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Saturday, December 29, 2012

Transitioning from fee for service medicine and spending money where it does the most good

I just read in a recent issue of "Aequanimitas," the newsletter of Johns Hopkins Osler medical service, a brief interview with J. Mario Molina, the CEO of Molina Healthcare, an organization which coordinates managed care for recipients of Medicare and Medicaid for several states. It looks like he must have been one of my senior residents when I was an intern. It sounds like he practiced for a few years before taking on the leadership of his family business. He expressed his firm belief that medical care would soon be moving away from paying physicians for the individual services they perform and, instead, paying them for keeping patients healthy. Since it will be organizations, not doctors, who are paid for care, it will quickly become clear that paying for anything that prevents dire illness with its astronomical associated costs will benefit the whole. Medical institutions may find themselves in the business of making their communities healthy. This is not foreign to large medical organizations, but being paid well to allow patients to become sick and then taking extravagantly good care of them does encourage organizations to focus more on the acute care aspect of what they do.

Physicians perform studies about whether a given medical intervention actually works, and whether, for what it costs, it is better than the intervention it seeks to replace. We have looked at the placement of stents in coronary arteries to treat or prevent heart attacks and have gained lots of information about which kind of stents are good for which kinds of coronary disease, comparing this technology to simply dilating arteries and looking at coating the stents with drugs that encourage blood vessels to stay open. This has at least given us information upon which to base what should be cost effective care.

But what about social programs? Giving a person financial aid, to eat, obtain housing, feed children, get medical care, is presumably for the purpose of improving health and happiness. But have we actually checked? Which social programs deliver the best result for the money? Could one public swimming pool prevent delinquency and save money on jail and public assistance? Could regular access to massage therapy save money of physical therapy or prevent orthopedic procedures? Could better training to prepare a person for work reduce devastating work related injury and associated medical costs?

It will be interesting to see how we make decisions about spending "health care" dollars as the dividing line between prevention and treatment of illness becomes blurred. If a community was given all of the health care dollars presently spent on caring for its members along with knowledge of which programs or services or projects made people healthier and so less in need of expensive medical interventions, effective prevention would be funded. It may be a bit of a trick to get data on what works. Perhaps it's time to start looking at this sort of thing more scientifically. I'm thinking about an article on the front page of the New England Journal of Medicine in some happy future time entitled, "Effect of ballroom dance classes and weekly social dancing on emergency room visits and admissions in elderly adults." Or perhaps, "Health outcome effects of regular home visits by a mobile primary care physician team." Or "Reduction in total joint surgeries in a community with publicly funded massage therapy and Tai Chi Chuan classes." The possibilities make me smile.

Monday, December 17, 2012

In the wake of marijuana legalization, what exactly are the health risks?

Colorado and Washington state have legalized the recreational use of marijuana. I thought this would take longer to legislate, especially with the recent backlash from the federal government about medical marijuana. Eighteen states (including California, Alaska, Vermont and Oregon) allow marijuana to be used for medical reasons, but have restrictions on which conditions can be treated with it, which don't necessarily correlate perfectly with the diseases for which it is effective. I have worked in a state which doesn't allow legal marijuana use for anything, but have seen patients from neighboring states who did use medical marijuana and have tried to stay abreast of the laws and issues surrounding use.

Marijuana is relatively nontoxic. Nobody has ever died of overdosing on marijuana, though it is theoretically possible. Combining marijuana with other drugs can lead to overdose death, and combining marijuana with driving or other activities which require fast reaction time has undoubtedly resulted in trauma related death. Still, the chemicals, including tetrahydrocannabinol, which cause marijuana's high and helpful effects, are mostly not terribly harmful.

Marijuana can be smoked, in which case its effects are noticed quickly and last for 2-3 hours, or taken orally, in which case effects can be delayed for hours and can persist for quite a long time as the drug is more gradually absorbed. Smoking is a particularly good delivery method from the standpoint of a pharmaceutical because of the quick onset which means that a person is more able to accurately judge the appropriate dose, titrating to the desired effect.

Mentally, marijuana can cause anxiety and even paranoia. Usually, though, it is more likely to be sedating than anything else. It can cause euphoria and perceptual distortions. It interferes with formation of memory, which makes it a bad choice for students. It is often good for treating anxiety and sleeplessness, is especially good for nausea and relieves various kinds of pain, including the pain of fibromyalgia (a brain related sensitization to bodily pain with associated symptoms of sleep disorder, irritable bowel, headaches and sometimes confusion) which is difficult to treat with other pain medications. It can significantly reduce the need for opiate pain medications in patients with chronic pain, and opiates really can kill people. It is also potentially inexpensive, or free if a person grows it themselves.

Physically, though, marijuana is not without drawbacks. It definitely increases appetite, which can be good in the setting of chronic illness, but can also lead to obesity. It causes men to grow breast tissue if it is used regularly, though the mechanism of this is not clear. This is primarily observational, but will probably be studied more as marijuana use becomes more common and legal. Marijuana, when smoked, does not appear to cause lung cancer or chronic obstructive lung disease, in fact it seems to be associated with increased lung capacity in regular users. There is an uncommon disease, usually of young men, called cyclic vomiting syndrome, in which patients suffer days of vomiting with intervening periods of normal gut function. This appears in many cases to be due to marijuana use, and is not limited to heavy or regular use. Marijuana is one of the many drugs that can cause pancreatitis, an inflammation of the digestive and insulin producing organ that can be painful and can eventually become chronic. It appears to be a very rare cause, though, and most people who develop this get it from alcohol abuse. There are physical symptoms of cannabis use, including conjunctival redness and increased heart rate, and there are withdrawal syndromes in regular users, including yawning, excessive sleepiness and panic attacks.

All in all, from a medical standpoint, is probably a good thing that marijuana is legalized. Patient who are presently dependent on physicians for opiate prescriptions might be able to be transitioned to marijuana, which would at least not kill them. When it becomes more practical to study marijuana's medical effects, there will be more evidence of both what it is good for and when its use should be discouraged. It is, of course, still a mind altering substance and people will need to learn how to use it responsibly. Significantly more people will probably use marijuana when they can do so without legal repercussions and physicians will probably see more issues with dependence and habitual use. This is probably an excellent time to begin to study the social and medical consequences of having a very popular and powerful chemical more generally available.

Wednesday, December 12, 2012

Evidence based medicine--but which evidence?

In the last year I've become more and more comfortable using online resources to determine the best treatments for the diseases I see. My favorite site is Up To Date, which has experts write articles which review the literature and share their experience to produce very readable background information and succinct recommendations. Up To Date is expensive, but most hospitals that have computer systems also have subscriptions to it, so it's easy to access when I am reviewing labs, tests or other data.  I've also been impressed with the American College of Physicians PIER (physicans information and education resource) which is available to me as a member of the ACP and has links to new articles and practical recommendations. It is less exhaustive than Up To Date, for instance there is no specific article dealing with Brucellosis (a cattle related infectious disease), but very easy to use and right up to the minute. For absolutely free I can use Medscape, as can anyone reading this, and articles there are also well written and frequently updated.

Mostly there is pretty good agreement among the different sources, but occasionally not, and often Up To Date does not include up to date information and fails to address controversy. Even when it does, it is sometimes dismissive, saying that a certain therapy "cannot be recommended." That sure carries more weight than "the authors have a bias against this because we haven't done it much" or "this is very promising and other physicians use it with good results but we don't."

Even though there are oceans of studies on any given subject, sometimes the studies are poorly done or don't address the most important questions. Sometimes apparently well done studies turn out to be wrong when they are replicated. Sometimes new data is just too counter-intuitive to be adopted right away. Nevertheless, on several subjects I have been disappointed by both PIER and Up To Date.

Acute Pancreatitis is a very painful inflammation of the pancreas, a digestive organ filled with really nasty juices which leak out and cause damage to surrounding tissues. The most common cause of this is heavy alcohol use, followed by gallstones, medications and bad luck. Some cases of pancreatitis are so severe that the patient dies due to complications of whole body inflammation or destruction of internal organs. Most cases are much milder and many patients may weather pancreatitis at home, unaware that they ever had it. Fully 35% of patients who come to emergency departments with pancreatitis are sent home and most of them do well. The standard treatment for pancreatitis, though, per Up To Date and PIER is to admit the patient to the hospital, have them take nothing by mouth and receive IV hydration and pain medications until the belly is no longer tender. Recently, I believe, Up To Date changed this to say until the pain starts to go down, which is definitely different. Nothing is said about discharging patients to home, other than to mention that some patients with recurrent pancreatitis will manage their attacks by taking only clear liquids and will not come to the hospital. And there are studies that show that patients who have mild pancreatitis can do better if they are allowed oral nutrition, which I've noticed sometimes makes a patient much more comfortable as well. The original argument had been that food made the pancreas squeeze out its juices and that the pancreas should be rested. It turns out, though, that the inflamed pancreas doesn't really do anything with or without food. I would like my sources to mention this, and give some guidelines for the outpatient management of pancreatitis, since many patients with this condition are not admitted to the hospital.

