Search This Blog

Follow by Email

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:

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.