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Thursday, December 29, 2011

How does Canada do it?

When I was at my marathon internal medicine update course at Harvard earlier this month, I sat next to a very bright physician from Tanzania who works as an internist in Canada. I am so glad I talked to her. I was really confused about the health care system in Canada, especially the meaning of "socialized medicine."

Canada has a publicly funded insurance program that pays for basic health services and covers about 99% of outpatient visits. Doctors, though, are not all on a salary through the government, which I thought they were. Most physicians receive fee for service, just like they do in the US.

What happens is that their "medicare" is much like ours, and pays doctors for seeing patients. I am not at all clear as to what a doctor can bill medicare for, whether Canada pays for things like management services not involving face to face contacts or that sort of thing, which would be really interesting to know. Some doctors are on salary through community health clinics like they are here, but my Tanzanian friend said that those who work fee for service are paid more generously and have more control over their schedules, so that is what she has chosen to do.

I asked her how Canada deals with the shortage of primary care internists, since I figured this probably isn't a peculiarly US problem. She said that for as long as she has been aware, Canada uses its internists as consultants to the family doctors who are the real primary care physicians. The internist may see a patient several times in a year, but will give recommendations for management to the general practitioner who is primarily responsible for the patient's care. She feels that internists are paid well and have good lives. They do also take call at the hospital and usually provide inpatient care, but most are not "hospitalists" per se, but more what we would call traditional internal medicine physicians. Internal medicine consultants, in order to be paid at a higher rate than general practitioners, must complete a 4th post graduate year, a fellowship in internal medicine, which is one more year than US internists do.

This sounds to me like a truly great solution to the problem the US is having with too few internists. As a consultant I could take care of many more patients, but be less likely to be burned out since those patients would have another physician to help care for them, and as a consultant I would not have to be available to every patient all the time.

Once again, it looks like another country has figured out a solution to one of our problems and if we were flexible we could just adopt it.

Being a hospitalist and watching our hospital get digital

Since quitting my primary care job 2 months ago I have been working at our local hospital as a "hospitalist". I take 24 hour shifts, several in a row, and during those shifts I am responsible for taking care of all of the patients admitted to the hospital whose doctors can't care for them in that setting. This ends up with me being a consultant for some patients who are particularly complex and time consuming and being the primary doctor for patients whose doctors don't have hospital privileges or are out of town or who don't have a doctor at all. I meet lots of interesting people and get to know them and do the diagnosing, communicating and treating that they need until I go off duty. For many of these people I miss being able to see the whole illness through, like I used to do. It is freeing, though, to know that my responsibility ends at a certain time.

My days vary from extremely busy, where I can't even answer a phone call from my family and have to keep multiple juggling balls in the air all the time, to relaxing, where I can talk to nurses about their vacations and pester the ultrasound technicians to show me how to do imaging. I can sometimes leave the hospital during the day if I need to do something, and sometimes I can barely find a moment to jam some food in my mouth, and don't get to sleep much at night. Our hospitalist program is just getting going and we are working on making processes in the hospital fit us. We are trying to standardize our documentation (admission and progress notes) and still are pretty haphazard with regard to knowing exactly what and how to bill. We are a small hospital so we have only one hospitalist working at any given time, and we rotate shifts according to the demands of our lives and the availability of other doctors to fill in. We fill extra spots with doctors in the area who do this sort of thing and doctors from further away who we get through a physician recruiter.

Many small hospitals just hire a group that provides hospital services to do the whole program, hiring physicians, standardizing signouts, billing and that sort of thing. This is expensive, since the hospital pays heavily for the administrative services as well as the doctors. If a doctor doesn't work out (and in our experience, that does happen) there may be some conflict between the hospital and the hospitalist company. It's very much like the difference between hiring a babysitter oneself vs using an agency. I am glad our hospital is doing it our own way since it allows us to figure out what works best for us and keeps the lines of communication simpler. If we can't fill our spots, though, I bet the hospital administration will get desperate and hire a company.

Next month I will be working at a hospital a few hundred miles away which is larger than ours and which gets its hospitalists from a large hospitalist company. I will get a chance to see how a big operation does this stuff, which may help our organization stay independent. I will plan to continue to work at least some shifts at our hospital which will help me share what I learn. I will be working 12 hours a day for 7 days and then will have a week at home to recover. I'll be doing lots of driving.

Tomorrow is the last day of a block of 4 shifts that I have worked. It has been really busy. I think that everyone waited until Christmas was over to get sick and come in to the hospital because I've hardly had time to breathe. I have met lots of great people though. What has made work in December particularly challenging has been the fact that our hospital just adopted a computer system to handle nursing, ordering, lab and x-ray data. We had been inching along in that direction, but finally jumped into the deep end and now we have no lack of annoying hassles to commiserate about. The system comes from the McKesson company and is called Paragon. Superusers have been working on this for much of a year trying to write the program so it will fit us, but like all electronic medical records, it is full of weird little bugs, crashes, lags and unexplained inability to access what we need at inopportune moments. Some people are slower than others and we have had support staff resign over frustrations with it already. But having watched what happened when my outpatient office went digital, this is not as ugly.

I look forward to 2012, especially sleeping late on Monday and turning off my cell phone, however briefly.

Tuesday, December 13, 2011

Blog maintenance issues

This month the stats for this site showed that there have been over 10,000 views since its inception about 2 years ago. I was bragging about this to my 17 year old son, a computer whisperer, who has very little patience for my relative ignorance of the digital world. He gave me some advice, sort of the "queer eye for the straight guy" variety of advice. ( Reference: "Queer Eye" is a reality TV show where gay men give advice on fashion and lifestyle to clueless straight men.) Apparently it is amazing that anyone visits this site at all, for a number of reasons. The first is "TL;DR"--too long, didn't read. All anyone sees when they visit this site is a wall of words which is probably quite overwhelming unless the visitor is pretty darn determined.

The second is that there is hardly anything to grab the eye. I went with the packaged blogspot formatting and haven't changed it at all the whole time I've been writing. It is really quite attractive, I thought, but maybe the furniture needs rearranging.

And third, there are no photographs. I was thinking that most of what I write is kind of abstract and doesn't lend itself well to photos, and also before this minute I hadn't even checked to see how to put them in.

Thus the beautiful Haitian woman from the island of La Gonave carrying the aluminum bowl of laundry on her head. She has absolutely nothing to do with this post, but she did teach me how to upload photographs. Perhaps with future posts I can experiment with including random photographs of nature or something gorey from work. I could also just leave it like it is.

Monday, December 12, 2011

How to lose weight, lower your blood pressure, have better cholesterol and live longer, all without me nagging about it

There are various things that appear to be good for people. These include maintaining a normal weight, or losing weight if a person is fat, drinking some alcohol, but not too much, quitting smoking and exercising. Doctors as a whole also believe that lowering cholesterol levels is good, and at my recent update in internal medicine course there was some good data that suggested that drinking coffee is a good thing! Controlling blood pressure is also very important.

Being obese is bad in a number on ways, increasing risk of getting cancer, increasing osteoarthritis of the knees, which in turn is responsible for quite a bit of suffering and death, and increasing blood pressure and heart disease. Diet changes can help, but unlike much of what I have believed, there is no particular diet that is better than other diets for everybody. One study looked at people attempting to lose weight using either a low fat or a low carbohydrate diet. The low carb diets are exemplified by the Atkins  and the "zone" diet, which are rich or unlimited in proteins, even fatty meats, but strictly control the amount of carbohydrates a person eats. When a person does not take in carbohydrates, such as breads or rice or pasta, or sugary foods, that person will begin to use proteins as fuel and produce ketones which have the effect of suppressing appetite. The low fat diet, on the other hand, has been ingrained in us for decades, and belief in its healthful properties has resulted in reduced fat everything, from milk to potato chips.  Although many people can lose weight faster with the low carbohydrate diet, after 10 years both types of diet are equally effective.

A study out of the United Kingdom demonstrated an average reduction in lifespan in moderately obese patients of 3 years. This means that a 5 foot 2 inch woman over the weight of 165lbs could expect to live 3 years less than if she were normal weight, up to about 130lbs.  Her life span would be 10 years less than expected were she 220 lbs. A person could expect to lose 1 pound a week of weight by either eating 500 calories less or exercising the amount it would take to use up 500 calories. On a stationary bike a person consumes about 500 calories exercising hard for 45 minutes, and heavy people use more energy to do the same amount of exercise as skinny people. It is more effective to both exercise and reduce calorie intake because the body can reduce its energy expenditures if it thinks it is starving, and conversely inactive people often find it hard to avoid inattentive overeating.

Drinking no alcohol at all appears to be associated with a shorter life, though long term controlled trials of alcohol drinking are totally impractical, so the evidence is not unassailable. There are many bad health outcomes associated with heavier drinking, more than 3 drinks a day for men and over 1 drink a day for women, but even heavy drinking statistically may be better than none at all! (Obviously this is only meaningful for populations, since an individual can drink him or herself to death and individuals do regularly do this.) Women who drink anything at all have a higher risk of breast cancer, but it is heart disease, not breast cancer that is the major killer of women, by a long shot, and drinking definitely appears to lengthen a woman's life.