Pulmonary emboli are blood clots produced, usually in the legs, that go to the lungs, potentially causing deficiency of oxygen and sometimes catastrophic effects on the heart and blood pressure. Some of these, though, are quite small and cause hardly anything, except maybe some mild chest pain. Because we have really sensitive CT scanners to look for pulmonary emboli, very small ones are more effectively diagnosed. The standard treatment for pulmonary emboli, and the one recommended by Up To Date is to start an injectable anticoagulant, along with an oral one, warfarin, that doesn't kick in for a few days, continue the injectable one for 5 days and then the oral one for anywhere from 3 months to lifetime. This last Spring, the New England Journal of Medicine published an article looking at the effectiveness of a new oral anticoagulant Rivaroxaban in the treatment of pulmonary emboli. It works right away and is less expensive than the combination of the oral and injectible option and requires no monitoring. The two treatments were equivalent, with less bleeding in the Rivaroxaban treatment arm. The FDA approved Rivaroxaban for this. Using Rivaroxaban rather than injectible anticoagulants makes it much easier to allow a patient to go home rather than stay in the hospital, which has turned out, in many cases to be as safe as hospital admission. Why is it not mentioned in my go-to sources?

Bleeding from ulcers in the stomach or duodenum can be devastating. They are often caused by use of anti-inflammatory drugs, also by infection with the H. Pylori bacterium and are more common in drinkers and smokers. Reducing acid produced in the stomach is very effective in helping these heal and so when someone is admitted to the hospital with a bleeding ulcer, they are started on a proton pump inhibitor medication right away. Originally the medications were only available as capsules, then  the intravenous version became available and now it is recommended that we give these medications by intravenous constant infusion for 72 hours when the bleeding is significant. This is based on the observation that the half life of these medications is rather short so constant infusion is likely to be more effective in keeping the acid levels persistently low. A recent article, however, found that twice daily bolus dosing of these medications was no less effective in preventing re-bleeding than the infusion. Infusions are fine, but require constant monitoring and a devoted IV line. Intermittent dosing can share an IV with other medications or blood products. When there is an infusion, frequently a central IV line must be started in order to have an adequate number of access points, and central lines have all sorts of potential complications, from collapsed lungs to blood stream infections. It would be nice if Up To Date would mention that intermittent intravenous dosing was a reasonable option for delivering these drugs.

And flu shots. A recent Cochran review questions the utility of routine flu shots for patients not at increased risk, yet Up To Date doesn't mention this at all. Phooey.

When physicians are judged by their peers or in law courts, our performance is compared to the standard of care for the communities in which we work. Standard of care is often strongly influenced by easily available references. As we move toward practicing medicine based on evidence of effectiveness, it would be nice to see the references we use recognize dissenting opinion and contradictory results.

Tuesday, December 4, 2012

Multitasking and information toxicity--is that why I feel stupid?

Today I've been feeling stupid. My job absolutely requires critical, creative thinking and the ability to focus well, which was really hard today. But I don't think I'm actually stupid. I think it has something to do with the task at hand.

So this is how today went. I think it kind of explains the stupid feeling.

My morning shift started at 7:30 in a small but busy 45 bed hospital that serves a chunk of rural Alaska.  The night shift doc told me about the 13 patients who I needed to take care of that day. Seven of the patients were new to me, admitted the night before. For those patients, I needed to review their medical histories in the computerized medical record and get to know them, with a focused physical exam and an interview to determine what needed to be accomplished in the hospitalization. For all of the 13 patients, I needed to review all of the lab tests completed in the last day  and all of the radiological studies and check their vital signs and review the nurses notes about what had happened in the previous 24 hours. Each person had an average of about 30 blood test values and some of them also had microbiological results that needed to be reviewed. There were an average of, I'd say, 20 vital signs per patient to review, since some of the patients were in the intensive care unit and had hourly blood pressures and pulses documented. There were inputs and outputs to be reviewed, which were relevant for about 60% of the patients. These data sets were a little difficult to find, and involved adding up numbers of milliliters eaten, drunk, pooped, peed and vomited to come up with an estimation of whether the patient was getting dehydrated or fluid overloaded. On each patient it was important to review the medications that they had been prescribed. This averaged maybe 12 medications per patient since many had been prescribed medications that they might need if they couldn't sleep, or poop, were nauseated or were in pain. Every day I find a medication on one of my patient's lists which is inappropriate in some way. I discharged 5 patients. For these I needed to fill out a medication reconciliation form to make sure that the medications that they took before they came in were reviewed and re-started if they were needed, and that any new medications given in the hospital were continued, if needed. I needed to write prescriptions for the new medications. They also needed things like oxygen and wheelchairs and that sort of thing, and these needed to be checked by the insurance specialists to make sure that they would be covered so that the patient wouldn't find that something that was unaffordable was the thing that they needed in order to survive at home. I had a meeting with all of the nurse manager type people, and nutritionists and physical therapists and social workers to discuss all of the patients, which took about a half hour. I had two new admissions to the hospital and for this I needed to walk to the emergency department, about 5 minutes away if I really moved, to see and evaluate the patients. One of these came in at 9 AM and the other at about 2 PM. The admissions involved discussing the case with the emergency room doctor, reviewing the computerized chart, including past visits, imaging studies and labs if relevant, reviewing paper chart materials from referring doctors and from the emergency department, vital signs, interviewing and examining the patients and then writing and entering admission orders which included all of the things that I wanted done to the patients for the hospitalization including diets, medications, physical therapy, imaging tests, vital signs and activity. I dictated notes on all of the patients I visited, discharged, admitted, concisely recounting all of the relevant data I had reviewed, the patient's history, the physical exam, family history, social history, a review of systems and then my interpretation of the problems and my plans for solving them. Discharged patients needed excellent notes so that their primary care physician would be aware of what had happened. I also answered 12 phone calls about patient care issues, visited the radiologist to review x-ray results, transferred two patients from the intensive care unit to the general medical floor, talked to 6 family members, and had 3 conversations about life and death issues including new diagnoses of cancer and HIV and endstage heart disease. I did 5 bedside ultrasounds, observed 2 echocardiograms and a carotid duplex exam performed by the radiological technician and discussed patient care with 4 referring physicians. I called the pathologist twice for imcomplete results on the man with cancer, got the out to lunch message once, busy signal the second time and then forgot to call again before the end of the work day, which potentially will delay the man's hospital stay by a day. Everyone who needed to be discharged needed discharging at the same time, and the people in the emergency room needed to be admitted at the same time as the people needed to be discharged. At this very same time sick people were having things happen which required measured and creative responses from me in order to continue to progress in the direction of good health.

I felt most stupid when I was dictating my reports. A good dictation includes about 10-15 elements depending upon what it is for, and helps me focus on what is going on with the patient. It is also really difficult for me because I am a very visual person and would do much better if I could see what I was writing rather than have it disappear into a recording device. Even if I take copious notes during the day I always feel like my dictations are missing something important.

But even if it weren't for the frustrations of dictating into a telephone, it is abundantly clear why I should feel stupid. My job is objectively impossible to do well. As an article in the Wall Street Journal puts it, "Multitasking makes you stupid."

My standard day consists of maybe 7 distinct activities:
1. interviewing and counseling patient and families.
2. reviewing data.
3. communicating with other doctors and staff.
4. examining patients and performing procedures
5. making orders for patient care.
6. documenting patient care, usually by dictation
7. answering phone calls.

These are very distinct activities and are, of necessity, done either simultaneously or in quick and random succession. I was reading some of the data on multitasking and I do realize that what I do decreases my efficiency and creativity due to the extra time and brain power required to change gears so often. I love every little part of my day, but I don't necessarily love trying to do all of it at the same time.

For me, heaven would be doing what I do, but one patient and one activity at a time. I would also like to get rid of at least half of the individual pieces of data, vital signs, labs, that sort of thing, and a large portion of the medications, to reduce risk of side effects. I would like to train my computer to present data to me in a way that I can best perceive it, without having to jump from page to page. I would like to see the notes I write as I write them.

It is possible to reduce the data that drowns physicians, and it would probably significantly improve our quality of care. It is possible to make our computer systems present data in a way that doesn't confuse our brains. I'm not at all sure, though, how to make patients who are sick simultaneously respect a physician's need to do tasks one at a time.

Sunday, November 25, 2012

Mammogram screening--reconsidering the wisdom of saying "No."

