’ll need to order, half-chiding ourselves about an oversight from our last patient, half-ignoring the red-flag alerts that keep cropping up, half-thinking about the next three patients in the waiting room, and half-pondering whether one of the EMR buttons could do something practical like conjure up a cup of coffee and a sandwich.

The only thing that’s not diminished by half is the feeling that we’re cutting corners on every front and scraping by with mediocre medical care.
— Read on danielleofri.com/empathy-in-the-age-of-the-emr/

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US, Canadian and Swedish Postoperative Opioid Prescribing – JAMA

I had an open appendectomy in Sweden back in 1972, weeks after returning from my year as an exchange student in Massachusetts. I remember distinctly that I was in relative agony but never asked about my pain level or offered anything for pain while I was recovering in the hospital. I remember spending a few days there. Then, as now, the Swedish healthcare system is lean on interventions and generous with bed-days, so by the time I was discharged I didn’t hurt much at all.

I was aware that Swedish patients to this day don’t receive as much pain medication as Americans, but I had no idea of the magnitude. This week I read an article that pegs the numbers – a seven fold difference:

This cohort study determines whether there are differences in the frequency, amount, and type of opioids dispensed after surgery among the United States, Canada and Sweden.

In summary, we observed differences in opioid prescribing after low-risk surgical procedures across 3 countries in North America and Europe. Patients treated in the United States and Canada received opioids after surgery more often and in higher doses compared with patients treated in Sweden. These findings highlight opportunities to encourage judicious use of opioids in the perioperative period in both the United States and Canada. Understanding the societal and cultural factors that influence these prescribing patterns could inform areas of further research and identify targets for future interventions.
— Read on jamanetwork.com/journals/jamanetworkopen/fullarticle/2749239

When Was the Last Time You Saved Somebody’s Life?

Published September 5, 2019 Progress Notes 1 Comment

I got an email Saturday from Laurence Bauer of the Family Medicine Education Consortium.

Larry said that when he talks to doctors and residents about saving lives they usually think of their preventive medicine efforts and few people have stories about the short term impact they have on people’s lives. Larry asked me if I had anything to say or write about that.

The first thing that comes to my mind is my work with substance abuse, our medication assisted treatment, which I still do for Bucksport via telemedicine even though I live and otherwise work 200 miles north of there. Statistics show that immediately upon entering a Suboxone program participants risk of dying from an opioid overdose is reduced by 50%. So it’s possible I’ve saved a life or two there. At the annual staff appreciation day in August patients from the Suboxone program had written greetings to me on the whiteboard and a couple of them had written that I saved their lives.

The other thing I think of is the triage type of decisions we make. Somebody comes in with chest pain and we have to decide whether or not to send them to the emergency room or order tests for heart disease or blood clots in their lungs. We’re supposed to make the right decision and when we do we don’t necessarily get a thank you card or anything. Perhaps if we don’t, there would be all kinds of repercussions. Very often in our line of work our reward is the absence of negative feedback.

In less dramatic cases, we make choices all the time that could be life altering or life saving. When we order an x-ray or CT scan rather than say, “let me know if it doesn’t get better”, we could be in a lifesaving situation, but once you have been practicing for a few years you don’t reflect on that as much as when you first start out.

In my post “Primary Care is Messy” I wrote about this five years ago, although I didn’t even remember the incident until I searched my own blog for “saved my life”. For non-physicians it may seem incredible that one might not remember a story like this one, but when you see sixteen to thirty patients day in and day out for forty years, you can only make so many personal notes and still keep up the pace.

“Knowing what constitutes success in frontline medicine is not easy. Let me illustrate:

A middle aged smoker comes in for a follow up on his blood pressure treatment and mentions that he would like to try Chantix (varenicline) to help him quit. My nurse has already secured our practice credit for documenting his smoking status. I can use certain billing codes to document my counseling on the subject, and I can get credit for printing out the drug information, even though the pharmacy also provides a printout. This is a successful visit, it might seem.

But I also ask, “Ron, what makes you want to quit at this particular point in time?”

“Well, I’ve had this funny cough, like a dry hack, for the last two weeks whenever I take a deep breath”, he answers.

