practice of medicine
The dull whir of the computer running in the background seemed to have gotten louder as the patient fell quiet. She was a young woman, a primary-care patient of mine, seeking a referral to yet another gastroenterologist. Her abdominal pain had already been checked out by two of the city’s most renowned gastroenterologists with invasive testing, CAT scans and endoscopic procedures.
But she wasn’t satisfied with her diagnosis — irritable bowel syndrome — or the recommended treatment and wanted a third opinion. I tried to reason with her but failed to convince her otherwise. Even when I acquiesced and gave her the referral, she walked out visibly unhappy. I sat there listening to the whirring, feeling disappointed.
Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?
Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.
But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.
In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.
Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).
On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.
Continue reading “In Medicine, More May Not Be Better”
Filed Under: Physicians
Tagged: Haider Javed Warraich, Outcomes, Overtreatment, Patients, Physicians, practice of medicine, Quality
Oct 23, 2013
Chicago Cubs fans of a certain vintage will never forget broadcaster Harry Carey’s signature line, “Holy cow!” Some have speculated that the exclamation may have originated in Hinduism, one of the world’s major religions, whose adherents worldwide number approximately one billion. Hindus regard cows as maternal, caring figures, symbols of selfless giving in the form of milk, curds, butter, and other important products.
One of the most important figures in the faith, Krishna, is said to have been a cowherd, and one of his names, Govinda, means protector of cows. In short, cows are sacred to Hindus, and their slaughter is banned in virtually all Indian states.
Medicine, too, has its sacred cows, which are well known to physicians, nurses, and patients visited by medical teams on their hospital rounds. In this case, the cow is not an animal but a machine. In particular, it is the computer on wheels, or COW, a contraption that usually consists of a laptop computer mounted on a height-adjustable pole with a rolling base. It is used to enter, store and retrieve medical information, including patients’ diagnoses, vital signs, medications, and laboratory results, as well as to record new orders.
As the team moves from room to room and floor to floor, the COW is pushed right along. The COW is often treated with a degree of deference seemingly bordering on reverence. For one thing, people in hallways and patients’ rooms are constantly making way for the COW. As an expensive and essential piece of equipment, it is handled gingerly. Often only the senior member of the medical team or his or her lieutenant touches the COW.
Others know that they have said something important when they see the chief keyboarding the information into the COW. Sometimes it plays an almost oracular role. When questions arise to which no one knows the answer, such as the date of a patient’s admission or the time course of a fever, they often consult the COW. Just as cows wandering the streets of Indian cities often obstruct traffic, so healthcare’s COWS can and often do get in the way of good medicine. Continue reading “Should We Sacrifice Medicine’s Sacred COW?”
Filed Under: Tech
Tagged: computer on wheels (COW), Data, doctor/ patient relationship, EHR, HIT, Patients, philosophy, practice of medicine, Providers, Richard Gunderman
Oct 14, 2013
Is excellent good enough?
As physicians, we are trained to diagnose and treat disease. We dedicate ourselves to searching for cures and perfecting procedures that will restore the health of our patients. Over the last 50 years, we’ve made some remarkable progress. We’ve reduced the death rate from heart disease by 32.5% with a better understanding of primary and secondary prevention and advances in treatment. We’ve made similar progress in cancer care with better treatment options through radiation, surgery, chemotherapy, and genomics. We’ve changed an HIV diagnosis from a hopeless death sentence with limited treatment options to a manageable, chronic condition.
These truly excellent accomplishments in medicine have been life-changing for millions of people. But is excellent good enough?
While we have made great strides in clinical care, the American dream is faltering. Americans are more obese, more medicated and more in debt than at any other time in the history of our nation. One-third of our nation’s total health-care spending, about $750 billion per year, is wasted on unnecessary treatments, redundant tests, and uncoordinated care . Health Care Reform will have limited impact on this waste. While the rate of increase of health care spending has slowed in recent years, the United States still spends 2.5 times more than most developed nations on health care . U.S. health care spending is on track to reach $4.8 trillion in 2021, almost 20% of our gross domestic product .
Continue reading “What Kind of Ancestor Will You Be?”
Filed Under: OP-ED, THCB
Tagged: FutureMed, health care delivery, Jack Cochran, Kaiser Permanente, Physicians, practice of medicine, The Permanente Foundation
Sep 26, 2013
The American Psychiatric Association recently published a new version of the Diagnostic and Statistical Manual (DSM). The DSM-5 is what medical, mental health, and chemical dependency professionals use to diagnose developmental, mental health, substance abuse and dependence, learning, and personality “disorders.” Now in its 5th edition, the DSM was first published in 1952. At that time, the DSM was 129 pages containing 106 diagnoses.