Three days ago, on November 22, 2012, an article was published in the New England Journal of Medicine questioning the utility of mammogram screening for prevention of death from breast cancer. The authors were research professor Archie Bleyer MD at Oregon Health and Sciences University in Portland, an oncologist who was chief of pediatrics at MD Anderson Cancer Center and H. Gilbert Welch MD, MPH, a professor at Dartmouth Medical School.  The article examines the ability of mammograms to prevent late stage breast cancer by diagnosing and treating breast cancer early as a result of detection by mammograms. They found that mammograms do detect lots of breast cancer, but when we compare women during the years 2006-2008 when mammogram screening was widely practiced to women during the years 1976-1978, there was no difference in the incidence of the really nasty breast cancers, ones that had spread beyond the regional lymph nodes, and only a small decrease in the less nasty but still significant regionally metastatic cancers. Many, many women were treated for breast cancer but only a few were saved from dying of late stage disease with mammogram screening.

Their evaluation was carefully done, making assumptions about the increase in rates of breast cancer over time that were designed to make the results of having a mammogram more favorable. They concluded, somewhat generously, that " Women should recognize that our study does not answer the question “Should I be screened for breast cancer?” However, they can rest assured that the question has more than one right answer."

Mammograms are x-rays of breast tissue and were first introduced by a German surgeon named Albert Salomon in 1913 when he examined mastectomy specimens with x-rays. Mammograms were used rarely before 1978 when widespread use of mammography was introduced in an attempt to identify and treat breast cancer early to reduce mortality and morbidity. The procedure has been controversial since 1978. The first objections regarded the danger of radiation to the breast. A mammogram is performed by squashing a breast between two plates and passing x-rays through it. A digital mammogram detects the x-rays with digital detectors and creates an image on a computer monitor. A film mammogram creates an actual negative on a piece of photographic film. These techniques are equally sensitive but digital machines are replacing film machines due to the overall convenience of storage and communication of images. The dose of x-rays with a typical digital mammogram is 3.9 milligrays, the same as for a film mammogram, and about 4 times the radiation dose of a chest x-ray. It is a small dose and is probably not a significant danger.

After initial worry about radiation, very reasonable concerns remained about the quality of mammograms and mammogram readings. In 1992 the Mammography Quality Standards Act was passed to assure that facilities that performed mammograms were accredited by the FDA to be of adequate quality. 

Mammograms are very big business. I can't find out how big, but if there are about 40 million women between the ages of 50 and 75 and half of those get mammograms at a cost of $100, that would be 4 billion dollars spent on mammograms alone, not to mention repeat mammograms and other technology to further identify actual breast cancer. If I am off by a factor of 4, that's still 1 billion dollars. It is a big deal to write an article questioning the utility of this test. Any move away from a recommendation of yearly mammograms starting at age 40 or 50 is met with outrage. Still, articles and studies continue to demonstrate that the benefit of screening mammography is limited.

Norway has been extensively studied with regard to mammogram screening because they keep excellent records and have had a staggered approach to universal mammogram screening for women. Over the last 20 years multiple studies have come out of Norway suggesting that breast cancer is overdiagnosed by mammogram. Overdiagnosis is what happens when we find a breast cancer that would never have caused harm if it had not been detected. Some cancers do not kill people and are probably taken care of by a healthy immune system. In an article published last April, a study group evaluated the data and estimated that, of all the breast cancers diagnosed, about a quarter of them would never have caused harm. This week's article concurred, but suggested that number may be as many as 30% and that over a million women have been diagnosed with breast cancer since the inception of screening who would never have been affected had they not had mammograms. 

But, one might ask, is it really a big deal to be diagnosed with breast cancer that would not have hurt or killed you? Yes. It is actually a very big deal. The British Medical Journal reported that 50% of women were depressed in the year after they were diagnosed with early breast cancer, the type of breast cancer most likely to be overdiagnosed. But we don't really need studies to tell us this information. It is clear after treating women with breast cancer that they are profoundly affected by this diagnosis, feeling ugly, self conscious, maimed. Treatment complications include disfigurement, chemotherapy side effects, infection, chronic pain, to say nothing of astronomical monetary costs. 

Still, breast cancer kills, and fewer people die of it now that mammogram screening has become standard. How do we explain this? Some of it is due to mammograms. We are detecting lots of breast cancer early. Some of it we should be detecting early and some we should not. Still, some early breast cancers would have become late, bad, killer breast cancers. The study published this week suggests that there are not many of these, but there are definitely some. The treatment of breast cancer has also gotten much better. People who used to die of metastatic breast cancer now remain on chemotherapy and remain in remission for many years, and some are cured. It is undoubtedly because of the huge increase in breast cancer awareness that therapy has improved, and likely the million women who were overdiagnosed were important in helping to pioneer excellent treatment. 

What is a woman to do? What is a doctor to do? I think it might be good to start with recognizing that a decision not to do mammogram screening is not tantamount to a death wish. We give women who reject the recommendation for regular mammograms a really hard time, and that is neither fair nor evidence-based. Mammograms are quite good for evaluating lumps, especially in older women. They are also good for giving peace of mind, since a negative mammogram suggests (but does not prove) that a woman does not have breast cancer. There may be a subset of women, those at particularly high risk of cancer for instance, who would be very wise to have regular mammograms. There may be technology that can help us identify which breast cancers need treatment and which do not. Tests that detect more breast cancers, such as MRI and PET scanning may not be particularly helpful in this situation unless they can reassure us that some breast cancers are of no significance. If we accept that medical resources should be limited, we might look at places where money now used for universal mammogram screening of women might be more effectively spent.

Thursday, November 15, 2012

Creating dependency--is that what we do for a living?

Lately, it seems, I have been treating quite a lot of people who end up in the hospital as a result of prescription drug abuse. Most of them have chronic pain and have been generously prescribed long acting opiate medications such as methadone and morphine by doctors of various types, have taken excessive numbers of these medications or mixed them with other medications and have ended up being unable to breathe for themselves.

In the beginning of the last decade there was a well intentioned movement to recognize that pain was a real issue and should be treated. Pain is not visible, usually, and can often be ignored. Having lots of pain for a long while or intense pain for shorter periods is bad for us. It causes depression, anxiety, leads to post-traumatic stress disorder, and just generally hurts a lot. Humans view torture, deliberately causing another being to have pain, as vile and unacceptable. Conversely we regard the relief of pain as a great gift. In 1999 the Veterans Administration started a campaign to make a rating of pain the "5th vital sign." That means that, in addition to  measuring blood pressure, pulse, respirations and temperature, nurses were encouraged to rate a person's pain on a scale of 1-10. This tended to cause doctors to be more aware of their patients' discomfort and perhaps to offer pain medications. As a doctor, I always find a pain scale difficult to interpret since, unlike blood pressure, it is very subjective. Not everybody is a number person and not everybody has experienced a truly redline pain level on which to base their 1-10 scale. Also some people recognize that stating a pain number above 5 will result in getting really delightful injectable opiate medications. Opiates are not delightful for everyone, in fact some people absolutely hate them, throw up, hallucinate, get hideously constipated, feel out of control. Still. Some people feel SO much better with opiates. They feel warm inside and nothing bothers them. Anxiety goes away and the world becomes a beautiful place.

Since pain became a major focus in medical care, the use of really potent opiates has increased nearly exponentially, and along with that so has prescription pain medication abuse, overdose and unintentional death. Between 1997 and 2007 prescription of opioids increased more than 600%, and that increase has (as far as I can tell) not slowed significantly.  In 2007, 27,000 people died of unintentional drug overdose, the majority of that due to prescribed medications. In our kindness and empathy we as physicians offer increasing doses of long and short acting pain medications that kill 10s of thousands of people and, possibly more tragic, make hundreds of thousands more just-on-the-edge-of-high-all-the-time people dependent upon us for refills. I have been such a physician at times in my many years of primary practice. I would see a patient, know that they had a legitimate reason for opiate pain medications, definitely they hurt and had been taking these pills for years with some improvement, and refilled or even increased the intensity of the medications prescribed. And I was practicing in a way that was encouraged by experts in the field of internal medicine. If a person needed opiates regularly, they should be on long acting ones, and should have short acting ones for breakthrough pain. To offer less was unkind and old fashioned. Sometimes this approach made my patients more functional but surprisingly often there was no dose of opiates at which the patient was truly happy, functional or their pain was actually tolerable. Occasionally, after trying everything I could think of, opiates, anti-anxiety medications, anti-depressants and anticonvulsants I would be forced to admit defeat and let my patient know that they needed to find help elsewhere because I could no longer ethically offer them refills of pills that I knew were not good for them and which were evidently not actually helping. I would offer these patients supervised tapering of the medications, but it was very rare that they were willing to actually get off of the medications completely.

