Thursday, September 20, 2018

Physicians

Physicians
The doctor is in ...

PHARMA/PHYSICIANS: Trying to stop the biting of the feeding hand

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So there’s a bunch of rabble-rouser docs who are actually trying to enforce the often mouthed concept that doctors shouldn’t take freebies from pharma companies. They’re called No Free Lunch

And of course, given the actual views of mainstream doctors who believe that life was better when the pharma companies had no restrictions on the graft they could send their way, they are being banned by specialty societies from doing things like handing out the specialty societies own guidelines on gift-receiving to its members, and of course from buying a booth at the oh-so-well incorruptible AAFP’s convention. Jim Edwards at Brandweek has more. But let’s not be too surprised.

Wonder if your doctor is laughing at you?

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That CNN headline grabbed my attention and got me to read a column that basically chastises the 17 percent of internal medicine residents who reported they had laughed at patient in a survey published in JAMA.

The author then goes on to express great relief that 94 percent of those who find humor in their patients considered it unprofessional behavior.

Lighten up! Of course, no doctor — or any professional for that matter — should laugh in a patient or client’s face or use humor maliciously. That’s basic human decency.

But humor is a release, and in a work environment as stressful as a
hospital, people need a release. Maybe that release should occur
outside the hospital walls, but funny things occur in stressful
environments and people do strange things that often merit a chuckle or
two.

Primary Care Workforce Situation: Not Hopeless

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I sometimes observe that the only sector of the economy as messed up as health care is higher education, where the US has some great institutions but where costs are incredibly high and have been rising relentlessly for long periods of time. These two dysfunctional systems intersect in multiple places, one of which is the cost of medical school and its impact on the physician workforce.

One of the reasons the cost of health care is so high in the US is the overemphasis on specialists vs. primary care relative to other advanced countries. That overemphasis is a result of multiple factors, including a reimbursement system that favors procedures and the prestige associated with specialties. But another significant factor is the cost and financing of medical school. Average debt levels for graduating medical students are around $150,000. Combine that with leftover debt from college and it’s easy to get up into the $200,000 range. That’s a big nut to pay off in primary care where typical compensation is $150,000 per year or so.

That large debt level certainly encourages graduating medical students from going into primary care. My guess is it also deters some would-be primary care physicians from going to medical school in the first place.

Can Hospitals Exist Without Doctors?

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“One cannot run a hospital without doctors, and one cannot run one with them.” – Peter F. Drucker

Yesterday Kaiser Health News ran a piece titled “Hospitals Clash with House Republicans on Medicare Cuts.”

The article revived these questions:

·Are hospitals friends or foes of independent physicians?

·Will the future of hospital-doctor relationships be one of cooperation, collaboration, or cooptation? (On the last bullet point, “cooptation” means hospitals take over the practice of medicine).

·What is the role of hospitals in health reform – hospitals after all have already agreed to $155 billion in Medicare cuts under Obamacare?

But I digress. What is the hospitals’ problem with the Republican legislation? What is the big deal? The Senate will probably not even take up the bill up anyway.

POLICY/PHYSICIANS: In which I criticize Uwe Reinhardt, really!

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Uwe Reinhardt has written to the NY Times about What Doctors Make, and Why. It’s great that they print his letter–they should be featuring a whole lot more of his stuff in comparison to their penchant for printing out of touch loonies who don’t we think we spend enough on health care. But, here’s the fact that may take some of you a moment to digest–I  don’t actually think Uwe’s entirely correct here. Here’s what he says:

In “Sending Back the Doctor’s Bill” (Week in Review, July 29), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid. A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.

Uwe’s right in saying that doctors pay per se isn’t a big enough share of medical spending (around 10%) that a cut in it would make much difference to overall health care costs. And he’s also right that we should change their incentives so that–at the least–they don’t make more by running up health care costs elsewhere in the system. And I’m including in that fixing malpractice, college debt and the other issues that make physicians feel under so much stress to increase their incomes.