Cigarette smoking has almost nothing, in fact I can safely say absolutely nothing, to recommend it as far as health goes. OK, I can imagine some scenarios in which cigarette smoking has probably saved someone's life. Perhaps once someone leaned over to pick up a cigarette and just barely missed being hit by a bullet, or avoided being bitten by a malaria carrying mosquito due to being surrounded by cigarette smoke, but in regular life cigarettes do cause heart disease, strokes, vascular disease, lung disease and cancers of many sorts.  The CDC reports that 1 in 5 deaths in the USA is attributable to cigarette smoking. Physicians are not very good at getting people to stop smoking, but there are various medications, including Chantix, budeprion and nicotine products that can significantly reduce cravings for cigarettes with very few side effects.

A gradual decrease in the amount of exercise that Americans regularly engage in is mostly responsible for our devastating epidemic of obesity which will lead to health care costs that we cannot even begin to imagine at this point. As little as 30 minutes of exercise a day for 5 or 6 days of the week can make a significant improvement in many health outcomes, ranging from preventing Alzheimer's disease to preventing heart attacks.

Elevated cholesterol levels, especially certain types of cholesterol, such as the LDL (low density lipoprotein) is associated with increased deaths from vascular disease such as heart attack and stroke. In some cases it may be a marker of bad health behaviors and bad heredity, but it also appears to be causative, and lowering cholesterol with lifestyle changes, weight loss or medications of certain types does reduce risk of these diseases. The most effective medications to reduce cholesterol are the statins (at least as far as we know) and every year another study shows that being on statins is good for some new thing. This information should be viewed critically since statins are hugely big business for pharmaceutical companies, but even I, a skeptic, admit that using these drugs (things like atorvastatin (lipitor) and simvastatin) probably saves lives, especially in those at high risk for early or recurrent coronary artery disease. Statins can, and often do, cause muscle pain and cramping, and combined with certain other drugs can lead to muscle breakdown due to interactions. In general, though, they are probably as safe as many over the counter drugs and herbal preparations.

Coffee, in the nurse's health study and in other well regarded studies, decaf or regular, and in large amounts, reduces risk of developing diabetes, improves diabetes control and reduces progression of fatty liver disease or hepatitis C to endstage liver disease. This is big. The effect is not tiny either, and if coffee were a new pharmaceutical it could be marketed for this indication. It would probably cost upwards of $20 a cup, though. Researchers have looked for negative consequences of coffee drinking for years and have failed to find any that are significant, other than that coffee can give one heartburn or a sour stomach.

Blood pressure should generally remain below 130/80, though medication treatment may not be indicated until the numbers go over 140/90 and the very old may do better with slightly higher numbers. There are a myriad of medications that work for this, but chief among them are mild diuretics, especially the generic pill chlorthalidone which has been around for decades. Ace inhibitors such as lisinopril are also very effective, and calcium channel blockers can be powerful. Sometimes combinations of these drugs are necessary. 

Diabetes is very common now and by 2030 is estimated to afflict 1 in 10 Americans. We could turn this around by changing our lifestyles to decrease obesity, but that isn't happening, so in the not too distant future, a sizable proportion of all patient visits will have something to do with diabetes. Good control of blood sugars with pills or insulin can decrease risk of complications such as heart disease, loss of sensation, blindness and kidney failure. Treating a patient with diabetes follows some pretty detailed guidelines laid out by the American Diabetes Association, and involves control of blood pressure, blood sugar, cholesterol and screening for early signs of complications.

Looking at the paragraphs above, it becomes clear to me that it is going to be really hard for primary care doctors to instruct their patients in all of the good things they should be doing to live longer and healthier, and I also note that many of the things that I've mentioned are things that I am not that good at telling patients how to do. I'm not great at getting patients to lose weight or exercise, though I think I do a pretty good talk. I can only get a patient to quit smoking if she already plans to do it. I can do the diabetes stuff pretty well, I think, but it sometimes gets forgotten as I focus on what the patient really wants me to help them with, such as some kind of acute or chronic suffering that they are experiencing. I haven't yet tried to get patients to drink more coffee. That may be easier, though having them drink it without cream and sugar may be tricky. High blood pressure treatment is sort of my bread and butter, but it is a task without much thanks since patients usually do not feel better on medications and don't notice the condition at all until someone measures it.

So what I was thinking is that maybe I shouldn't be doing all of this stuff. Maybe I don't need to be the nag, especially since I am not that good at it. I prefer to be the good cop, which means I desperately need a bad cop, or at least a charismatic motivator. What is so special about me as a doc that I need to do all of this counseling? Other people might be better at it and wouldn't need the broad training that I have to accomplish a good 90% of the stuff I laid out. Posters, TV commercials and education in schools could much more effectively beat into peoples' consciousness the importance of diet and exercise and not smoking or quitting. Exercise and life coaches can be awesome motivators. The alcohol industry could be tapped for the funds to advertise the health effects of moderate alcohol, and I bet they would do a darn good job of making the point that alcohol is good for us. Some level of industry/public health cooperation could make sure that this didn't move into the realm of "a little is good so more is better." Diabetes treatment, at the level of periodic visits and medication adjustments, is much better done by a multidisciplinary team, including nurses and pharmacists, and not heavily dependent on physician input. Much of control of blood pressure could be done after home monitoring by a nurse or a pharmacist with a decision flow chart for which drugs to use, and I honestly think they would probably do a better job than I would. If things got dicey, the patient could come to me and I could sort things out. Cholesterol would be the same issue. The drugs to treat cholesterol are pretty limited, and with a fingerstick test at the pharmacy of at my office, medications could be prescribed per a protocol and the patient could be monitored until the dose was correct. Pharmacists can certainly monitor for drug interactions, at least as well as I can. What about the patients who don't want to do all of these good things? I applaud them--not everyone should be a sheep. As the good cop, I doubt I would be much more effective than my somewhat less extravagantly educated colleagues at convincing them to toe the line. If it was really important, I could of course give it a try.

If much of this public health and protocol driven medicine were not my job, I would have more time to sit down with a patient with complex medical and psychosocial issues and work with them to come up with solutions to problems. I could diagnose their fascinating and disabling diseases, inject their swollen joints, see them the same day they called in with a cough and a fever or blood in their bowels or vomiting or a suspicious lump. I could be a doctor, not a cross between an accountant and a mother hen. I, and my colleagues, could begin to see clearly towards being able to take care of the genuine needs of the scads of patients already in need of primary care, and those who will, if all goes well, be insured by 2014.

Wednesday, December 7, 2011

Harvard Medical School Internal Medicine Update--Deepak Chopra and more

Having now attended 4 of the 6.5 days of the Harvard Internal Medicine Update CME I am now more grateful for being here. The first day of talks was disappointing, with some of the presenters actually pretty much reading their notes word for word, which I could have done in the comfort of my own home. But many of the speakers since then have been more confident and have been speaking from their hearts and their experience and there has been more to think about.

Yesterday Deepak Chopra gave a special 2 hour lecture about the meaning of life which was quite moving. He is a physician turned writer, though reading his biography it looks like he was always destined to do things that didn't fit comfortably into the medical profession. He started as a medical student in India, went on to become an endocrinologist, was involved in Transcendental Meditation and was a follower of Maharishi Mahesh Yogi, learned Ayurvedic medicine and now is able to span the gap between alternative medicine, established allopathic medicine (what I do) and leave his toes dipped in the positively way-out-there, publishing books and even the occasional article for the New England Journal of Medicine. As a speaker, he probably makes boatloads of money, and spoke to us because his brother, Sanjiv Chopra, a gastroenterologist at Harvard, is the organizer for this course. The talk reminded us about the incomprehensible vastness of the universe and the math and physics which describes that. He described some advances in mind-body medicine, including some data that the genetic markers of aging can be partially reversed by a lifestyle that includes meditation, enough sleep, and a generous helping of peace and joy. There was a brief guided meditation that was delightful, followed by a description of what actually might have happened in our brains during that process. It was gratifying to see such a variety of physicians, who can sometimes be pretty concrete, especially as a group, listen and participate. My take home message included realizing that I shouldn't take myself too seriously.

Today, the first half of the morning was devoted to leadership, which the medical profession can sorely use more of. Four different speakers talked talked about their favorite leaders and what they felt made them particularly effective. They talked about some very significant changes that Harvard had made, as a health care delivery system, and how they did that. It took humility and a sense of humor for the world's best medical school/hospital to recognize that it had problems and to also recognize that making changes could come some distance towards solving them. Like most hospitals, Harvard has trouble making patients feel supported, communicating with families, coordinating care between different caregivers and deciding what care they, as a community, wanted to be giving. They had trouble making sure that frail elderly people didn't go bonkers in the hospital due to weird sleep cycles and changes in activity and medications and stimuli. The process of improvement involved convening groups of people from all levels of service delivery, from janitors through nurses, social workers and physicians, to come up with plans that then were tweaked relentlessly and evaluated constantly until they started to get them right. One example they gave was the diabetes center associated with the Harvard health system, the Joslin Diabetes Center. It wasn't providing consistent diabetic education and despite helping to develop guidelines for care, wasn't actually achieving those guidelines with their patients. They found that by having a team approach, centered on patients' needs rather than on doctors' preferences, they were able to get patients in to be seen much sooner and make everyone, eventually, happier, though not without significant gnashing of teeth.