Ron turns out to have a very small, resectable lung cancer. My question about the reason for his request probably saved his life, and catapulted us from shallow administrative success to probable or at least possible clinical victory, without making any further difference in my own quality metrics.”

So, Larry, I think there is a lot of focus on doctors supporting each other when they feel burned out or inadequate, but I’m not hearing much about taking notice and stopping to celebrate the small and large clinical and relationship progress or downright victories we have in our everyday work. With no doctors lounge to visit anymore (another blogpost of mine from just four months ago), how do we do that?

Magnesium Deficiency: An Undiagnosed Epidemic Behind the Epidemics of Heart Disease and Diabetes

Published September 2, 2019 Progress Notes 6 Comments

A patient who hadn’t felt good for many years came in the other day and told me an osteopathic physician she had gone to for OMT, manipulative treatment, had suggested she take a basic 400 mg magnesium supplement and it had been life changing for her.

She handed me a xeroxed little essay the osteopath had written about the many functions of magnesium in the human body and the symptoms of deficiency.

All her vague gastrointestinal symptoms were gone, her skin had cleared, her energy level had improved and she felt more clearheaded.

“What was your level?” I asked.

“He didn’t check it” was her answer.

I didn’t know what to think, I mean it’s probably harmless to take, but without knowing the level…

I started looking into this and the more I read, the more intrigued I became.

I found several articles from the last century (the 1990’s) all the way up to last week (news that excess vitamin D can lead to osteoporosis, apparently through lowering bone magnesium levels), all saying mostly the same things:

Even though magnesium is abundant on this planet, many people (for example 80% of postmenopausal women with osteoporosis) have low intracellular magnesium. Almost half the US population consume less than the recommended daily amount of magnesium.

Serum levels of magnesium tell us nothing about total body magnesium, because we are programmed to pull magnesium from our tissues to keep blood levels in range. Only 1% of our body’s normal 25 grams of magnesium is found outside our cells, and about 90% is found in bone and muscle cells.

Magnesium is essential for the function of 300 enzymes, mitochondrial ATP production and activation (cellular energy), synthesis of DNA, RNA and protein and regulation of ionic gradients (keeping sodium and potassium levels normal).

Magnesium deficiency is linked to inflammation (as measured by C-Reactive Protein, CRP), atherosclerosis, vasospasm, insulin resistance and metabolic syndrome as well as isolated hypertension.

Magnesium deficiency has been linked to sudden cardiac death.

The magnesium content of ur modern diet is decreasing, because of more and more processing of food as well as modern farming practices and soil depletion; we are also consuming things like phosphorus (in soft drinks) that lower body magnesium levels.

According to the NIH:

“Early signs of magnesium deficiency include loss of appetite, nausea, vomiting, fatigue, and weakness. As magnesium deficiency worsens, numbness, tingling, muscle contractions and cramps, seizures, personality changes, abnormal heart rhythms, and coronary spasms can occur. Severe magnesium deficiency can result in hypocalcemia or hypokalemia (low serum calcium or potassium levels, respectively) because mineral homeostasis is disrupted.”

Not only can low magnesium contribute to the development of diabetes, but there are indications that magnesium supplementation may improve blood sugar control in diabetics. Magnesium supplementation has been shown to improve lipid profiles. Other not yet certain possible benefits of magnesium supplementation are migraine prevention and asthma control.

People at risk for magnesium deficiency, besides diabetics, include the elderly, patients taking diuretics or Proton Pump Inhibitors, those with inflammatory bowel disease or chronic diarrhea from other conditions, patients who have had small bowel surgery, people with gluten sensitivity and patients with alcohol or soft drink dependence. Perhaps surprisingly, people who exercise vigorously can also become magnesium deficient.

Foods that supply good amounts of magnesium include almonds (check), spinach (check), black and kidney beans (check) and avocado (check), and also some things that aren’t on my meal plan: Peanuts, soy milk, shredded wheat, bread (presumably whole grain) and yogurt.

So, this is from someone who usually doesn’t think much of vitamins and supplements: Because I’ve been taking PPIs for my hiatal hernia since they first came out and because my blood pressure is higher than I’d like in spite of being pretty ideal weight – I picked up a bottle of magnesium capsules the other day.