Now, 61 years later, the DSM-5 consists of approximately 950 pages and roughly 375 diagnoses. The DSM-5, while researched far more than previous editions, is based on the medical model or the model of disease. Simply put, the medical model finds the causes of disease and illness and then prescribes a treatment to cure the disease or illness. This means a person has a pathology or pathogen that needs to be treated and cured.
The questions that eat at me during my day as a psychologist and at night as a person searching for answers are:
- Is it possible to accurately identify mental health “issues,” “illness,” or “disorders?” versus extreme ranges within the sphere of the human condition?
- Even if it is possible to identify these conditions, does it determine the course of “treatment” or “intervention?”
- If so, is there a “treatment” for every identified “condition?”
- Does it mean there is a treatment that works?
- Do you need a diagnosis to get help?
Over the years, many have been critical of this approach to mental “health” issues. Referring to mental “health” is actually a newer name as people have historically been thought to have mental “illness.” This makes more sense for people who are unfortunately compromised by severe conditions termed schizophrenia, bi-polar (manic-depressive), and severe depression and anxiety. But does this make sense for children, adolescents, and adults who are challenged with some other, and possibly less severe, aspect of their functioning and development? Do all human problems warrant a medical or mental health diagnosis? When did a weakness become a “disorder” that requires “intervention” and/or “treatment?”
To be fair, the DSM provided structure and guidelines for approaching the complicated business of determining who had a “problem” that required help. However, it seems things have gone too far. Critics of the DSM believe that this latest edition has taken the business of diagnosing to a new level, one where approximately 50% of the population can be diagnosed with something. Critics also believe that this pathology finding approach supports the continued trend of medication prescribing as the number one mode of treatment, and continued trend of increased health care costs and premiums with increased utilization of individuals who need a “diagnosis” to meet “medical necessity” to receive services. What does that mean? It means if you don’t have a diagnosis, you don’t get help. It means you have to have a problem (pathology) to get help (treatment and intervention).
Without going into detail about some of the changes in the newest edition of the DSM, some diagnostic categories have been added and some diagnosis “thresholds” have been lowered. This means that you need fewer symptoms to “meet diagnostic criteria.” Here are some examples of concerns with the new DSM-5:
- Temper tantrums will now be diagnosed as Disruptive Mood Dysregulation Disorder
- Normal forgetting will now be diagnosed as Minor Neurocognitive Disorder
- Gluttony will be diagnosed as Binge Eating Disorder
- Grief will be diagnosed as Major Depression
- First time substance users and college partiers will get a diagnosis of Substance Use Disorder
- Everyday Worry will be diagnosed as Generalized Anxiety Disorder Continue reading “Pathologizing the Human Condition”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: American Psychiatric Association, Dan Peters, Diagnosis, DSM-5, Mental Health, practice of medicine, public health
Sep 1, 2013
The original Hipoocratic Oath states:
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.
One modern version reads:
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
The idea here is that a doctor needs to recognize when another practitioner has a skill that they do not, and that they must refrain from “practice” when another person has demonstrable expertise in that area of practice.
It is now 2013. It is time for doctors to stop “writing their own EHR” from scratch. They need to bow out of this in favor of people who have developed expertise in the area.
I just found out about another doctor who has decided to write his own EHR, because he has not been able to find one that supports his new direct pay business model adequately. In the distant past I encountered a doctor who believed that his “Microsoft Word Templates” qualified as an EHR system. This is a letter to any doctor who feels like they are comfortable starting from-scratch software development for an EHR in 2013 or later.
You might believe yourself to be an EHR expert.
Are you sure about that? Are you sure that you are not just an EHR expert user?
This difference is not unlike your relationship with your favorite thoracic surgeon. Or for that matter, your relationship with the person who built your car. The fact that you are capable of expertly evaluating and using EHR products does not mean you are qualified to build one. Just like the fact that you are qualified to treat a patient who has recently had heart surgery or to discern when a patient might need heart surgery does not make you qualified to perform that heart surgery. Similarly, the fact that you can drive, or even repair your automobile, does not provide you with the expertise you need to build a car from scratch.
The ethical situation that you are putting yourself in by developing your own EHR is fairly tenuous. Performing heart surgery without being a heart surgeon, building and driving your own car without being an automotive engineer and a doctor coding their own EHR system from scratch all have the same fundamental problem: You might be smart enough to pull it off, but if you don’t you can really mess up another person’s life. Make no mistake, you can kill someone with a shoddy EHR just as easily as by performing medical procedures that you are not qualified for or by driving a car that is not road-safe.
Continue reading “Why Doctors Should Stay Out of the Business of Building EHRs”
Filed Under: Physicians, Tech, THCB
Tagged: Design, EHR, Fred Trotter, HIT, Patient Safety, Physicians, practice of medicine
Aug 26, 2013
A fashion faux pas almost prevented me from getting into my dream medical school. Midway through the interview there, the interviewer pointed to my left earlobe and said, “Do you really think we accept men who wear … those things?”