One of the things that the Joslin Diabetes Center does is to make sure that the first visit for a diabetic involves teaching and an eye exam. Usually our diabetics wait for an appointment and then have an eye exam with an ophthalmologist who may or may not give appropriate feedback to the primary care doctor about the eye findings. Diabetics can become blind with because of changes in the blood vessels after years of elevated blood sugars, that can burst, destroying the retina of the eye. If the changes are caught early, laser surgery can coagulate the abnormal blood vessels and save vision. There is a machine that can photograph the retina without the patient seeing an ophthalmologist which is right in the diabetes center. It takes a few minutes and does a better job of screening the retina than a real human. So far it can't be billed to any of the public insurance companies. One participant in the class asked how it was paid for, and I could see that was a sore spot with the speaker, because it really wasn't paid for. I suspect that the patients who can afford to pay do, and those who can't don't. It is clear that technology like this is a great idea. It is also clear that the only way technology like this will be adopted and not add to the burden of costs for medicare is for medical care to be paid according to results rather than "fee for service" as it is now. I suspect that if costs for work like this were not directly handed on to a third party payer, machines like the one that images diabetics' retinas would quickly come down in price and complexity.

Much of what we have been hearing about is state of the art by specialists in the different fields that make up internal medicine, delivered by specialists. This gives us a much more in depth level of understanding, but also presents a standard of evaluation that is way more detailed and time consuming than even the most thorough of general internists could produce. Most of the physicians attending the course are general internists in non-academic settings, and many of us are under horrendous time constraints which are getting more horrendous as the primary care shortage progresses and payments tighten. Even though fee for service is on its way out the vast majority of physicians still practice that way, which means that to make the same amount of money that we used to, we have to see more patients, and with increasing insurance and government oversight to assure quality, we have to do more things with each patient we see. I don't practice that way, but most physicians do and are burning out. One doctor got up and told the presenters that she worked in the Bronx with a patient population that is very poor and high needs and she is expected to see 30 or more patients in a day, with no support from nurse practitioners or physician's assistants, and that even though she wanted to change her systems to make them work better, she just didn't have the time to start the process. If she wasn't so committed to her patients she would quit, but she can't imagine what would happen to the system if she did. It is more than sobering to realize that people like her will likely be expected to bear the brunt of the huge increase in diabetics that are coming out of adolescence, large colas in hand, along with aging baby boomers and the newly insured and also take up the slack as thousands of primary care internists retire with nobody to take their place.

It is clear that a herd of physician leaders are going to have to pull their heads up out of the writhing mass of needy humanity, stop seeing 30+ patients a day, and build systems that reduce waste, not only as far as spending on unnecessary testing and procedures goes, but also allowing physicians to do the things that it takes a physician to do, not be involved in busy work and things that we are not good at doing. It will be necessary to design ways to allow patients to use technology for what it is good for, and the medical profession so definitely can't shy away from social networking and digital communications for those patients who can work that way. And if we don't want to waste still more time and energy and human power trying to bill for each one of these communication steps, the payment scheme will need to change. And all of this has to happen REALLY SOON.

There is one thing about the talks (the ones about the nuts and bolts of medicine, not the leadership ones) that continues to disturb me. It is the "evidence based medicine" piece. There is a tendency by the speakers to stick closely to recommendations for therapy that are based on research trials with large populations of patients, getting away from telling us about what they, as individual skilled physicians have seen and done successfully in their practices. Clearly both the science and the experience deserve airtime. But worse than just presenting the studies is a little pervasive lie, or really more of a misapprehension, that accompanies the presentation of the data. The speaker will say, "in the CHARM trial of heart failure in patients with diastolic dysfunction, Candesartan did not reduce the endpoint of hospital admission or death. So you see candesartan just doesn't work in these patients." Yes, but no. In the study, a population of these patients did not get significantly better, but that doesn't mean that the drug doesn't work on our individual patients. I'm sure that when individual patients were evaluated it worked very well on some and absolutely abysmally on others, in fact it might actually have killed some of them. Which is also true for the drugs that did work in the clinical trials.  Saying that a drug does work or doesn't work based on a clinical trial is incredibly misleading and encourages us not to believe our patients when they say "Doc, that stuff really helped" or "I stopped it after a week because I got much worse." Patients often do know how things affect their health. There are many variables in our patients that govern what works for them, and studies do their very best to reduce these variables, making them more reproducible but less relevant to the treatment of real people.  It is valuable to reduce a problem to measurable parts and then perform an experiment because it makes it possible to interpret the data and then allows us to make an educated first approximation about how best to treat our patients. Until we are able to genetically and environmentally define all of the characteristics that make up a human, however, predictions based on our population based science will be inaccurate.

Monday, December 5, 2011

Ranting about continuing medical education, evidence based medicine and cost ignorance

I am attending Harvard Medical School's yearly internal medicine update this week. In a little over 6 days we experience 62 hours of medical education, sitting for 12 hours each day in the conference room of a shiny glass and steel hotel in downtown Boston. We hear world authorities on diseases of all of the major organ systems tell us what they think we ought to know. I am two days into it and still pretty excited, but losing a bit of my enthusiasm.

Most of the presenters follow a set of power point slides, sometimes word for word, that are reproduced in our course syllabus in a size that is nearly entirely unreadable. The form of the talks is to present the scope of the problem, then the recommended testing and treatment, interspersed with the research that is the basis for the recommendations, with an occasional cartoon or anecdote. There are also brief question and answer sessions and cases presented with recommendations on management. There are audience response handsets so we can participate in multiple choice questions, in order to keep us awake and focused.

Each of the presenters is a specialist, the worlds expert on irritable bowel syndrome or sleep apnea or one aspect of liver disease. They teach us how to treat the problems they see as the final go to doctors for the entire world. Some of the diseases are common, but we are encouraged to entertain a differential diagnosis that includes diseases only seen a few hundred times a year. Most of these I have heard of at some time, but could only really say what organ system they involve, not what they look like or how they are treated. We are taught the treatments that studies show work, at least for a proportion of patients. We are taught the 10 blood tests or imaging studies that we should never forget to order if we don't want to miss something. They mention that they realize that we, as general internists, have limited time with each patient, but rarely do they tailor their information to make it practical for us to achieve in a patient visit. They haven't been doing what I love to see clinical teachers do--telling us what they know to be true from their vast experience. I think that the emphasis on "evidence based medicine" has made them doubt the value of their hard won wisdom.

A few of these excellent clinicians have, however, been starting to talk about limitations of population studies to guide therapeutics. One oncologist said that different types of cancer will eventually be seen as collections of "orphan diseases".  Orphan diseases are usually considered to be rare diseases that are well described, but not prevalent enough to warrant as extensive research and treatment development as diseases that are more common and have more of a social impact. What this oncologist meant is that each cancer may have slightly different genetics in different individuals, leading to very different responses to chemotherapies or other treatments.

He gave the example of a new treatment for a cancer that completely melted away bulky metastatic disease in one of his patients, based on a genetic predisposition of the cancer cells in that particular person. I have seen this kind of thing on several occasions. One of my patients is completely free of melanoma nearly 20 years after receiving a cancer vaccine in a trial that failed. The study showed it didn't work. Except that it did, in my patient. She had had a recurrence of her melanoma, in a lymph node, which is nearly universally fatal and pretty much untreatable. It went away and she is alive now with no evidence of disease.

Most of the rest of the researchers have not mentioned, though, the fact that different genetics and maybe environments make this "orphan disease" concept true for other common ailments. We are taught that diabetes is best treated with a certain drug first, then another can be added and so on, but anybody who listens to their patients knows that although it is right to start out with certain guidelines, some patients do terribly with drugs that should work and do great with drugs that are bad. There are drugs that are good for people with heart failure, make them live longer and go to the hospital less, except that in some patients these drugs make them sick or even kill them.  Population studies are just not very good for helping us navigate this kind of water. Anecdotes from colleagues with a wealth of experience are, though.

I am also disappointed, again, as I often am in this sort of situation, but the complete lack of awareness of the cost of the therapies and diagnostics by the clinical teachers. Maybe they are aware, but they don't share that information. In the rare cases where they do share some cost data, the numbers are left in some raw form that doesn't give us useful data as to what cost our patients or their payers will see. A radiologist presented some information on new imaging tests which are stunningly beautiful and potentially very useful. He said that he was aware of how radiological testing was overused, leading to unnecessary and harmful radiation and unsupportable costs, but gave no indication about how that information would be integrated into potential use of his new technologies. An oncologist told us that the cost for a course of chemotherapy for metastatic colon cancer that might give a person 2 more years of life compared to the older chemotherapy cost over $30,000 compared to $60 for the old stuff, but didn't say how many courses a person would get in a year. Letting us know this kind of data should be standard. We want what's best for our patients, but we need this kind of data to help counsel people who shoulder at least part of these costs.

Saturday, November 19, 2011

how to become a hospitalist part 1

The field of "hospital medicine" has become increasingly popular in the last 10 years, especially for internal medicine physicians. When a person finishes medical school and enters residency, there are nearly boundless possibilities. Residency choices can include specialties such as radiology, surgery, dermatology, emergency medicine, neurology, psychiatry, family practice, pediatrics, obstetrics and gynecology, pathology and lab medicine and even internal medicine. I'm sure I'm missing something. If a person chooses internal medicine, she can still choose to become a cardiologist, rheumatologist, endocrinologist, oncologist or...again I'm sure I'm missing something. But after 4 years of medical school and then 3 years of internal medicine residency, which is a job, but with almost no time off and very little pay, some people are ready to start doctoring. I wanted to be able to be useful anywhere and be able to use the knowledge I'd spent so much time  picking up in medical school to its fullest, and felt that specializing in one organ of the body would be a waste. That is why I am a general internist rather than a specialist. But internal medicine residency was full of taking care of enormously sick patients in the hospital, with small amounts of supervised clinic time, and when I first finished, I was really good at hospital medicine and pretty clueless about taking care of the many issues that come up in primary care. This is also true of internal medicine residents finishing up today. These doctors now have the choice of continuing to work just in the hospital, a choice that I didn't have. It is attractive. The schedule for a hospital physician is pretty cushy compared to a resident's schedule, and the pay is excellent. A standard hospitalist schedule is 7 days on, 12 hours a day, then 7 days off.  What's not to like?