PHYSICIANS/POLICY: NY Times is surprised about its Ps and Qs in Prostate Cancer Therapy

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Das KapitalSo there are three treatments for prostate cancer. Medicare pays physicians a whole lot more for one (new snazzy non-invasive one that patients prefer too)  than the other two. So they rush off to get the necessary equipment and staff-up to perform the new procedure. Then they start doing that rather more than they others. And the NY Times is surprised!

Wow. Just wait till they hear about chemotherapy, and how much of that treatment “choice” is based on incentives to physicians. (Cue Greg to tell us!)

Just another reminder why non-globally budgeted FFS in a system with no mandated technology cost-effectiveness assessment does not work. And that’s roughly what Medicare provides. Instead we should be trying to figure out what is the best patient long-term outcome is for a pre-determined amount of spending.

The Drug Formulary Death Cage Match of Awesomeness

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I got an unusual request last week.  I had written a prescription of a generic medication (which has been generic for a couple of years) and the prescription was denied by the insurance carrier.  The reason for denial: I had to try a brand-name medication first.

Stop.  Read that again.  They wouldn’t allow me to give a prescription for the (cheaper) generic drug because I had to try the brand-name medication first. This is opposite of the usual reason for denial, the availability of a cheaper alternative than the prescribed drug, and, to my knowledge, is the first time I have ever seen it upside-down like this, and I have been in the ring for the duration of the drug formulary death cage match of awesomeness.  I’ve seen it all unfold.

Here is what happened.

I am not, like many physicians and patients, against the idea of cost-control through the use of drug formularies.  Medications are very expensive (unnecessarily expensive, as I have discussed previously), and the previously strong influence of drug reps made many doctors quick to jump for the latest and greatest medication.  I did this myself, during the first few years of practice – before the advent of drug formularies.

We were constantly detailed on new NSAID’s, antibiotics, cholesterol, and blood pressure pills.   There was always a reason the latest drug was worth using over the old one (sounds a lot like fancy smart phones, doesn’t it?), and since insurance paid the same for brand drugs, I was often influenced by the drug reps.

Embracing palliative care as mainstream medicine

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I’m on clinical service now and my patients are dying left and right. And I’ve never been prouder of my own care, and that delivered by my colleagues and hospital.

When I was in training, a patient’s death was invariably considered a medical failure, and thus an occasion for shame and silence or “the outcome that must not be named.”

We treated it coldly. We might dissect a death case in an M&M conference (“Why didn’t you start heparin at this point?”), but I can’t remember ever seeing an attending role model an end-of-life discussion with a patient or family, talk about palliative care on rounds, or work with a multidisciplinary team to ensure that a patient’s last days or weeks were pain free and dignified. The dying patient was the Elephant In Our Room, but we stayed huddled in the other corner, where medicine was clinical, safe, and emotionless.

A profound change in this sad state of affairs has been gaining momentum over a generation. The hospice movement began in England in the 1960s under the tutelage of Dame Cicely Saunders, and ultimately was embraced in the US, spurred on by Kubler-Ross’s landmark book, On Death and Dying. The first mention of palliative care in the English language medical literature came in 1956, with hospice first described 7 years later. But these movements remained far outside the American mainstream well into the 1980s.

In the hospital, recognition of the absurdity of the Full Court Press in patients with poor prognoses led to a major focus on Do Not Resuscitate orders in the 1980s. This was my first research interest – as a UCSF resident in the mid-80s, I cared for scores of AIDS patients with pneumocystis pneumonia who died terrible deaths in the ICU. Working with my wonderful faculty mentors Bernie Lo, Phil Hopewell, and John Luce, I began investigating their mortality rates and how we could make better and more informed decisions regarding CPR and mechanical ventilation [for example, see here and here].

But in the hospital world, these twin trends – hospice on the one hand, and decision-making regarding CPR and mechanical ventilation on the other – remained strangely dissociated. The movement promoting compassionate care for dying patients was largely community-based and tended to focus on patients dying slow and painful deaths – mostly those with terminal cancer. Meanwhile, in the hospital we were exploring the senselessness of “doing everything” for (or, more to the point, to) patients with poor prognoses, troubled by seeing lives end so violently, stripped of all dignity. But we spent virtually no time thinking about how to bring hospice-like sensibilities and resources into the hospital. Frankly, as I think back, many of us saw that work as being a bit too touchy-feely for our tastes. We were doctors, after all, not social workers.

