Search This Blog

Follow by Email

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.