After quitting my primary care internal medicine practice, I have, by default, become a hospitalist. It is possible to do hospital medicine pretty much anywhere and still have time at home. Committing for the long term is not strictly necessary since most patients come in to the hospital, are discharged, and don't come back for a long time, unlike primary care where the relationship with a single physician is key to good care. I will certainly not do it forever, but I'm doing it now. I am presently helping to cover the shifts at my local hospital which is only 25 beds, so quite small. The standard schedule for tiny hospitals which have hospitalists is 24 hours shifts, but typically seeing no more than 12 patients a day, and sleeping at home most of the time. Our hospital is just now developing this program, which will allow the primary care doctors to not come in to admit patients on their off hours if they don't want to, and will give sick patients without a doctor someone who is pleased to take care of them.

There are many companies that just do the job of providing doctor manpower and organization for a hospital that needs hospitalists. These companies are kind of like temp agencies, making sure that the job is done to certain specifications and taking on the responsibility for coverage. I have recently signed up with one of these companies to provide services in a community about 6 hours drive away from where I live.

The company first has to credential me, and the hospital needs to credential me as well. This means I have to submit all of my vital statistics, including history of malpractice suits, even if frivolous, licensing information, straight from any licensing board that has licensed me, and a complete education and job history with verification from all of those places, plus letters of reference and yet more stuff. After credentialing, I need to complete an online training course in how this company does things. One of the primary focuses of the online training is making sure that I document (write, type, dictate) notes sufficient to avoid losing a malpractice case should I be unlucky enough to be called in one, and be paid at the highest ethical rate for anything I do.

I have been dutifully watching the required videos, and have been feeling like maybe this is the wrong job for me. Perhaps I should go to cooking school or start selling real estate or better yet go overseas to treat the really truly sick in a situation in which what I do has more to do with helping people and less to do with satisfying payers and covering my vulnerable rump. I love taking care of people, learning what their issues are, using my experience to help them navigate their way toward better health. In order to document as this company requires, I actually need to change what I do to fit a framework that revolves around billing.

Each encounter I have with a patient in the hospital must be billed in order for the hospital to be paid for what I do. In the notes for these encounters I need to document various elements of the history of present illness, the family, past medical, personal and social histories, specific elements of a physical exam, even if I don't consider them relevant, a systems review, make notes of all of the data that I review and in some situations document start and stop times. After awhile this will become natural to me, and take up less of my brain, but when it becomes natural, the patient encounter will be a different thing than it should be. It will have elements of a checklist and will not truly be about hearing my patients' stories and collaborating on a solution to their problems.

I do think this whole bizarrely complex routine will someday be obsolete, since it seems clear that medical care will move in the direction of being paid for results, that is making people well, rather than by the individual nit that is picked. Still, in the meantime I am feeling like my brain is being filled with drivel.

It appears that all of the good hospitalist companies do training similar to the one that has signed me on.  Even though I don't like learning the intricacies of evaluation and management coding, it is the system we are presently using, and standardizing the way we interact with that system is not entirely a bad thing. It would be disappointing to learn that when I worked very hard taking care of a patient my hospital was paid as if I had done very little, simply because I had failed to mention that I had asked about new rashes or ear discharge or that I had personally looked at the chest x-ray.

The primary inventor of the complex billing schemes is Medicare, though many other insurance agencies follow the same guidelines. If I had my way, physicians and payers would sit down to produce a payment system that wasted minimal amounts of doctor and biller time on producing and reviewing documentation, focusing on making it serve the purpose of communicating important information among caregivers. Payment would be based on achieving goals derived through communication between the patient and or family and the care providers.

Friday, November 18, 2011

Bedside ultrasound--what a great way to improve medical care and potentially reduce costs

I just completed a 2 day course in "point of care ultrasound" at Harvard Medical School.  It was great. I am completely sold, a convert, a true believer.

Ultrasound is by no means a new technology. Bats use it. Bugs use it. Whales use it. A very high frequency sound wave is produced and when it hits an object it bounces back and is sensed by the creature that produced it. Submarines have used it since the first world war to locate objects, since other detection methods based on light were not useful. Doctors have used rudimentary forms of ultrasound since the 1940s to detect abnormalities in the body. In the last 30 years the machines used in ultrasound imaging have become smaller and more accurate, and the number of conditions that can be detected by ultrasound has increased vastly.  

Medical imaging studies of all kinds have become better since I emerged from medical school, and the pictures of the body that they produce are beautiful.  We have x-rays, an old technology, which look at the body by projecting radiation produced by electrons through flesh and detecting the emerging rays on the other side, initially being recorded on a kind of photographic film, and now more often by a silicon detection screen which converts the image into a digital file. X-rays impart ionizing energy to tissue and can cause healthy cells to develop DNA abnormalities which can turn them into cancer cells. CT scans use x-rays in larger numbers to produce more accurate images which a computer can use to create images that look like slices through the body. CT scans impart even more radiation to tissue than standard x-rays. They are also very expensive (at our hospital a CT scan can be billed at two to three thousand dollars.) In order to get more accurate pictures, a contrast material is often injected into a vein, which can cause fatal allergies and kidney failure.  MRI scanning produces even prettier pictures, using the fact that powerful magnets can tweak protons (present in water) in such a way that they produce a signal which can be recorded digitally. MRI scans are not particularly dangerous, except that contrast material used for MRI can cause a horrible scarring condition of the skin in patients with kidney problems, and they are even more expensive than CT scans.  All of these imaging procedures have probably saved countless lives while contributing to the development of iatrogenic disease and billions of dollars of health care related economic mischief.

Ultrasound imaging is very different than x-ray, CT or MRI scans. Safety is one of the greatest differences. Sound waves impart very little energy to tissue at the wavelengths and amplitudes used in medical machines.  Although ultrasound can be used to clean your jewelry or your teeth, imaging ultrasound is much more gentle and does no appreciable harm.

Cost is another issue: ultrasound machines, unless treated roughly, are durable and can take many pictures without using resources beyond the initial cost of the machine.

Immediacy is the difference that has impressed me most. If I have a patient in my office who I suspect has something wrong inside their body, somewhere I can't see or feel adequately (and the body has lots of those places) I often recommend that they have some sort of imaging test. If it is an x-ray or a CT or an MRI, I order that test, send the patient to the radiology suite where the technician takes the pictures after administering the contrast material if that is required. Those pictures go to the radiologist, a physician who I know but usually don't actually see very often, who interprets what I think is wrong with the patient from a brief sentence I write on my order, looks at the picture, dictates an interpretation (or sometimes calls me, but not often) and I later read that interpretation. Sometimes I look at the picture too, but I am not as good at looking at those pictures as the radiologist, so often I don't. Traditionally, I only order an ultrasound to look for specific things that ultrasounds are very good at seeing: gallstones, blood clots in the legs, function of the heart or blockage of the kidneys. If I do, the technician performs the ultrasound and the radiologist then reads the moving picture of the ultrasound images after they are performed, because ultrasound is a very dynamic procedure, looking at the body's inner workings in real time and from many different angles, since every body is a little different. Still shots from an ultrasound are blurry and hard to read like a glimpse out of the window of a fast moving car. I rarely look at ultrasound images, because only the still shots are available to me and they are of limited use.

Enter "point of care" ultrasound, that is to say ultrasound performed by the examining physician when the patient is seen. When a person gets an ultrasound, a smooth plastic transducer, shaped a bit like the handle of a paintbrush, liberally coated with ultrasound gel is applied to the skin and images appear on a screen. If I am doing the ultrasound, I slide the transducer around, looking at the structures underneath the skin and adjusting my angles and the pictures on the screen until I have seen all that I need to see. If I see something interesting, I can look at it from another angle, can look at structures near it and generally investigate until I am satisfied. There is no sending the patient to a technician, no radiologist being unsure of exactly what I am interested in, no delay. The examination is simply an extension of my history and physical exam. Nice for the patient, because I can tell them more, nice for me because looking inside the human body is unimaginably cool. In the setting of an emergency room, where belly pain could be gas or something life threatening, ultrasound can make a huge difference in survival. Right now, many people with problems that are  trivial get CT scans of everything, just to make sure. Costs are huge and radiation exposure considerable. Routine use of ultrasound by the physician at the bedside could be game changing.

There are drawbacks. Ultrasound can't see everything. There are lung conditions that can be identified, but many that can't be. Certain tumors are too small to be seen, certain other conditions just don't register on ultrasound. MDs who aren't radiologists may miss subtle abnormalities, and if they don't recognize their limits, could reassure a patient in error. Patients may assume that when a doctor has a look with an ultrasound, they will find everything that is wrong inside. Much like the standard history and physical, bedside ultrasound is limited. Doctors worry that if they are not great at ultrasound, they will be sued by patients who discover that something was missed. Still, after the experience that I have had (combined with medical knowledge and 25 years of looking at images) I think that I could help people considerably more with an exam that included ultrasound. And it doesn't really take that long, which is pretty amazing.