This was a profound failure of both imagination and conscience, and it led to the emergence of a thriving underground economy in death. In a 1998 study, Tom Prendergast and John Luce demonstrated that most of the patients who died in American ICUs had some portion of their care withdrawn or withheld. This was a shocking finding, particularly since few caregivers talked about this common practice openly, fearful of being sucked into the public broo-ha-ha surrounding euthanasia and Right to Life. But the silence came with a terrible price: Nobody was ever taught how to do this well, and the medical literature simply airbrushed out the practice.

But the larger tragedy of our failure to embrace palliative care as a legitimate discipline was that by continuing to view death as a failure, we failed to gain the expertise and garner the resources to promote affirmative conversations with patients about alternatives to aggressive care. Sure, we might close the curtains, bump the morphine, and allow the patient whose care was near hopeless to pass peacefully, but we virtually never spoke openly with patients or families about how a focus on comfort might be a better way to complete one’s life.

This has been the magic of the palliative care movement. By naming and legitimizing the field, defining its competencies, promoting research, and training experts, we have made clear that this part of medicine is a crucial part of being a great doctor. (I can’t go on without paying tribute to several foundations, particularly Robert Wood Johnson under the leadership of my colleague Steve Schroeder, and Soros, for seeing this need and supporting it with real money).

The results have been spectacular. Today, when a patient is admitted to UCSF Medical Center with a potentially terminal illness, we spend less time on a narrow and largely irrelevant discussion about “would you want us to shock you if your heart stops” than on a much broader dialogue about two different philosophies of care: doing everything to keep you alive longer, with all of its attendant burdens (not to mention costs, but that’ll be a subject for another day), versus focusing on keeping you, and your loved ones, as comfortable as possible during your final days. We have that discussion now because a) we’re all much more at ease with the concept; b) we are now relatively well schooled in how to conduct these conversations; and c) we can bring to bear resources and experts to help us out – both in having these discussions and in implementing the plan when patients and families choose comfort over cure.

Which brings me to our Palliative Care Service (PCS), which I’m proud to have live within my Division of Hospital Medicine at UCSF. (Parenthetically, since most American patients die in hospitals  – Oregon is the only state in which they don’t – the marriage of the fields of hospital medicine and palliative care is one literally made in heaven; that so many hospitalists are interested in palliative care, and visa versa, is a source of great strength for both fields.) Launched a decade ago by “the Two Steves” – Pantilat and McPhee – our Palliative Care Service has utterly transformed the way we practice medicine. In fact, I could no more imagine how a modern hospital could function without a robust palliative care service than I could without a strong cardiology service.

Whenever I call the PCS to help care for one of my patients – as I’ve done several times this month – I am always awed by my colleagues’ skill and compassion, and the practical help they, the PCS-trained nurses, and PCS social worker Jane Hawgood, bring to bear at times of great need. And every time they are involved in a case, my medical students and residents, and the ones rotating on the PCS (which – as one small measure of the transformation – has become one of the most popular electives at UCSF) broaden their definition as to what it means to be a great doctor.

Back to my team this month – in the past two weeks, we’ve had 5 patients die out of about 25 admissions, a 20% mortality rate. And I couldn’t be prouder of the way we managed the patients’ care, our communication with the patients and their families, and the tears that we’ve all shed along the way. At one point or another in virtually every case, family members hugged me, members of my team, or members of the PCS and thanked us for our wonderful care – this at the most horrible time in their lives. It is uniquely sobering and gratifying.

We are entering a world in which case-mix adjusted mortality rates will be reported on the Web – and what other “quality” data could possibly resonate more deeply with the public? But I always recall the amusing story that arose from New York’s early experience with mortality reporting. About 15 years ago, goes the tale (probably part apocryphal), the state began publishing hospital mortality rates, and one local newspaper decided to republish the results. Of course, someone must be the worst – in this case, it was an upstate institution with a mortality rate near 75%! The paparazzi flocked like locusts to this small institution and set up their sea of boom microphones and klieg lights on its front lawn. Shoulders slumped, the hapless director trudged out to the mikes to answer questions about these shocking data. “We’re a hospice,” he said simply.