And even with all of this said, I believe that the products of the opium poppy, in all of their glorious diversity, are some of the greatest remedies that the field of medicine has to offer. For post-operative pain, for a toothache, for a kidney stone, for cancer pain there is just nothing like an opiate. Codeine, a low potency opiate, is one of the most useful drugs I can prescribe, relieving stomach cramps, stopping diarrhea, quieting a cough and gentling a headache. There are pains that have no visible cause but are just as intense as a drill press, and opiates can make these tolerable, sometimes. But, as I remember  it, the world of 1997 did not include more people who were miserable than the world of 2007 when there were 600% more opiates prescribed. Regular use of opiates changes people. This is not something I know because I read a study, but because I have treated so many of them. They are less motivated, more foggy. They are tied to the schedule of my office because they feel very unwell when they don't get their medications. Their memories are worse. Their bowels are usually slow, which becomes an issue in itself. Occasionally they overdose and die. Many patients prescribed opiates share them or sell them which leads to dependency in a whole host of other people.

There have been many government and medical profession based responses to this problem, including closer observation of our prescribing habits, efforts to keep patients from getting huge numbers of pills by seeing multiple physicians, pain medication contracts to make explicit the risks of taking the medications and our expectations of the patient for whom we prescribe them. Pain medication prescribing has become big business and many areas have clinics who advertise themselves as treating chronic pain, but really just write prescriptions for patients who are willing to pay for cursory visits. These clinics are being scrutinized and shut down in many places. All of these are good ideas, but I am seeing no decline in the number of patients who are on opiates and who show up with grave consequences of opiate use and abuse.

The problem is that prescription pain med dependence is just the tip of an iceberg of overall increasing dependency on the medical profession due to inappropriate use of medical technology. Physicians generally have ethical motivations, but regardless of our (mostly) good hearts, it benefits us economically to make sure that our patients continue to need us. We have increasing numbers of patients on hemodialysis, whose kidneys have failed. They absolutely require several hours of artificial filtering of their blood at least 3 times a week at the cost of close to $100,000 a year. They are some of the sickest patients we see in the hospital because hemodialysis is not as good as having functional kidneys and they are at least a little bit sick all the time. We do increasing numbers of orthopedic procedures which often are associated with complications including life threatening infections and failure of hardware. These procedures can be wonderfully effective in the right patients, but they are becoming more standard for patients who are at extremely high risk of complications. Our intensive care is more and more effective at making the very sick survive, but they are not, thereafter, well. They have continuing needs for multiple medication an procedures.

Most people don't like dependency. I have heard people say for years that what they dread most is becoming a burden on others. Often what we offer people is the opportunity to become a burden. When we discuss the risks of procedures of medications, I think it should be standard to bring the concept of increasing dependency into the conversation.

Sunday, November 4, 2012

Hospitalists and the field of Hospital Medicine: why we are sometimes terrible and how we can be excellent

Internal Medicine is the branch of medicine that deals with diseases of the internal organs in adults. It also involves dermatology, minor surgical procedures, general psychiatry and preventive care of well people. It is an excellent field, full of opportunities to think and feel and connect with people, mysteries to be solved and an endless variety of stuff to be learned. Internal Medicine contains the subspecialties of nephrology (kidneys), cardiology, oncology and hematology (cancer and blood), infectious diseases, pulmonary and critical care medicine, endocrinology (glands), rheumatology (joints), gastroenterology (guts and livers), neurology and hospital medicine. The most recently invented of those subspecialties is hospital medicine. Unlike the rest of the subspecialties, hospital medicine is defined by the place it is performed, not the body system it aims to treat.

Hospitalists (the internists who practice hospital medicine) take care of patients who are admitted to hospitals when their own doctors do not. Primary care doctors are less and less often involved in taking care of hospitalized patients because they are so busy taking care of patients in their offices that taking the unscheduled time to go to a hospital as well has become impractical. When there is a doctor at the hospital to take care of a patient who comes in very ill, there is no delay in getting appropriate care and the primary care doctor doesn't have to cancel a waiting room full of patients in order to come in. Hospitalists get really good at taking care of the illnesses that are severe enough to lead to hospitalizations. Conversely, primary care doctors forget how to take care of these problems. Hospitalists are paid to be in the hospital at night, so it is no hardship to be at the bedside in the wee hours when people so often  decompensate. Doctoring in the past was more often a profession that was not compatible with having good family time or enjoyable hobbies. Separating office work from hospital work makes it much easier to be a reliable spouse or friend.

On the other hand...The absolutely best care a person could get would be delivered by a competent physician who had known a patient for years, with appropriate input from other physicians depending on the patient's specific needs. As a primary care doctor, when my patients were admitted to the hospital, I knew what had happened that lead up to their illness, what we had tried before, how the person interacted with their family, what their values were. The patient also knew me, trusted me, and felt better in the hospital with its strange smells and routines just seeing my familiar face.

Hospitalists are shift workers, usually working 12-13 hour days, 7 days on, 7 days off, and they are randomly assigned patients as they come in to the hospital. They usually see 10-20 patients a day, discharging and admitting patients to the hospital and coordinating their care. They have access to the patient's computerized and sometimes paper charts, can call their primary care physicians for more information (if they can get them on the phone) and can often take a pretty good history from the actual patient. There is not a whole lot of time for all of this, though, and with up to 20 of more unfamiliar faces in a day, it is pretty difficult to have the kind of intimate knowledge of a patient that would lead to optimal care. Although most doctors are internally driven to do the right thing for every patient they see, it is more work to take a good history than to just go with what the emergency room doctor who originally saw the patient said, it is more work to discharge a patient than let them stay in the hospital one more unnecessary day, and generally just more work to do the job right. Because the hospitalist has to be efficient in order to get all of the tests ordered, evaluated, documented, patients admitted and discharged, consultations ordered and checked, crises averted or alleviated, they often don't ask the questions that would allow a patient NOT to have a test or procedure, they don't necessarily have the gentle conversation that allows a person to make a decision to forego end of life heroics, they don't have time to realize that the patient is really now well enough to go home if certain arrangements can be made. And since the patient doesn't really "belong" to the hospitalist, will not come back and see the hospitalist again, making a meaningful connection is harder, even though it is the right thing to do. Solving the mystery is still interesting, but not imperative, since chances are good that an unsolved mystery will only come back to haunt a different hospitalist.

And yet some hospitalists are excellent. And some hospitalist systems foster excellence.

I have worked in 5 different hospitals in the last year, in 5 very different hospitalist programs. What makes a good one seems pretty clear. First, although good systems are important, there is nothing that can take the place of good doctors. Some of the doctors I have worked with are outstanding. They are patient, have good senses of humor, work well with nurses and patients' families. They take time to really listen to patients. They love the challenge of severe illnesses and have creative minds. Bad systems, though, can burn out and chase off good doctors. The best programs have slightly smaller work loads than the worst programs. Seeing less than 15 patients in a day makes us much more likely to do a good job, to do that little bit extra that makes a difference, to read about what the experts say. When the patient transitions from one doctor to another, either day shift to night shift, or going away after a week of work, it is very important to actually talk to the doctor who will be taking over. Writing  something doesn't cut it. The back and forth conversation, in which doctors ask each other what is really going on, suggest alternative diagnoses or testing not only is good for patients but counteracts the isolation that leads to burnout. Some small hospitals foster collegiality because doctors from all of the specialties end up at the same nurse's station and conversation happens. One program actually had a meeting of the hospitalists every morning which included nurses and other specialties and really improved communication  and broadened perspectives.

All of the hospitals have had some sort of computer system for  record keeping. A simple, user friendly computer system could free up so much time to spend at patients' bedsides or talking to their primary care doctors. Unfortunately, though each of these hospitals computer systems had some clever ideas, none were anywhere near what I would call simple and user friendly. If it was possible to  cut and paste them together, the Vista, McKesson, Paragon, Meditech, Hero systems, it might be fabulous. The one thing that is common to all of these computerized medical record programs is that most of the people who use them hate them. Interesting.

So I guess it's easy to have an excellent hospitalist program. All you need is great doctors, a simple and user friendly EMR (electronic medical record), moderate work loads and face to face signouts. Since this recipe is difficult to concoct it's not too hard to see why hospital medicine is sometimes not excellent. I would like to blink my eyes and find out that we had gone back to the system in which patients were seen by their own doctors in hospitals but the trend right now is towards more hospitalists, not less.

Wednesday, October 31, 2012

A sort of apology to hospitals, especially little ones struggling to make ends meet

In my previous post I said that an obvious reason why we over-diagnose serious conditions in patients who are not terribly sick is that this results in higher reimbursement to hospitals, "...and when a hospital does well they get remodels with big fish tanks and fountains and flat screen TVs which makes everybody happy."  This gives the impression that hospitals are evil and money grubbing, which is not true. Many small hospitals can barely make ends meet and are absolutely vital to the economic health of the communities they serve. Over-diagnosing and inflating severity are definitely the wrong way to go about making enough money to survive, but it is the strategy they are using now for lack of a better one. 