Here is an example of how bedside ultrasound might change my practice:

Scenario 1--appointment without ultrasound. A 35 year old woman comes in and tells me that she has been really fatigued lately and has had some belly pain. I ask her the usual questions, do a physical exam which is normal and decide that I need some blood tests and see her back in a week to discuss them. We talk about stress and irritable bowel syndrome and getting more fiber and more exercise.

Scenario 2--appointment with ultrasound. Same patient, same issues. I do a quick ultrasound. I am able to look at her liver, spleen, kidneys, and see nothing of concern. I quickly check her heart, and it is pumping normally, with no obvious problems of the valves or muscle. I then take a quick peak at her uterus and find out that she is pregnant. We can still discuss exercise, stress and fiber, but she and I have learned a great deal more with just a touch of technology thrown in. Blood tests? maybe not necessary. Followup? If needed, and more likely with an obstetrician.

There are certifications for certain physicians who do point of care ultrasound, which involve taking courses and doing a certain number of procedures which are corroborated by radiologists. Really only emergency medicine has standardized requirements like that, and the rest of us docs are left to invent the standards ourselves. These standards should allow us to use this technology and keep us from doing stupid things like saying or implying that we know things we don't know. Most physicians don't know how to do ultrasound, but many medical residents are now learning it as a matter of course during their training. It seems likely that it will become part of what we do, and that when it does, many of our routines will be streamlined.

The course that I took was excellent, but there are many other ultrasound courses throughout the US which are also excellent, at least that's what some of the other participants told me. The American Institute of Ultrasound in Medicine publishes a list of some of the practical ultrasound courses that are available at this website: http://www.aium.org/cme/events.aspx

Wednesday, November 9, 2011

Advanced Trauma Life Support

My 2 year "sabbatical" started a week ago. It has not, so far, involved much sleeping late or eating bon bons, which is fine, I guess. I am working several 24 hour shifts this month for our local hospital, covering the "hospitalist" service. This involves care of hospitalized patients who have no primary doctor or whose primary doctor is unable to take care of them in the hospital. Some of these patients are critically ill, some have fallen through the cracks of our health care system and others have doctors who choose to do only outpatient or specialty practices.  In some communities, especially in big cities, doctors who have office practices are just too busy to be available to their patients at the odd times that hospital medicine requires and so nearly all of the patients in the hospital belong to designated hospitalists. In our community, most of the doctors do at least some hospital medicine, which is good for continuity of care.

After quitting my primary care practice the first item on my agenda has been to take some continuing medical education classes that I have been too busy to take in the past, and ones which significantly broaden my scope of practice. The first one that I have done is Advanced Trauma Life Support, a course sponsored by the American College of Surgeons to help bring physicians who treat injured patients up to a basic level of competence in the process and procedures involved in good care.

There are various courses that physicians take that are represented by initials. I have recently updated my skills in ACLS (advanced cardiac life support) and PALS (pediatric advanced life support.) The ACLS course involves memorizing several algorithms for treating patients who present with life threatening heart events. These patients are familiar to me, because internal medicine, my specialty, involves lots of work with cardiac issues. Since my patients very rarely die or threaten to in my presence, it is good to review the steps involved in resuscitating them so that when fast action is required, I don't have to delay while trying to remember what to do. I have taken the course many times, and it is now familiar and easy despite the fact that recommendations change a little bit each time. PALS involved lots of studying and working through scenarios online and then a practical test. It was fine, but not remarkable. I now feel entirely capable of saving digital and rubber babies from various near death events.

I chose to take ATLS because feeling confident in taking care of victims of assaults or motor vehicle accidents is basic to being able to provide emergency care, and I may end up doing some of that. When I decided to take the class I had to find a location that offered it at a time that was convenient. I asked friends who had taken it what their experiences were and I searched online and eventually decided to take the course at Harborview Medical Center in Seattle.  I had done several months of residency training at Harborview and found it to be staffed with skilled and committed doctors and nurses who saw lots of very sick and injured people and who were at the front line of innovations to make care better. I wasn't sure that a structured course like ATLS would be different when taught at a major trauma center like Harborview.

The ATLS curriculum started after a doctor crashed his small plane in Nebraska and observed from the inside just how fragmented and inadequate trauma care was.  His wife died instantly and three of his children were critically injured. In the year that followed he and others in the medical community began to design a course that would standardize trauma care in a way that would dramatically improve its quality. What is taught now has been changed and honed and continues to change based on research and experience. The class involves lectures and practical sessions, scenarios and written and oral testing. Harborview did a terrific job. The course director, Dr. Sam Arbabi, is a trauma surgeon who is actively involved in caring for injured patients as well as doing research in public health and teaching students and residents. The different systems were covered by a diverse array of surgeons from all over the country, all of whom had different practices and experiences which they incorporated into  their course material.  The students were also extremely diverse, from small town emergency physicians to surgical residents to primary care physicians who needed trauma background to meet the needs of their injured patients when specialty care was not always available. In some continuing medical education courses, students, despite the fact that they are MDs, are assumed to be stupid. ATLS at Harborview was very collegial. We, the students, were recognized as the front line in trauma care. Patients with multiple severe injuries often end up at Harborview when the small hospitals that initially see them are unable to provide the kind of care that they need. If we, at these small hospitals, take good care of them, Harborview will be much more likely to save them.

We learned a method of thinking about injured patients that allows us to make good decisions when our brains might be overloaded with emotionally relevant pieces of data that can lead to being unable to do the right thing first.  The process involves the familiar ABC mnemonic, standing for Airway, Breathing and Circulation. No matter how bad a person looks after being hit by a car or beaten up by a gang or trampled by elephants, if air moves in and out of their lungs and their heart continues to beat, they are alive and their other injuries can be treated in good time. The details of how to do all of this are made up of thousands of hours of training throughout medical school and residency and beyond, but remembering that it is necessary to support movement of breath in and out of the lungs and to staunch bleeding is basic to trauma care and can provide an anchor for the rest of what we do.  Beyond this, each professor taught us about a specific area of care, including broken bones, injured brains and spinal cords, lungs which may be popped, contused or bleeding, hearts with similar issues, and the whole collection of innards which work so beautifully when unmolested, but so very poorly when squashed, skewered, perforated or macerated.

The final exam, which leads to certification, involved a practical demonstration of my ability to verbally and physically walk through treatment of a volunteer paramedic or nursing student with gorey makeup and rubber wounds associated with a realistic scenario, such as having been run over by a truck after falling off of a motorcycle or running into a bridge abutment. There was also a wickedly tricky multiple choice exam, with which I didn't entirely agree given the fact that much of what is right to do in any given situation depends on things which aren't possible to clarify in one paragraph. The very last activity of the very last day of the class was a small group discussion of triage of patients in disaster or multiple victim events. Who among the hurt and dying can best benefit from the limited resources available? These discussions allowed us to get to know each other and the course directors better and work through our conflicting values to come up with a consensus that will probably be helpful in future apocalypses.

So the class was excellent. I heartily recommend ATLS at Harborview in Seattle.

As I drove back home, the 5 1/2 hours from Seattle to Idaho, I thought about the fact that the vast majority of traumatic injury that leads to death, disability and dismemberment is directly due to our unconditional love for the internal combustion engine, particularly the automobile. Without motor vehicle crashes, trauma medicine would be a significantly smaller specialty. I clung somewhat more tightly to my steering wheel and drove more slowly and wished I could be footloose without driving my car.

Tuesday, October 25, 2011

Should you get a flu shot? (plus comments on intranasal and intradermal vaccination)

Influenza is a nasty viral illness characterized by fever, headache, sore throat, runny nose and a cough. These words don't come close to conveying the actual misery of a real whomping case of the flu. Most of my patients with the flu feel too miserable to come in to the office, which is good, because influenza is very contagious. Not only is it contagious when it first occurs, it remains contagious for 1-2 weeks. But I stray from my description. The patients who do come in to see me with the flu are usually too miserable to adequately describe their symptoms, preferring to moan and answer my questions with short answers. I have had the flu several times, and what I most vividly remember is being nearly unable to move. Usually when I get the flu, I start the day out thinking that I might be getting a little cold, but that I can certainly work. Then the viruses start doubling and infecting my vulnerable cells and I realize that I need to get home. I have traditionally been able to time this pretty well, arriving at my house just before I am completely unable to take another step. I will then sit down on the couch and wait until somebody asks me if I want something at which time I will ask for water which I will be too miserable to drink. Highlights of the symptoms I remember include feeling like my eyes and the linings of my nose had been burned, so I would be unable to either close or keep open my eyelids without pain, hurting in every muscle, whether I moved it or not, mouth dry, bad taste, can't drink because throat hurts too much, racking dry cough. One time years ago my husband and I both came home from work with the flu at the same time, sat down and spent the next 2 hours trying to decide if either of us had energy to reach for the TV control. The flu rarely involves gastrointestinal symptoms, so really does not cause nausea or diarrhea, though the recent H1N1 swine flu was associated with these things, but not to a major extent. The flu is mostly seasonal (though now we have a circulating  year round H1N1 from last years over-advertised pandemic) and occurs anytime starting November on up through March. Each year there are 2 major varieties of the flu, an A and a B type, each usually a different serotype than the previous year.