Sure, in some cases a high mortality rate will be a marker of poor doctoring or dysfunctional systems. But sometimes it will demonstrate that a caregiver sat down with a patient and her family, honestly discussed the alternative ways of providing care, listened carefully to both facts and emotions, offered resources to orchestrate a “good death,” and shed a tear with the family when the terrible time came. We’d better be awfully careful about creating a set of incentives that stands in the way of that kind of medicine.

So on this Day of Thanksgiving, this is what I’m giving thanks for – to be practicing in an institution, in a specialty, and in an era in which this kind of care is recognized and celebrated for what it is: medicine at its finest.

The Most Important Thing (code: e.280.11) I didn’t Learn in Med School (code: 780.92)

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Mrs. B was washing dishes in the kitchen when she heard a thump where her twelve-month-old son was asleep. She ran to him and found her son had fallen from a chair (code: e884.2). He was crying (code: 780.92) and visibly shaken, but did not have overt signs of bleeding, bruising, or trauma. She picked him up and immediately brought him to the emergency room. There, he was triaged by the nurse (nursing report #1) and vitals were taken (nursing report #2). Shortly after the mother and son pair settled into the pediatric emergency room, he vomited once (code 787.03).

The emergency medicine residents came by an hour later to conduct a focused interview, and performed a comprehensive physical exam (code: 89.03). He took care to ask at least four elements of the history of present illness that included location, quality severity, duration, timing, context, or associated symptoms from the event. He performed a complete review of at least 10 organ systems and surveyed the patient’s social history (code: 99223). It was decided that the boy was to be observed in the ED for the next few hours for signs of brain injury or concussion.

No labs or imaging studies were ordered. The nurses were instructed to check for vital signs every hour (nursing reports #3,4,5,6). During the observation period, the boy was found to be active, interacting well with mom, hungry, without signs of lethargy or focal neurologic deficits. When the attending physician came by to evaluate and assess the patient, he agreed with the resident’s report and signed the discharge note. The mother was given discharge paperwork and instructions for returning to the hospital if she noticed any new, alarming symptoms.

This is what Kelly, an emergency department medical coder, gathers while reading an ED admission note.  She turns to me and explains that the few lines of attending attestation are the only way the patient can get billed. Kelly types in “959.01” into her software because she memorized the diagnosis code for “head injury, unspecified.” She has been doing this for the last 18 years.

As I listened, she explained that a head injury in a twelve-month-old infant is automatically a level three, so long as the resident documents a review of ten systems, past medical history, and a physical exam. These levels indicate the complexity and severity of the patient’s disease/injury. “It’s all about the documentation,” she says. “If just 9 organ systems instead of 10 are documented,  even a critically ill patient could be down-coded to a level 4.”

PHYSICIANS/HOPSITALS/INDUSTRY: Customer service: are new market entrants showing the way?

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Interesting piece from a marketing consultant called Chris Bevolo from boutique firm GeigerBevolo Inc., in Minneapolis. The report looks at new entrants into health care services and responses to improve the patient experience at Mayo and Park Nicollet.

The new entrants profiled are Steve Case’s Revolution Health, Best Buy’s eq Life ( a pharmacy with manicures while you wait), and MinuteClinics (nurse practitioners in shopping malls). The choice of Revolution Health is a little off, and its attempts (as well as the track record of its advisory board)  has been well slagged off on TCHB and by Joe Paduda before. But the other two are well worthy of a look.

And the message seems to be a) provide shopping while people are waiting to see the doctor as Americans like shopping, and b) do it in Minnesota, because those Minnesotans like innovation. I actually think that Chris has missed a third option which is edutainment while patients are waiting.  But I’ll have more to say about that when I finally get around to discussing Phreesia’s in-office tablet entertainment/patient history service again.

But while I’m more than half-joking, I am full serious. The level of customer service in health care remains abysmal, and whether or not the market forces plans and providers to do something about it sooner rather than later, it surely can’t hurt for them to get out ahead of this trend.