It is important to change payment structures so doctors and hospitals don't waste their time and energy doing the equivalent of clipping coupons in order to cover costs. Part of the costs that make it hard to survive are the administrative and documentation burdens that hospitals carry in order to be paid by insurance companies for what they do. Another issue is that some of the very sickest and most expensive patients to treat are folks who can pay little or nothing to defray their costs, and receive most of their care through hospitals and emergency departments. All that said, though, hospitals are businesses and do not necessarily have the same motivations as the health care providers who work in them. If payment to hospitals was based on their ability to keep their communities healthy, rather than for individual services rendered, incentives would not favor exaggerating the severity of illnesses.

Tuesday, October 30, 2012

What is health care like in India, why do Indian doctors come to the US and why are so many patients septic these days?

Lately I've been working in an unfamiliar state in a rural, but not small, hospital, and have been noticing all kinds of curious things. This is not the first time I've noticed these curious things so now I am sure that they mean something.

1. There are a lot of Indian doctors, especially in small towns in the US.

2. Small hospitals outside of major metropolitan areas often find it difficult to hire physicians, even though they pay lots of money.

3. There are many foreign doctors in the US who are not employed as physicians. They often work in hospitals but not as doctors.

4. In many hospitals patients are admitted to the hospital when they are not very sick and then proceed to have scads of tests and procedures done that are really expensive and not particularly helpful.

5. People who are not particularly ill get admitted to hospitals with the diagnosis of SIRS (systemic inflammatory response syndrome) which is a kind of synonym for "sepsis". (When I was training, sepsis was actually a really dangerous condition of which one might reasonably expect to die if not treated aggressively.)

A little more on SIRS. When a person gets really sick due to a life threatening infection, the body turns on all of its resources to kill bacteria. Our temperature goes up, our heart pumps faster, the blood vessels dilate, we breathe faster. Our white blood cells come out to fight and if we are really sick they are consumed in the battle. The 4 criteria for systemic inflammatory response are a high heartrate (over 90), a high or unusually low temperature, a low carbon dioxide level or high respiratory rate and a high or unusually low white blood cell count, especially with immature cells present. If we have two of these we qualify for SIRS. Today I had two patients with SIRS. One was a woman who developed chest pain while barbecuing, came in, belched and it went away. Her tests were all normal except that she had a slightly high white blood count with immature cells and a low temperature. She also felt fine. She was started on heavy duty antibiotics and had a super expensive stress test and went home, grateful for the care she had received, which was actually completely unnecessary. The other one was a man who was chronically ill with hepatitis who had a cough. He was bedridden so when he got to the hospital his heartrate was somewhat elevated and his respiratory rate was up, and because of the hepatitis he had a low white blood count. He was diagnosed with pneumonia and SIRS. I know what pneumonia with sepsis looks like and it is a medical emergency. It is also not what he had. He had a cough and some changes in his vital signs.

So why does everybody and his brother have SIRS now, even if all they have is a cold? Because hospitals get reimbursed according to how sick the patients who are admitted to them are, and hospitals pay our salaries. And when a hospital does well they get remodels with big fish tanks and fountains and flat screen TVs which makes everybody happy. So in another few years when they do studies on survival from SIRS, they will find that we are much better at treating this dread disease than we used to be. Probably because we have better antibiotics. Oh yes, that must be it.

At this hospital where I have been working I met two interesting doctors from India who were not doctors in the US. One was a cardiologist who was working as a computer tech at the hospital, teaching people how to use the computerized health record system. She was planning on doing a residency in the US which is what she will need in order to actually work as a doctor here. She will have more, but very different experience, than the other residents in her program, since she has already done a residency and fellowship training, but she will also have to settle for a probably not excellent training program because, as an Indian trained physician she will not be very competitive. The other was a dialysis and IV tech who was the go-to person when any intravenous catheter was needed. He had finished medical school but never practiced as a doctor in India, but he did own two hospitals there, which his brother was running while he was in the US. He answered several questions I had about medicine in India.

In India there are private hospitals, which are entirely funded out of pocket, and there are government hospitals, which will serve anyone who can't afford to pay. Most people prefer private hospitals because the care is better and the hours are better and because they are actually pretty inexpensive. "If you need a coronary artery bypass," my friend said, "and you have $2000, we can get you one." They buy medical equipment from China, where it is cheaper than in the US. He bought an EKG machine for $1700 that he priced in the US at $17,000. This allows him to provide services for costs that regular people can afford.

So why do Indian doctors want to come to the US, then? It sounds like things work pretty well there. Actually things don't work very well there, from many different perspectives. Infant and maternal mortality rates are very high. Emergency care is extremely poor, even in big cities. Here we pride ourselves on getting peoples' heart attacks and strokes treated within an hour, which saves people from long term disability. We have well trained paramedics and EMTs who can rescue people in the field who have accidents or injuries. This kind of care is rarely available in India. And then, of course, there is the money.

Doctors in the US can make a lot of money. Huffington Post had an article that looked at the best paying jobs in the US, and doctors and surgeons were at the top of the list. The doctors who make the most are in varying fields, some of which might be considered the dirty jobs that nobody in their right mind wants to do. Some of these dirty jobs are in the field of internal medicine, my chosen specialty. Internists often go on to specialize in hospital medicine and nephrology (kidneys) which are jobs that put one in the position of always treating patients who are pretty sick and having terrible hours. Hospital medicine is usually in 12-14 hour shifts during which one must see a crew of up to (or even more than) 20 patients, all of whom could, conceivably, need the doctor at the same time. Nephrology involves knowing the sickest of patients, folks whose kidneys no longer work, who have dialysis 3 times a week, which they don't love, and which is the nephrologist's bread and butter. It is not at all uncommon to see a large proportion of hospitalists and nephrologists who are graduates of foreign medical schools, especially Indian ones.

Doctors in the US have to put up over a quarter of a million dollars just to go through medical school, and since a fair portion of this for US trained docs is funded by loans, early in a doctor's career quite a bit of salary goes into paying off loans. In India, though, tuition and fees at a medical school are nominal. The medical education system is run by the government, or so says a friend who trained there, and many (though not all) of the schools are excellent. Education is in English, so Indian doctors do not have much of a language barrier once they have finished school. How very very tempting to come here, repeat a little medical training and then make more in a year than you could in 10 or 20 years in India. But why the US? Certainly other countries also pay doctors huge amounts of money. Well, actually, no.  Although some articles looking at cost of living and such say that the US is right in line with other developed countries, I don't entirely buy that. Our absolute salaries are definitely higher, and a person can live on very little money in the US if they put their minds to it. A doctor practicing long hours can eat at the hospital for next to nothing, sleep and shower there, and some do, especially foreign medical graduates, who are probably supporting whole extended families on their very generous paychecks.

So here's how it goes, how the little mysteries arrange themselves.  America loves medicine (gross generalization, but based in truth.) We pay our doctors really well (except primary care, because it's sexier to cut people open and save them from the jaws of death than keep them from getting sick in the first place.) We have to be paid really well because medical education is really long, hard and expensive. Hospitals are becoming the pocketbooks for the American healthcare dollar. They
pay us really well because otherwise we would refuse to work for them. They get us to admit lots of really not very sick patients in order to stay in the black and we cooperate because they pay our generous salaries. Patients get procedures that they don't need and become convinced that they are really sick and really depend upon the medical profession or they will certainly die (of sepsis.) Foreign physicians come here because the pay is so good that it is worth working in hospitals that are in the middle of nowhere after journeying far from the land they love.

What is the actual problem, though? We are wasting our time and energy treating patients who are not sick and convincing insurance companies that they are sick. This is bad for everybody. Some of it may be driven by fear of being sued, but more, I think now, is driven by money. We have such wonderful technology now for treating truly sick and salvageable people, but we waste it on people for whom it is not appropriate. It is not a problem that we have lots of foreign doctors (other than the issue of stealing them from their generally underserved countries.) They have interesting perspectives and skill sets and they take care of patients in rural areas and in unloved specialties. The fact, though, that foreign doctors are flocking to our shores may mean we are paying doctors too much money.