Not only is influenza really unpleasant acutely, it can last for over a week, and then cause a sinus infection that can take weeks to clear or a cough that can persist for months. It can even kill people, either through weakening their systems or from direct effects, such as infecting the brain, causing severe life threatening viral pneumonia or even heart problems. Each year 30-40 thousand people die of direct effects of the flu, which is a huge loss of life and mostly underappreciated. Most of those who die of the flu are very young or very old or weakened by disease, but not all. Some healthy people get the flu and die.  In the influenza epidemic of 1917, 50-100 million people died over 3 years it lasted, and they were primarily young and not otherwise ill. Some years, however, flu outbreaks are pretty minimal.

The influenza vaccine has existed since the 1940s, and has been tested extensively since then. Each year now the vaccine is created anew, based on the predicted viruses identities for the next year.  Vaccine side effects are usually quite mild, though causing the body to create disease fighting antibodies is sometimes associated with a vaguely ill feeling. People do not get the flu, per se, from the flu shot, though they might become ill in the doctors office while waiting to be vaccinated by being around other coughing and sneezing patients.  In 1976 a vaccination aimed at preventing swine flu ended up causing a severe nerve disorder called Guillain Barre syndrome in 1 of 100,000 people who received the shot. Guillain Barre can also happen in a person due to any actual infection, including influenza itself.

Being vaccinated results in a rise in the antibodies that protect against the particular variety of the flu that the vaccine was designed to prevent. In many studies of flu shot effectiveness it has been shown that people who get vaccinated are less likely to go to the hospital, get pneumonia or die. During an influenza outbreak, usually about 1 in 10 people under the age of 19 become infected and it is possible to judge the presence of flu in a community by large numbers of students being absent from school.  Vaccinated healthy people are less likely to miss work during flu season and vaccinated elderly people have a 68% reduction in death during flu season. Some of this effect may be due to the fact that healthier and more affluent elderly people are more likely to be vaccinated than the poor and homebound, but this does not entirely explain the effect. Healthy vaccine recipients are significantly more likely to have good immune response to the vaccine than elderly or very young or otherwise medically vulnerable people, so their protection from the virus is probably correspondingly higher. Some years vaccine designers guess wrong about which influenza virus will be the most prevalent and so there have been years when the vaccine was all but useless. Production of enough antibody after vaccination to protect against flu varies significantly for different subgroups of people, from as low as 20-30% in older adults and as high as over 60% in healthy volunteers.  The fact that the only a small proportion of the elderly respond to flu vaccines in any measurable way, and yet their death rate during the flu season is profoundly reduced does bring into question whether getting the flu shot is merely a marker of good health rather than protecting against disease.

Each year about 100million people receive the flu shot in the US. Some much smaller number of people are vaccinated by the nasal route, receiving, instead of an inactivated vaccine, a live virus that infects the body without causing harm, thus raising the flu related antibodies more naturally. Evidence suggests that this route of vaccination may be more effective in children, but recent studies have overall shown more influenza type disease in recipients of the live vaccine. The more common, inactivated flu vaccine is given as a shot in the upper arm, into the muscle. It can cause aching that may last a few days, and occasionally causes significant swelling. Two years ago when there was a vaccine shortage information was released showing that injection just under the skin into the subcutaneous tissue of 1/5th of the volume of a standard flu shot was at least as effective as the intramuscular injection. It was suggested that physicians might be able to give more shots to more people with less vaccine if they did the vaccination this way. This year, as an experiment, I vaccinated myself and my family with a smaller than standard dose of flu vaccine subcutaneously. We all felt that it stung a little bit more, but didn't ache as deeply as the intramuscular route but was otherwise a little bit superior due to the shorter and tinier needle that is usually used for that type of injection. I have been curious, for the last two years, about why a subcutaneous injection of the flu vaccine had not become standard of care if it works better and utilizes fewer resources. Vaccines are very big business, though I'm not sure exactly what the numbers are. The biggest manufacturers of influenza vaccine are Sanofi Pasteur and Glaxo Smith Kline. If they make even 2 dollars per shot, which is probably a low estimate, the profits would be $200 million dollars in the US alone. If influenza shots were given subcutaneously, the world could get by with 1/5th the amount of vaccine, significantly reducing profits. But I just read in the Medical Letter today that Sanofi Pasteur has figured out how to avoid that pitfall of cost savings by producing a single dose subcutaneous injection of flu vaccine for...only $4 more per dose than their standard flu vaccine which costs the pharmacist or physician $12! Clever Sanofi Pasteur. If we physicians are not mindless sheep, however, we will figure out that we can start giving 1/5th size subcutaneous flu shots with tiny little needles in the not to distant future.

So--bottom line--should you get a flu shot? Probably yes. If you are healthy, your antibody response will be robust and you will be less likely to get the flu this year, miss work, feel terrible and possibly (but not likely) die.  If you are very old or infirm, your immune response will be less but your downside should you get sick is significantly higher, and might more reasonably include dying. It also seems clear that more research is needed to define exactly who will benefit from flu shots, and that the ethics of withholding flu shots from a random group of people in order to do good science is complex. If it turns out that flu shots really don't protect well from death and disease, we are wasting a colossal amount of resources in vaccinating everybody as we are now.

What is the very best way to prevent the flu? Probably by avoiding exposure to sick people by having more comprehensive policies to discourage sick people from going to work and school.  This will never be perfectly effective due to the fact that people can be significantly contagious before they get sick enough to realize that they need to be home. That said, I do wonder if even this approach is optimal. It may be that frequent exposure to germs in levels insufficient to cause actual disease might serve to immunize those exposed and make them less likely to catch or spread the disease in the future.

Flu shots are available to anyone at a cost of about $25 a pop at grocery stores and pharmacies and are covered by virtually all insurance companies. They are usually offered to patients starting in late September commercially, but since immunity only lasts for 3-4 months and outbreaks frequently occur after January, waiting to get the vaccine until the end of October is recommended.  In the US flu vaccine is recommended for all people over the age of 6 months, including pregnant mothers. It is particularly recommended for healthcare workers who are more often exposed and who have a higher likelihood of spreading the disease to vulnerable populations.

Saturday, October 22, 2011

The perfect electronic medical record

I have had a love hate relationship with our computerized medical record since we first started using it in 2007. Much like computers in all of American society, the idea that our computerized medical record is just a small facet of what we do, involved in the storage of information, is a gross simplification. In the US (also elsewhere, but I can't speak for Europe or Asia from much personal experience) the ubiquitous presence of computers has affected how we work, play, think, communicate. These interfaces with brains that we use so frequently have made us fatter, more connected to each others' thoughts, less connected to each others' bodies, has reduced our ability to use non-visual senses, has partially convinced us that 3 dimensions are optional, and I could go on for hours (at which time all hope of going out for a walk would be gone.) In my medical office, my near-umbilical connection to my laptop has touched all parts of what I do. The production of a document, which integrates information from as many sources as I am aware of that refer to my patient, is one of the most important goals of a visit. I also try to solve the patient's problem and answer their questions and listen to them, but I do it within the context of my computerized medical record. This sounds overstated, but in my particular case I think it is pretty accurate. So the fact that our particular software package sucks is profoundly irritating.

Now "sucks" is a pretty strong word, and I only use it because we just had an update which has been as infested with bugs as a cheap motel and I am frustrated. Oh so slow. I feel like some sort of a bivalve sea creature as I wait for the screen to allow me access to my patient's vital information. I feel trapped and claustrophobic as I attempt to stay within one layer of the record while needing simple information such as what happened last time or how old they are, that exists but is clicks away. The love part of "love hate" comes in when I see how many great features there are, including the ability to communicate to other doctors in my practice and support staff and pharmacies in a way that is accurate and nearly instant, and the fact that I can organize and transmit information that is coordinated and readable to the patient or to unconnected physicians in a printed format. That doesn't sound like much, though, in return for essentially marrying a computer.

I can, however, imagine a computerized medical record that I would really love, and have been doing that exercise for the last few days. I will now state what I want, and maybe at some time in the future, the universe will provide.

I would like my documentation system (EMR, for electronic medical record) to allow me to record information quickly and efficiently. I would like it to remind me to do things that I don't want to be thinking about while I am trying to concentrate on listening to my patient and formulating a reply or solution or whatever is called for. I want my EMR to keep me from doing obviously stupid things. I would also like it to tell me how late I am getting for my next patient. This is not much to ask, and I know computers can do this stuff. In fact, it may be that somebody's EMR somewhere in the world does do this.

When I first sit down with a patient, my nurse has been in the room, has gotten vital signs (blood pressure, weight, pulse, temperature) and, time allowing, has asked what issues the patient has and even typed them up in the medical record (yay Joy, you are an awesome nurse.) I would like my EMR to have already given my patient a chance to answer some of the more routine questions, such as "is this really your medication list?" and "in addition to your issues today, do you have any alarming symptoms such as passing blood or fainting or chest pain?" When I first looked at the screen it would show me a summary of the most recent medical visit and labs, so I would be reminded of salient information. I would then like to have a discussion with my patient about what they want help with and the stories, questions and answers surrounding that (the history of present illness.) I then want my computer to prompt me to ask questions about the corresponding systems. (Patient says "trouble swallowing", computer brings up review of nose throat and intestinal system "do you have post nasal drip, cough with eating, vomiting, heartburn or blood in the stool".) I then want it to remind me to review the background information: still in the same job? marriage? family history, clues to stress related issues? medical history? Then I will do my physical exam. I want it to highlight any abnormalities of the vital signs (sometimes I don't notice until later that the patient's blood pressure was elevated) and come up with a form to document my exam that is consistent with what I normally do. After I finish that, I would like it to highlight any area that the complaint suggests would need more careful examination. Then I want it to ask me what medical orders I wish to add and which medications I wish to prescribe or change. If I order a medication that interacts with another or that the patient is allergic to, I would like it to tell me (it does this now, but in such a ridiculously lame way that it is unusable). If I order a test or procedure that has been done or ordered in the last year, it should tell me that, too. Then I want it to suggest patient education handouts which I would press a button to print out. I would then tell the patient what I am thinking, ask if they had any other questions and the EMR would notify the nurse to come back in and it would lead her through a brief review of preventive medicine recommendations to tell the patient (due for a mammogram, stuff like that), but only once or twice yearly for any given patient. The nurse would also then make sure the patient had prescriptions and followup information which would already be clearly documented in the record. As far as reminding me how late I am, I would like there to be an appointment bar at the edge with present time and color coding and actual numbers to indicate how long my upcoming patients have been waiting.