And the more I read, the more I worry about the decreasing nutrient value of much of our mass produced foods. The BMJ article cited below points out:

“The loss of magnesium during food refining/processing is significant: white flour (−82%), polished rice (−83%), starch (−97%) and white sugar (−99%). Since 1968 the magnesium content in wheat has dropped almost 20%, which may be due to acidic soil, yield dilution and unbalanced crop fertilisation (high levels of nitrogen, phosphorus and potassium, the latter of which antagonises the absorption of magnesium in plants).”

Here are two comprehensive references:

National Institute of Health Office of Dietary Supplements Fact Sheet for Health Professionals

Subclinical magnesium deficiency: a principal driver of cardiovascular disease and a public health crisis (BMJ)

A Country Doctor Reads: August 31, 2019 – Polypill for CVD risk reduction; Assisted living is a money-making fantasy; Why doctors should read business journals

Published August 31, 2019 A Country Doctor Reads Leave a Comment

The Polypill is Back – The Lancet

One of my first posts on “A Country Doctor Reads”, in 2011, was about a Polypill study that promised dramatic reductions in cardiovascular disease rates from a combination of inexpensive generic ingredients. In the past few weeks another such study reported similar results in The Lancet. When will we be able to prescribe something like this? So far, I’ve only seen Caduet, a combination of atorvastatin (Lipitor) and amlodipine (Norvasc), which was an expensive brand name for many years…

— Read on acountrydoctorreads.wordpress.com/2011/02/26/trial-begins-of-another-polypill-for-stroke-and-heart-attack-prevention/

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Assisted Living is a Money-making Fantasy – The New York Times

There are nursing homes, boarding homes and assisted living facilities. I have certainly seen patients who are unsafe on their own at home who themselves or whose families are hoping they “don’t have to go to a nursing home”. But assisted living facilities, just like their advertisements often suggest, are really only for people who want an extra level of support available in case they need it, but not right now.

“Assisted living seems like the solution to everyone’s worries about old age. It’s built on the dream that we can grow old while being self-reliant and live that way until we die. That all you need is a tiny bit of help. That you would never want to be warehoused in a nursing home with round-the-clock caregivers. This is a powerful concept in a country built on independence and self-reliance.

The problem is that for most of us, it’s a lie. And we are all complicit in keeping this dream alive.

The assisted living industry, for one, has a financial interest in sustaining a belief in this old-age nirvana. Originally designed for people who were mostly independent, the number of assisted living facilities has nearly tripled in the past 20 years to about 30,000 today. It’s a lucrative business: Investors in these facilities have enjoyed annual returns of nearly 15 percent over the past five years — higher than for hotels, office, retail and apartments, according to the National Investment Center for Seniors Housing & Care.

The children of seniors need to believe it, too. Many are working full time while also raising a family. Adding the care of elderly parents would be a crushing burden.”

“We need to let go of the ideal of being self-sufficient until death. Just as we don’t demand that our toddlers be self-reliant, Americans need to allow the reality of ourselves as dependent in our old age to percolate into our psyches and our nation’s social policies. Unless we face up to the reality of the needs of our aging population, the longevity we as a society have gained is going to be lived out miserably.”

www.nytimes.com/2019/08/29/opinion/sunday/dementia-assisted-living.html

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Why Doctors Should Read Business Journals and Books (Like HBR)

Hey, Doc – read this and tell me if it makes you think of anything that’s happening in your organization. I can, off the top of my head, think of at least one post I have written that totally resonates with the front page story of this month’s Harvard Business Review. That post is about taking advantage of, if not exactly rigging, the numbers, titled “Don’t do Chronic Care in December“.

Quoting from HBR:

Idea in brief

THE PROBLEM

Companies that work hard on their strategies and carefully monitor their progress often run into spectacular trouble.

WHY IT HAPPENS

People have a behavioral tendency – known as surrogation – to confuse what’s being measured with the metric being used.

HOW TO FIX IT

To reduce the risk of surrogation, make sure that the people executing your strategy have a role in formulating it, don’t link incentives too tightly to strategy metrics, and use multiple metrics to assess performance.