Second thoughts about my ranting:
In addition to the apology, above, to hospitals which are trying to make enough to survive, I realize that I have also been somewhat misleading to patients who may be reading this and have been admitted to the hospital. There are still plenty of patients admitted to the hospital for very good reasons. There is no actual shortage of really sick people, truly and dangerously sick people. But there are more not-very-sick people in certain hospitals than would be ideal, and once admitted, such not-very sick people can stay there for a long time. (An old adage says "no reason to admit means to reason to discharge.") The culture of a hospital and the population it serves determines how many of the patients inside are really sick. Some hospitals are at capacity for the population they serve, and simply cannot admit patients who don't really need to be taken care of in a hospital. Inflating the severity of illness in documentation is common even in these high acuity hospitals in order to get stingier payers, like Medicare or Medicaid, to pull their weight. These two entities pay far less than private insurers and usually require much more specific documentation. They will pay our hospitals more if we, for instance, document "hypokalemia" when the patient's potassium level is a little low, but if we say "the potassium is a little low" that won't count. So we end up making long lists of little picayune things that are wrong using big Latin derived words which makes a patient appear to be horrendously complex and gravely ill. Right now I could probably give myself a list of dire sounding diagnoses if I really put my mind to it (I'm thinking rhinorrhea, actinic keratoses, menopausal syndrome, shift work sleep disorder, presbyopia, irritable bowel syndrome, female pattern alopecia, chondromalacia of the medial femoral condyle, bunion deformity) though I'm actually vigorously healthy. Just going through this exercise makes me want to start thinking about buying a prepaid funeral policy. I will continue to assert that inflating diagnoses and severity is wrong, but it is based in our perverse payment system, not a result of individual greed or dishonesty. 

Saturday, October 27, 2012

Balancing the budget: how exactly will we eventually pay for health care?

This week the American Medical News featured an article with the disturbing title, "Massive health job losses expected if Medicare sequester prevails." I wasn't entirely sure what a "sequester" was, since I thought it was a verb. Sequestration, I thought, was the noun. (I hear a loud knock. It must be the grammar police.) The story, as I understand it, is that when our government decided to pull together and raise the debt ceiling, they also passed the Budget Control Act, which was intended to reduce the deficit by $1.2 trillion by 2021. This was to be achieved by a bipartisan Joint Select Committee on Deficit Reduction, which would make well considered cuts in funding for various projects. They were unable to come up with a plan that they could agree upon (imagine that) and so automatic across the board spending cuts are mandated to go into effect in 2013, excluding only a few programs, such as childrens' health and disaster funding, and capping yearly cuts to sensitive programs such as Medicare to 2% per year. These funding cuts are called "sequesters."

This sounds so very familiar. Several years ago Congress passed the "sustainable growth rate" formula which mandated that medicare costs would rise only as fast as inflation. Up until recently Medicare costs continued to outpace inflation, and so yearly congress must legally cut Medicare payments, across the board, but then at the last minute they don't. Doctors and patients say that the program will surely not survive since across the board cuts mean that as well as cutting the numbers of unnecessary procedures and devices that are used, we must also cut payments to primary care docs, who already receive far less than they are willing to accept in payment for office visits. Applying the SGR is then delayed, again, by a last minute agreement. Congress does this at least yearly.

Across the board cuts are a bad idea, yes they are. Some parts of programs need to be cut and others need to be grown in order to make systems more efficient. Good primary care more than pays for itself in saved hospital costs (I'm making this fact up entirely out of reason and good sense. There are no studies that exactly address this question.) If payments to hospitals shrink, it should be via improved health of populations who then will need less hospital care. But across the board cuts don't allow for this. So, one might imagine, the specter of across the board cuts would be very effective in making us come to a consensus on how we could control expenditures so that such cuts would never become necessary. It clearly has not been an adequate deterrent. Doctors and others in the field of health care continue to allow their piece of the financial resource pie to grow, to the detriment of all kinds of things.

Nobody, it seems, wants to be seen to cut money that goes to programs when doing so would anger a significant portion of the voting population. And lawmakers don't really understand that there are huge areas of unpopular inefficiencies whose elimination would be mostly painless. They don't know this because they are rarely in the thick of medical care, either as caregivers, health care providers or patients. Those who know about inefficiencies are too busy to speak up or are not likely to be heard by lawmakers.

But on the subject of job losses related to cutting spending on Medicare--yes. That will absolutely happen and there will be economic repercussions. Excess money spent on health care sometimes goes into the pockets of greedy people who already have enough money, but it also supports families, via health care employees who do jobs enmired in inefficiency, such as insurance adjusting and device sales and pharmaceutical advertising. These are homegrown jobs and paychecks often go to local industry and support real live American people pursuing life, liberty and happiness. The inefficiencies of health care sometimes grow our economy, but at the cost of lowering effective take home pay for all insured workers and creating dependent and indebted individuals who are forced by ill health or poor decisions to make use of acute care.

What to do? I would favor some kind of health care industry/government collaboration to make binding decisions regarding where best money can be removed from the Medicare budget. Failure to come to an agreement should not be an option.

Thursday, October 18, 2012

The Ryan Plan and the Affordable Care Act--can market forces improve quality and cost in health care?

In today's New England Journal of Medicine an article by Republican health policy analyst, Gail Wilensky, brought up several excellent points. The article is entitled "The Shortcomings of Obamacare". She points out that the Affordable Care Act does not directly address the forces that have lead to high costs and less than optimal quality in American health care.  She points out that physicians are paid according to a relative value scale that creates perverse incentives to do more procedures regardless of whether they work, and that this has not been addressed by the ACA. She says that if we want to use market forces, putting consumers in a place where they can have an impact on cost and quality of the care they receive, we should look to Paul Ryan's health care proposal.

So I did.

I read the version called "Summary of the Legislation" in a .gov site dedicated to the "Roadmap Plan" that is part of a republican budget. It is much simpler than reading the ACA. Perhaps if it is in the form of an actual bill it will also be 1000 pages, but I doubt it since it covers much less. It appears to be a tax and insurance reform that allows people to pay for health insurance with tax credits, and aims to transition medicare to a voucher system which gives medicare recipients an amount of money equal to the average cost for a year's healthcare on medicare to be used to buy private insurance. The medicare change would not go into effect until 2021.  People would be able to keep their insurance when they changed jobs, and insurance companies could sell coverage across state lines which would improve competition and maybe costs. There were also provisions for income tax reform and for privatization of social security.

The amount of tax credit that a person would receive was less than I pay for my super high deductible plan by a substantial amount, and my family has no health problems. A medicare voucher equal to what medicare pays out per person would come close to buying insurance for a healthy elder but would not approach the cost for someone with multiple medical problems.

But that isn't the big issue with the Ryan Plan. The big issue is what Gail Wilensky said in her article: market forces are not acting to reduce costs and improve quality. There is no way that market forces will do what they do so well as long as people depend on insurance companies to pay their bills. Dr. Wilensky implies that the Ryan Plan will do that, but it won't. With the Ryan Plan people would maybe shop smartly for health insurance, but even that is questionable. Health insurance companies are so good at misrepresenting their product that it would take a genius with nothing else to do to figure out which plan does what and for whom. But even if we were able to find cheaper, better insurance through the magic of the free market, we would still be financially detached from our actual health care. We would still continue to be seduced into more, better, fancier, technologically more advanced care which might but probably would not make us healthier.  This would happen, is happening, because insurance pays for these things, and it is always nice to get as much care as possible after paying a hefty health insurance premium. Doctors would continue to make more money for doing more stuff, but not for better outcomes. At least the Affordable Care Act, in its more than 1000 pages, has some provisions that would create incentives for doctors and hospitals to keep patients healthier.

Dr. Wilensky also says this thing that people say when they talk about what's wrong with our system: she says that it is a big problem that such a large number of people in America are uninsured. That just isn't the issue. The problem is that such a large number of people don't have adequate medical care. Many of these people are insured. Costs have gotten so out hand, due in part to the third party payment by health insurance companies, that the consumer's portion of the cost is still out of reach for many people. They can't afford to go to the doctor or buy the medicines they are prescribed because the out of pocket costs are just too high. There is also a looming primary care shortage which means that, even with money, many people who live outside of the metropolitan areas where doctors are plentiful can't get a good doctor at all.

What I see in hospital practice is that many patients are getting expensive procedures done that really don't work. A patient will get 3 or 4 cardiac stents put into minimally narrowed arteries when they were not really having troubles that couldn't be solved by taking a medicine or improving their lifestyle. These stents cause their own problems, require their own dangerous pills to work, and often cost hundreds of thousands of dollars. People get multiple ablation procedures for heart rhythm disturbances which don't work. People get joint replacements which don't reduce their disability. All of these procedures are life giving and wonderful when used appropriately, but since insurance pays for them and doctors, hospitals and medical device companies make lots of money when they are performed, many more are done than are truly beneficial.

I would like to see everyone get adequate medical care. Health insurance companies have been in the business of making money for themselves and their shareholders for a very long time. They are not our friends. I don't think most of them have the ability to be repurposed to help channel the truly adequate amount of money we presently spend on health care such that it buys health rather than the commodity of medical services. Community based cooperatives have the potential to do this. Transitioning to this would be slow and maybe painful, but ultimately so very worth it. We need to stop thinking of health insurance companies as the disagreeable but necessary body guard that stands between us and health care related financial ruin, because there are other options.