Could I go through all of this in a 15 minute appointment? Depending on the complexity of the problem, most likely yes. Would the patient feel heard and supported? I think yes. I know for sure that if I spent less time in combat with stupid evil software  I would have more mind and heart to spend on being a human helping another human in need.

Computerized medical records are here to stay because their potential for improvement in communication is so awesome. The most important trick is for us to make them facilitate real care of patients rather than let them suck us into their information vortex only to have us lose sight of what we as caregivers are for.

Wednesday, October 19, 2011

Telemedicine: where could it lead?

I have only 6 more days in my present job as a primary care internist in my home town. The process of wrapping things up has been new and time consuming, but ultimately very rewarding. I get to see patients I've known for over a decade, in some instances, and review what has happened with their lives and their health and we work on future plans for maintaining what they have gained and getting a handle on problems still bothering them. We say goodbyes and good lucks and talk about the important, big stuff, like hopes and dreams and medication refills. Interspersed among these appointments and phone calls are multiple communications about my next job, whatever that will turn out to be.

I am signed up with 2 locums companies, and in contact with 4 recruiters who are my agents, as well as the recruiters that are associated with my possible new jobs. The phone calls are mostly really interesting, since I get to hear about new places and how they are doing what they do in health care. Many of the jobs that sound perfect have been non-starters because they need me at times when I can't be there, or for lengths of time that would take me away from my family for too long. Primary care positions would like me to be around Monday through Friday, with the occasional call weekend in some cases, for 3 months. This could work if they are within a reasonable traveling distance of my home and family, which does cut down on my options. Hospitalist positions, where I would take care of just patients in hospital, usually for 12 hours each day, are considered full time if I work 1 week on and one week off. If they are willing to fly me in and out, and the location is within a reasonable distance of an airport, that could work anywhere in the country. I would not have to be away for so long that my dog forgets who I am.  Of all the jobs I could get, I would prefer "traditional internal medicine" which involves both outpatient and inpatient work because I think it will teach me more about a whole community and how it is coordinated to do health care. It is good  locum tenens etiquette to apply for only one position at a time, which can lead to serial disappointments and presently I remain on the edge of my seat as I wait for confirmation of my first assignment. I'm sure it will be just fine and dandy, whatever it is, but it would be so reassuring to know where I will be in 2 months.

My resources for this adventure (my 2 years off from my regular primary practice) include quite a few friends and colleagues who have done or are still doing locum tenens (latin for "place holder") work. They tell me what places they have liked, where the ethics or the support might be thin, which companies take care of their clients. Sometimes they even know of specific needs, where I might work without using a recruiter at all. One such opportunity is doing telemedicine.  Telemedicine is the practice of taking care of patients remotely, using telephone or computer. It is often practiced in places where the right doctor cannot be present physically, such as when a rare specialist is needed in a tiny hospital. It is used to share expertise over great distances, and is used internationally by some medical aid organizations. At the recommendation of a friend, I contacted an organization called MDLivecare, which provides telehealth services domestically, with private clients (people who arrange e-visits on their own) and corporate subscribers. A large company may wish to provide their employees with a way to contact a physician quickly, easily and inexpensively as a way to reduce time lost from work and in order to provide services more inexpensively. The telehealth visits include many of the trimmings of a real doctor visit, including documentation of what was discussed, communication with the primary care physician if there is one, and even prescription of medications (though controlled substances are strictly out.)

At some point in the future I will probably know more about telemedicine because I will probably try  doing it. I have always enjoyed the challenge of treating patients over the phone, and having a video chat interface will be even easier than that. Much can be communicated verbally, and though loss of the touch aspect of medicine is a considerable hindrance to some diagnoses, I think it will be really interesting to see how much can be done in this type of an encounter.

Yesterday I visited with a patient who had a very odd neurological problem, a "funny walk" that was new and didn't really fit into patterns I had seen before. More than anything, I wanted her to be able to see a world class neurologist, who could probably ask a couple of questions, watch her walk down the hall and know what she had. But we were in a small town in a small state, and getting to a world class neurologist is probably nearly beyond her. It would be so simple, if telemedicine were more widely accepted, to call my favorite world class neurologist, web cam her funny walk, tell him my concerns and ask any questions he might have and get our answer. What presently hinders this are the fact that even practicing telemedicine requires a state license, and that there are no easy ways to bill for this service. Clearly that needs to change. We have technology at our fingertips that would reduce human suffering and we are hamstrung in our ability to use it. I look forward to the inevitable adjustments in payment schemes and regulations that will allow us to use what we have to its best advantage.

Wednesday, October 5, 2011

Meaningful use: the top heavy nit picky route to possibly better health care

As part of the 2009 American Recovery and Reinvestment act (the massive stimulus package enacted at the beginning of our economic slump) doctors were offered money to start using computerized medical records for their patients insured by Medicare and Medicaid.  It was felt to be evident at that time that use of a computers to document patients' medical encounters would make communication between providers better, reduce errors, reduce redundancy of testing and procedures and overall streamline documentation. Many physicians had already started on the road to making their records digital, but government support made others take the big step.  Our office bought a very expensive computer software package from GE along with all of the hardware to support it in 2007, and by the time the stimulus package passed, we had almost adjusted to the change. We figured we would probably be well set up to be rewarded for having made this momentous change before the majority of offices.

Adjusting to an electronic health record (EHR) is not easy.  The programs for keeping such records are extremely complex, owing to the demands of privacy, legal issues, communication with other entities, drug prescribing, and the fact that most of these programs have been written over many years by programmers who no longer work for the same company and are no longer around to explain the rationale of the code they wrote, much less to fix it. The resulting products do really weird things and don't do some of the normal things that one would expect them to do.  They don't automatically check spelling, for instance. They do lag, significantly. Perfectly simple tasks make them crash, and though these bugs are fixed, they reappear whenever there is an update. Of course, my experience is with GE's product, in our office, and doesn't necessarily apply to all EHRs, but from what I hear, many of them are plagued with the same problems.

In our office in the weeks following changing from dictating or writing our notes and communicating our plans orally or in handwritten notes to doing about all of this with a computer interface, our productivity dropped precipitously. If we could see half the number of patients we had seen prior to EHR it was a good day. People, including physicians, cried, yelled, quit their jobs. It was kind of awful. We had sick people to treat, and we couldn't access their histories, write their prescriptions, and we would sit with them, powerless in front of a computer screen that would not navigate to what we needed. After a couple of years we had almost become as fast as we were before computers, but truly we have never entirely recovered. Some things are definitely better. Our notes are readable. We know what we have prescribed and when. We are reminded of schedules for vaccinations and that sort of thing. We can produce a nice looking typed note for work in a couple of minutes. But we still spend lots of time staring at a screen rather than focusing on a patient and I, personally, am still slower, even though I am quite comfortable with computers.

It was a disappointment when we learned, about a year ago, that our computer system did not qualify us for any sort of reward through the Recovery and Reinvestment Act. What was required was "meaningful use" of an electronic health record. How, we wondered, were we to make it meaningful? It sure felt meaningful to us. The cost of it was pretty meaningful: over $100,000 for the initial investment, plus more than that much in updates and lost productivity. For a bunch more money, we found out, we could have "meaningful use" and be eligible for some payments. We have embarked on that road, and a rocky one it is.

Meaningful use requires 15 "core measures" be met along with 5 out of 10 menu items. We don't have do do every one with every patient, at least not yet, but we need to make a good start. The 15 core measures are:
1. We need to enter our orders (for things like tests and consults) on the computer.
2. We need to have the drug ordering part of the program be set up to tell us about drug interactions.
3. We need to keep an updated computerized problem list for each patient.
4. We have to transmit our prescriptions electronically, those that legally can be sent that way.
5 and 6. We have to keep active medication and allergy lists.
7. We have to keep demographic information of everybody, stuff like age, sex, language and ethnicity.
8. We have to keep record of all vital signs, including the body mass index and be able to graph growth in children.
9. We need to document whether the patient smokes (age 13 and older.)
10. We need to be able to transmit clinical quality data to Medicare.
11. We need to have our EHR help us make clinical decisions about at least one condition.
12. We need to supply patients with a summary of their health record on demand, including diagnoses, allergies, medications.
13. Within 3 days of a visit, the patient needs to receive a summary of their visit, including their problems
medication changes, what referrals were made and to whom, with contact information and what followup was recommended
14. We need to be able to transmit medical records to other providers electronically.
15. Our records must be secure.
The 10 menu items, from which we can choose 5, require that we:
1. Check insurance formularies so that patients know if the prescribed drug is covered and what other options are available.
2. Have lab tests be entered in such a way that the EHR can search them and use that data in various ways (i.e. not a scanned image.)
3. Generate lists of patients with specific condition.
4. Send patients reminders for followup for certain conditions and for prevention.
5. Provide patients with electronic access to their health information within 4 days of results being available.
6. Provide patient specific education resources (I think this means things like handouts on specific diseases.)
7. Do "medication reconciliation" -- making sure that medication lists from each provider are the same.
8. Provide summaries of care when a patient is transferred from one doctor to another.
9. Electronically submit vaccination data to agencies that collect that data.
10. Submit data on diseases or syndromes observed to appropriate agencies (like Dept of Health for infectious disease outbreaks.)