Tuesday, October 16, 2012

The changing nature of truth, answering questions for a chance to win a free MKSAP subscription and should we now stop using warfarin (mostly) for atrial fibrillation?

I am presently really excited about learning all over again what I thought I knew when I finished my medical education about 25 years ago. Since that time I have become wiser, learning how to do things and what works for patients by practicing medicine and reading literature. I also retain a body of knowledge that I absorbed from my grand old doctor professors at Johns Hopkins which is sacred and dear and not necessarily true.

Just recently in my e-mail I got an invitation from the makers of the MKSAP (the medical knowledge self assessment program which I used in studying for my internal medicine boards) to answer a set of not-ready-for-primetime questions in the various subspecialties, for which I will be rewarded with a chance to get the next MKSAP materials for free. I must answer these questions without using outside materials and the answers from all of the folks who do this will be used to standardize the test.

I took the endocrinology section first and had an answer for each of the questions, based on what has been true over the last 2 decades. I then looked on UpToDate, the online resource that is updated constantly by recognized experts in every field, to find whether I had been right, and yes, sometimes I was right. But the answers I found didn't necessarily even correlate with the multiple choice answers, obviously also written by worlds' experts. So on subjects about which it is critical to do the right thing, it is really not clear what that is.

When I graduated from medical school I knew the right answer to questions that were of the ilk where there might be a right answer. Like "Is chemotherapy helpful for pancreatic cancer?" or "What are the most effective antibiotics for a simple urinary tract infection?" At some unclear moment in time, those and many other answers that I knew were no longer correct.

While cruising UpToDate I chanced upon a page called "Practice Changing UpDates" in which I found that a whole bunch of things that we do are wrong. I always feel warm inside when I find out that something that had seemed unnecessarily painful or expensive or complex is of no value. I wonder, though, how soon these new recommendations will also be wrong and when, perhaps, the previous ones will be right again, or whether the whole thing is a huge oversimplification and everything we've ever done was perhaps right, given the appropriate circumstances.

But a larger issue, for me, is the fact that it is now completely impractical to be an expert in the field of medicine, unless perhaps the field of knowledge to which on aspires to have wisdom is itty bitty. Research is just happening so very fast, communication is nearly instantaneous and discussion amongst the many diverse practitioners who very much have a right to their own educated and experienced opinion is limited. For instance: last night I heard another physician tell a patient that he shouldn't drink so much coffee because he was having heart arrhythmias and the coffee would make it worse. He had heard a cardiologist say this and berate another physician for allowing a patient with a heart attack to have a cup of coffee. Studies show that coffee doesn't cause heart arrhythmias and that it is in general good for people in large quantities, reducing risk of liver disease, diabetes and all sorts of realms of misery. But certainly the studies that purport to show that coffee is of no harm and nearly infinite help are not designed to look at this particular individual's risk from caffeine, which definitely can cause an increase in heart rate (check your own pulse after a strong cup if you are not a habitual drinker.) What is true, then, about coffee, or anything else for that matter?

But all that said, I do think the news from UpToDate as of September 20, 2012 is pretty interesting, if not necessarily true.

Of the clinical pearls in the article, 3 stand out as particularly relevant to my practice. First--people with allergy to eggs CAN get a flu shot, even though it is made with eggs, because there is hardly ever any problem. They should be observed for 30 minutes where there are personnel capable of handling an allergy issue after vaccination, but they can go ahead and be vaccinated. The question of how important vaccination is for healthy adults and children is, of course, not addressed, and is still very controversial.

The second is that UpToDate recommends use of Pradaxa (dabigatran), Xarelto (rivaroxaban) or apixaban for prevention of strokes in patients with atrial fibrillation rather than Coumadin (warfarin.)  I have written several articles about these new drugs which reduce the ability of the blood to clot and do not require monthly blood test monitoring. They are not easily reversible should abnormal bleeding occur, but honestly neither is warfarin, and the risk of bleeding is so much higher with it because of all of its drug and food interactions and its tendency to be taken wrong. The new drugs are more expensive, but with the expense of monitoring and paying for the morbidity from bleeding or clotting when using warfarin, the costs will end up being similar, and much less once there are generic options. There have been studies looking at various possible risks of the new drugs, including more heart attacks with the use of Pradaxa (dabigatran) but the vast magnitude of error related illness with warfarin dwarfs these risks.

And still. After all of my ranting, I am absolutely positive that many patients will still find that warfarin is the best drug for preventing clotting. There are many people whose doses are always perfect and have absolutely no problems, monitor their own blood tests at home without difficulty and the drug is, in fact, cheap. I could go on with pros and cons for a very long time, but I won't.

I would really like to see these new anticoagulants replace most of the injectable anticoagulants such as enoxaparin and dalteparin since this will profoundly change the way we treat patients with artificial heart valves and blood clotting disorders such as pulmonary embolism.

Last on the "Oh, cool. Finally." list is that it is unnecessary to follow liver function tests for people taking statin drugs such as lipitor (atorvastatin), crestor (rosuvastatin) and simvastatin. They are not liver toxic. We thought they were and they aren't. Again, like with the flu shot, the question of whether so many people should be taking these drugs is begged, but at least they don't need to get blood tests all the time. They also don't need to get their cholesterol levels checked all the time if they are on a dose that is stable and works, but that isn't part of the article, just information from long ago that still hasn't made its way into standard medical practice.

Wednesday, October 10, 2012

Back, but still a bit jet lagged: Health care in the Republic of Georgia

The Republic of Georgia is beautiful, welcoming, has great food, ancient and rich culture, is quite inexpensive, and I am now back. The language is fascinatingly complex, with an alphabet that does not resemble ours in any way, and the capital, Tbilisi, has the feeling of a thriving European city, but there is almost no crime and you can see snow capped mountains and farmed fields if you look up or out. I did no doctoring, but did sit down with a now unemployed pediatrician who told me a bit about their health system. I also talked to other Georgians about how they felt about their health care. Georgians are proud of their wine, their music, their architecture, their food and their loyalty, but they are not particularly proud of the quality of their medical care.

In the Soviet era, before independence, health care was entirely state funded and mainly based in hospitals. After the fall of communism, Georgia was torn apart by the sudden dissolution of their economic system and loss of their major trade partner. Health care rapidly deteriorated and most people had no money to cover it.

Government sponsored insurance covers some of the health needs of kids up to age 6 and adults over the age of 60. Families and patients are still responsible for paying for treatment of serious diseases in kids, and I'm not sure about the elderly, but it sounds like they also have to pay out of pocket for serious illnesses. Doctors are not particularly highly respected or highly paid, though they now have about as many years of education as we do in the US. I'm not sure how good that education is, however. A primary care pediatrician may see 15 or 16 patients on a busy day (a light load by US standards) and make a little over $100 a month.  A highly paid surgeon might make as much as $800 a month. Doctors do not make more than the average worker, and some make less. The cost of living is lower than in the US but not correspondingly lower. Some medical care is inexpensive by our standards: an office call for an uninsured patient costs about $15, but that is actually very expensive for a Georgian. The full cost of a surgery, per my pediatrician friend, might be as much as $15,000, which almost nobody can afford. People do die because they can't afford medical care, though hospitals will not refuse to treat the very ill on the basis of inability to pay. Like in the US, there is a safety net for the very sick and the very poor. My pediatrician friend does not know where the money that people pay for medical care goes, but it is not to the doctors.

Dental care, on the other hand, is a good deal. A British friend said he had gone to Georgia for a root canal which cost around $100. The work was excellent, he said. I don't believe there is dental insurance.

Wikipedia tells me that life expectancy is a little over 74 years, which is low by the standards of the more wealthy European countries and their maternal and infant mortality rates are somewhat higher than those countries, though not as bad as the rest of post-soviet Russia. Smoking (over half of the male population smokes) and automobile deaths are public health issues that contribute powerfully to death rates, but there is still a significant amount of preventable and treatable infectious diseases that kill people.

There is no shortage of physicians in Georgia, with about 1 per 200-250 people. But for whatever reason, quality, cost, accessibility, they are not used.

What wisdom can be gleaned from all of this? There are many recipes for not-good health care systems. In Georgia's case, a soviet model of health care delivery, followed by economic collapse and a war plus many doctors without access to basic technology and without high standards of competence predictably has not been successful. Clean water, adequate nutrition and strong communities go a long way towards keeping the health of the country good despite lack of what I would consider to be adequate medical resources.

Sunday, September 9, 2012

Not dead, just on vacation

The joy of locum tenens work is that I can, actually, take a vacation. I have been working a lot, and so now I am going to be away from anything that begets blogs about medical care for most of a month. I will be singing polyphonic music in the Republic of Georgia and canoeing, briefly, in the Skagit River. I will miss the doctoring, but only a little bit. I will then return and jump right back in, with both feet.