Most of these requirements are both reasonable and a good idea. Some of them are a really great idea, but figuring out how to do them is going to be a bear. The main one that has me worried is the summary of the patient visit. I used to write summary letters to patients after their yearly physicals. It took forever. Not only did I need to document the visit for my chart, I had to rewrite it in a way that a patient would understand. It just about doubled the amount of time it took to document a visit. It was also a great gesture, and I'm sure the patients usually benefited from it and appreciated it. I won't deny it is a good idea, but with the slowness of computer documentation as it is now, I wonder where we will find the time. I'm pretty sure that even a good computer can't take the data from a doctor's visit and turn it into prose that will be comprehensible to a real person, so to the extent that these documents are really useful, they will have to be generated by the doctor. We are expecting a bunch of new patients to be needing primary care doctors in the next several years, associated with a shortage of these providers, which will make it nearly impossible to spend more time in documentation.

Another thing that worries me is the requirement to submit data on quality to Medicare. Some measures health care quality are deeply meaningful, for instance, is the patient happier and healthier due to a medical encounter? Unfortunately, those outcomes are difficult to measure. Instead we measure whether diabetic patients have their blood sugars below a certain, somewhat arbitrary number, or whether women over a certain age have gotten mammograms. Many of the things that we decide are good and important in health care turn out to be not good when the next study comes out. For instance, we found that vitamin E wasn't good for anything, then found that it effectively treats fatty liver in obese patients. We still disagree about how often to get mammograms on patients, and screening for prostate cancer is a hotly disputed topic.

The updates to make our computer systems jump through these hoops will make us tear out our hair, once again, and stare helplessly at poorly functioning screens while sick patient wait for our help. I still hope that one day the intelligent and computer savvy generation behind me will be hired by Medicare to produce an EHR that is as lithe, supple and fast as a cheetah and we will all use that wonderful product which will be affordable due to economies of scale. I'm waiting eagerly. If that cheetah-like EHR comes to exist, it may well improve efficiency, reduce error and lead to better communication.

So how much money is offered to physicians who choose to attempt meaningful use? If we achieve this in 2011, we get $18,000 each. In 2012 we would get 12K, in 2013, 8K, 2015 4K and then in 2015, if we haven't achieved it, we will be penalized 1% of our medicare payment, then 2% the following year.  If it takes until 2012, we only get 3 years of bonus, and so on. At most we can make $44,000 from meaningful use. That is a lot of money. It is also a drop in the bucket compared to what we will have spent in computer software, hardware and lost productivity. But that cat is out of the bag, and $44,000 is still a lot of money. The present meaningful use criteria will be replaced by stricter criteria, and it is not at all clear what those will be.

I'm not entirely sure what to think of this whole process. It seems that we are scurrying in vaguely the right direction, with better patient care as a goal, and an electronic health record as a tool to reach that goal. The way we are going about it, however, seems haphazard and destabilizing. Our aversion to truly standardizing our concepts of quality and our medical records is making these transitions much more difficult that they need to be.

Wednesday, September 28, 2011

Patient Centered Outcomes Research--a good start

The affordable care act, in its 2000 plus pages, provided for many projects with the potential to improve health care delivery in the US. The most actively debated part of the bill, the mandate to insure just about everyone, may not turn out to be the most important piece. The problems the affordable care act attempted to address are the fact that American health care spending is too high and buys too little, including poor outcomes for those who do get health care and the fact that too few people who need health care actually receive it. All of these issues are addressed in some way or another in the myriad provisions of the bill.

One rarely advertised provision of the bill is the Patient Centered Outcomes Research Institute (PCORI).  This is a private institute, publicly funded, which includes a huge diversity of players, from patients to providers and sundry others, who are charged with figuring out exactly what Patient Centered Outcomes Research is, and then making it happen and disseminating the results. According to a recent article in the New England Journal of Medicine, they have been holding meetings, many of them public, just to figure out what it is that they feel they should do and how they will most effectively do that thing. At this point the groundwork is mostly done.

The PCORI has decided that its prime directive is to help patients answer these 4 questions:


  1. “Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”
  2. “What are my options and what are the benefits and harms of those options?”
  3. “What can I do to improve the outcomes that are most important to me?”
  4. “How can the health care system improve my chances of achieving the outcomes I prefer?
Given the present scurrying behavior of most physicians to try to  develop systems to help them practice evidence based medicine which will theoretically pay them more for reaching certain benchmarks in treating various common diseases, these patient centered questions are very relevant and an absolute necessity. As we as physicians begin to see our paychecks depend upon whether our diabetic patients are getting statin medications to prevent heart attacks and maintaining certain blood glucose levels, we vitally need to be reminded that our job is truly to improve patients' lives. That means adjusting what we do to respond to those patients' educated preferences. Results of patient centered outcomes research may help us do that.

I have some misgivings about the PCORI. It is very large. I can't quite figure out how large, but large enough that it sounds as if decision making is slow going. That will not slow the research that they fund, since that can be done by small groups with good ideas. Still, implementing change based on new research may be slow. I also wonder how information that helps doctors and patients make individualized decisions about care will interact with the freight train of "pay for performance" based on scientific evidence which usually demands strict adherence to a protocol. 

I presently choose to have faith that the process of patient centered outcomes research will eventually meet up with pay for performance and we will actually be paid for the performance of individualized care for patients who are undeniably individuals with individual needs and preferences. It is just possible that the truth shall set us free.

Saturday, September 24, 2011

Physician non-compete clauses--another way to gut rural health care

Lately I have been dealing with the painful process of separating from my medical group. I have been part of this group since its inception, about 12 years ago. It serves two small towns in adjacent states and has about 30 employees and 12 providers, mostly located in the larger of our two clinics, in which I do not work.  We originally came together from 3 primary care practices in order to share resources and reduce overhead. Cultures and values were somewhat different, but we did all care about delivering good quality medicine, letting our physicians have autonomy in decision making, and about making sure that each one of us could have lives that were humane, valuing family time or outside interests and covering each others' patient's needs so that care would not suffer.

When we came together we wrote a contract which was longer and more formal than any I had signed before and had various elements that made me somewhat uncomfortable. One was the "buy-in". This was an amount of money that we all agreed to put in to essentially buy the practice. I balked at the size of this, since my location of practice was very inexpensive, and the physicians in the larger office were "buying in" to a large and brand new medical office building. My concerns were respected, and my buy-in was smaller, as was that of my two partners.  The other issue was a non-compete clause, which I was told was standard and non-negotiable. This clause in the contract stated that if my employment with the corporation ended, I would not practice medicine within 20 miles for 2 years.

Physician non-compete clauses are strongly disfavored by the American Medical Association and considered unethical. They restrict choice of practice and they penalize patients when a physician is at odds with his or her employer.  They are hard to enforce and void in some states, most prominently California. They have been viewed as restrictions on trade, though various interpretations of this have arisen from court cases. They remain a common component of physician contracts. They are particularly hard to enforce if it can be shown that the physician is needed in his or her community and that enforcement of the clause will harm patients.

In the case of me and my clinic partner, who are obliged to sever our connection to our parent organization because our clinic is no longer viable after loss of half of our provider staff, there are a multitude of reasons why a non-compete clause is going to be unenforceable. The most important of these involves the patients in the community. Our town of just over 20,000 people now will have 2 rather than 4 internal medicine physicians, which is inadequate for our aging population. In another practice in town which has an even more restrictive non-compete clause, physicians are unable to make changes that might be in everyone's best interest, since if they leave the practice they must also leave the community and most of them are strongly tied to it, with children in school and spouses with jobs.

If a non-compete clause is unenforceable, unethical and disfavored by our national organization, why do we even worry about it? It is very common for an organization to threaten to enforce a non-compete clause, and to have this happen would be painful or disastrous. Court cases such as these cost 10s of thousands of dollars to complete and result in frequent and unpredictable time commitments that make it difficult or impossible to concentrate on a medical practice.

I have chosen to do a 2 year sabbatical at the end of my association with my present group for many reasons, and mostly because I really want to and think that the experience and knowledge I will pick up will be positively transforming in ways that I can't predict. But I would like to be able to fill in here or there in my community if I am needed during those two years. I can do the exile thing, but it is hardly good for my patients or colleagues, including those at the corporation I am leaving. Nevertheless, sabers are rattling and threats being spoken. My colleague is experiencing the same constraints. It affects both the community and our families, who will be mightily disrupted by our departure or frequent absences.

I have learned an important lesson, which I will not have trouble remembering. I will NEVER sign another contract which contains a non-compete clause.

http://www.wahcnews.com/newsletters/wa-jshore1210.pdf  provides a lawyerly review of some of the issues.

http://www.gklaw.com/news.cfm?action=pub_detail&publication_id=842 presents a bit more on the AMAs position.

http://www.doctoremploymentlawyer.com/2011/08/physician-non-competes-being-e.html recognizes the power of the threat of enforcement.