I might write another blog while I am in foreign lands, but probably not, so I'm guessing I'll be checking in again sometime in early October.

Should physicians treat friends and family?

It is a very odd thing that most doctors, especially ones who really love what they do, provide advice and sometimes treatment to family members and good friends. It is also held to be true that this is a bad practice. How do we reconcile this?

In 1847 the AMA published its first "code of medical ethics" which covered many subjects and, though short, is dense and diatribe-like. It seemed to me, when I read through it, that it was mainly concerned with discouraging various forms of quackery, which was rampant in the relatively unregulated environment of the early 19th century in the United States. We physicians were enjoined to "unite tenderness with firmness and condescension with authority" and our patients were reminded that they needed to do what we told them and not fuss and argue with us. Physicians were required to be always available to sick patients, to get consultation when necessary, to treat those who could not afford to pay. In turn, patients were told to avoid seeing more than one doctor because we might disagree and then there would be dissension within the profession. Physicians were to be of superior moral character, not advertise, not have patents on surgical instruments, be cheerful and treat each other and each others' family members for free. It was noted that if we were to treat our own family members, we would be apt to be timid and irresolute.

The American College of Physicians published its 6th ethics manual last year and said this about treating family and friends:

Physicians should usually not enter into the dual relationship of physician–family member or physician-friend for a variety of reasons. The patient may be at risk of receiving inferior care from the physician. Problems may include effects on clinical objectivity, inadequate history-taking or physical examination, overtesting, inappropriate prescribing, incomplete counseling on sensitive issues, or failure to keep appropriate medical records. The needs of the patient may not fall within the physician's area of expertise . The physician's emotional proximity may result in difficulties for the patient and/or the physician. On the other hand, the patient may experience substantial benefit from having a physician-friend or physician–family member provide medical care, as may the physician. Access to the physician, the physician's attention to detail, and physician diligence to excellence in care might be superior."

Which leaves me ethically stranded about where I was before. It is wonderful to be able to provide medical care to friends and family. When I look at what a patient has to go through when they have any one of a number of very common symptoms, a rash, vaginal itching, urinary discomfort, an upset stomach, a productive cough, and the eventual outcome, often an unnecessary antibiotic after a wait of several hours, with almost no history taken and precious little planned followup, I cringe. Can I do better than that for someone I know well and love? Yes. I can. 

And yet.

It is not uncommon that the easy problem that I can take care of in no time leads to another problem and then I may not be available. Then I have treated the patient but left no easily accessible record to help the next care provider figure out what's going on. And sometimes I give really good advice, but the patient doesn't believe me because I'm not really their doctor. Then they do some wrong thing and come back to me for advice when  that doesn't work and I am annoyed because they didn't listen to me in the first place and I'm now doing something else important and for annoyance of this magnitude I really should be paid. And sometimes my familiarity really does cloud my judgement. I don't insist on actually seeing them and miss a very important piece of information that I would never have ignored in a patient in my office.

I have provided hospice care for close friends and family. I think that worked out very well, and I can't imagine standing by watching communication snafus worsen the pain of dying. And yet it was pretty tricky. My heart strings were pulled and decisions really were more difficult than they would have been had I not been so intimately involved. My children have not had much experience with being doctored in the way that has become standard in our culture. But much of what is now done in doctors' offices has traditionally been the job of a mother, including managing the countless colds and tummy troubles that plague children and the inevitable bumps, bruises and lacerations. When I meet the children of physicians, they speak proudly of how their physician parents hydrated them, placated them, benignly neglected them. It is what is most often done, at least with really healthy children. I have traded uncomplicated medical care of close friends for jars of honey or gratitude or just the satisfaction of knowing that the right thing was done, all so far with no ill effects. 

I have also refused to treat people close to me for issues that were complex or required prescriptions for controlled substances, or when my relationship with them was one which made the blurring of roles a bad idea.

I salute the American College of physicians for the final two sentences in the paragraph about treating those with whom one has a prior relationship. They didn't have to recognize that care of family and friends can be "substantially benefi(cial)" to both the patient and the physician. I can just imagine the arguments that may have accompanied this as the document was written. It is as  deeply ambiguous as the subject it addresses.

Monday, August 27, 2012

On the RAC--the recovery audit contractor informational letter and me

In 2003 the Medicare Modernization Act established the Recovery Audit Contractor (the RAC) program to evaluate Medicare overpayment. It was extended to involve all 50 states in 2006 and will eventually involve Medicaid payments as well. The government hired 4 companies to audit payments to hospitals, durable medical equipment suppliers, physicians and other providers throughout the country. Health Data Insights is responsible for the largest geographical area, including my state, Idaho.

Since 2006 we have expected visits and inquiries from various individuals involved in the audits, and eventually we expect that we will all be presented with requests for repayment of money to Medicare in settlement of what the auditors believe are overpayments. This is definitely happening but, other than various highly publicized cases of fraud, I haven't heard that this process has been particularly odious or destabilizing. Nevertheless, in Medicare's report to Congress last year ( 92.3 million dollars in "corrections" were reported for 2010. 18% of these were actually underpayments and the rest overpayments. The auditing companies were paid based on recovery, and were allowed to keep 9-12.5% of the money they recovered.

In July a letter came to me at the hospital (where I only pick up mail sporadically) which reported what the auditors felt was an overpayment. Apparently their automated system noticed that both I and another physician had billed for discharge services for a patient on the same date, and they intended to reopen the claim and send me an adjustment letter. The letter they sent me was informational only, and began a "discussion period" during which I could send information that might affect the claim. I was given a website ( at which I could find a discussion period submission form. It wasn't obvious where to find that, but it was available under the provider information tab.

I reviewed the medical records and found out that I had, in fact, taken care of the patient and discharged her on the date in question, and I printed out a screen shot of the medical records which was blurry enough that I knew it wouldn't fax. So I called the provider relations number (866) 376-2319 and actually talked to a real person. I asked her what happened, why they couldn't read just as well as I that the claim was valid, and she explained that there had, in fact, been two claims by different doctors (me and one of my partners who had taken care of the patient earlier) for the same service and that they hadn't looked at any medical records, just the automated billing. I'm a bit annoyed, but I guess it makes some sense that the burden of proof would be on the doctors who got the disputed payments. I will send them the records tomorrow. If all else fails, I will pay the disputed amount which is only a bit over $73.

Mostly doctors don't bill for hospital services, but communicate what was done to a billing office. We have pretty much no clue what happens after that, other than, in some general way, we get paid. If we work for a small group, we see a spreadsheet which shows that we made so much money from hospital work and then we eventually get money based on overhead and the various things that were paid to us for the myriad of services we provide. It's actually pretty amazing that huge orders of magnitude mistakes don't happen all the time, and so perhaps they do. I suspect that the fact that this patient's discharge was billed twice was an error of foggy wits, not of evil intention, but it is likely that such mistakes are very common and ongoing.

The most common error mentioned in the report to congress, which resulted in the greatest amount of claims adjustment was billing for medical equipment that a patient used while hospitalized. Hospitalization costs are bundled for medicare and the hospital receives the same amount of money for a certain diagnosis and level of service intensity regardless of the resources they use. If Medicare is also billed for medical equipment used during the hospitalization, this is clearly a mistake. If it is a mistake that has resulted in millions of dollars in recovered payments, my guess is that this is because of a colossal misunderstanding resulting from a ridiculously complex payment structure.

The details of medical billing are so complex that people in billing offices need to go to classes to learn how to do it and the people who provide the services (doctors etc.) are usually not aware of what is being billed. When we do see the details, it is hard to make sense of them and so most of us go no further than shaking our heads. I am completely willing to believe that a significant amount of the billing for my services could be inaccurate. It is very likely that a non-negligible portion of the work I have done in the last 25 years was never even billed, since it requires some effort on my part to report what I have done to the billing department, and on a busy day that is the least of my concerns. Even if I do report my work, there is a good chance the communications could be lost in transit or could be misunderstood or wrongly transcribed. It makes perfect sense that Medicare would hire auditors to look for mistakes. For Medicare, the RAC is a clear win, since they pay only commissions on the recovered money. For us as physicians it is scary and annoying, and if it is financially painful will probably make us more careful.

A physician I know from Canada told me that she does have to bill the government for her services, but it is incredibly easy. She just does it on the computer at the end of each week. Errors and fraud are nearly unavoidable with the system we now have, and the remedy we have chosen (RAC) is painful and time consuming. It will make overworked and disillusioned physicians approach their jobs with even less energy and enthusiasm, which is far from a desired outcome. Reform of the fee for service system is in the works, and it truly can't come soon enough.