I had no idea what he was talking about at first, but then remembered the gold post I’d forgotten to remove. In a disdainful southern drawl the interviewer let me know how dark a shadow this stylistic error cast on my otherwise favorable application.
I left his office fairly sure I would not be admitted. I also doubted whether I wanted to be admitted to a school that selected physicians on the basis of their jewelry. Really?
Twenty years later, medical schools around the country still struggle to find the right way to decide who should be the physicians of the future, and who should not. Most have evolved past caring about male earrings, but what are the right criteria for admission – what makes a good proto-doctor?
Over forty thousand students apply to medical school each year. Each applicant spends thousand of dollars in fees and plane tickets, and institutions spend still more to screen, host, interview and pick among the hordes of black-suited applicants. Increasingly, medical schools are considering innovative and creative ways to distinguish the most promising applicants from the rest.
New approaches include:
1. Using a more holistic review rubric that de-emphasizes grades and MCAT scores, such as at Boston University;
2. Suspending traditional pre-med requirements for humanities students, such as at the Icahn School of Medicine at Mt Sinai; and,
3. Creative admissions interviews that include problem solving, multiple mini-interviews and even observed standardized patient interactions.
Each of these innovative methods sounds great. Used in combination I suspect they will identify applicants with the necessary academic chops plus a great bedside manner.
Continue reading “A Modest Proposal: Replace the Med School Interview With fMRI”
Filed Under: Physicians, THCB
Tagged: FutureMed, Malcolm Gladwell, Medical Education, Nalini Ambady, practice of medicine, Tim Lahey
Aug 12, 2013
One of US President Barack Obama’s key health advisers has just published a review in the aftermath of the Mid Staffordshire hospital scandal. Don Berwick’s review is both thoughtful and reflective but one of his key recommendations – to create criminal sanctions against health staff – will not make the NHS safer for patients.
Many patients, particularly elderly ones, suffered unnecessary indignities and avoidable harm at Mid Staffordshire.
The Francis report into the crisis concluded that patients were routinely neglected by a health trust more preoccupied with cutting costs and meeting targets rather than its responsibility to provide safe care. Patients’ calls for help to use the bathroom were ignored and some were left lying in soiled sheeting or sitting on commodes for hours. Events and failings there will probably go down in history as the blackest and bleakest moment for the NHS.
When the report was published in February, the government committed to appointing a advisory group of patients to consider the various accounts of what happened and the recommendations made by Robert Francis and others. The idea was that they would distill for the government and the NHS what lessons should be learned and what changes needed to be made.
Don Berwick, who worked on the long fought for Obamacare provisions in the US, is director and co-founder of the Institute for Healthcare Improvement in Boston. He was called in by the government to reflect on the Francis report and on patient safety.
Berwick’s review makes ten recommendations including that sufficient staff are available to meet the NHS’s needs now and in the future – staff should be well-supported and able to ensure safe care at all times; quality and safety sciences and practices should be a part of the initial preparation and lifelong education of all health care professionals, including managers and executives; and leaders should create and support learning and subsequently change, at scale, within the NHS.
But most controversial is his final recommendation:
We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.
Berwick proposes the government creates a new general offence of “willful or reckless neglect”, applicable both to organisations and individuals. Organizational sanctions might involve removing leaders and disqualifying them from future leadership roles, public reprimand of the organization and, in extreme cases, financial sanctions – but only where that will not compromise patient care.
Continue reading “Criminal Charges for Providers Won’t Fix the NHS, Dr. Berwick”
Filed Under: Hospitals
Tagged: criminal sanctions, Don Berwick, health care providers, John Tingle, Malpractice, Mid Staffordshire, NHS, Nurses, Patient Safety, Physicians, practice of medicine, Senior Care, The Conversation
Aug 6, 2013
Good for Healthcare?
Sarah Jones was an anomaly in contemporary healthcare. Despite shifting alliances between physicians, hospitals, and insurance companies, she had been under the care of the same physician for over 20 years. Over this time, patient and physician had gotten to know each other well and had developed a fine relationship. Mrs. Jones had always assumed that, should she ever need to be admitted to the hospital, this relationship would pay big dividends, ensuring that her medical decision making would be based on long acquaintance and strong mutual understanding.
When the dreaded day came that she finally needed inpatient care, however, her hopes were dashed. Her physician explained to her that he no longer sees hospitalized patients. Instead she would be under the care of a team of physicians known as hospitalists. When she arrived, the hospitalist on duty introduced herself and told her that she would be the physician responsible for her care, while colleagues would be responsible during off hours. Unlike her regular physician, who would have been on hand only once or perhaps twice per day, the hospitalists would always be in house and ready to address her needs.
Mrs. Jones was surprised and disappointed to discover that her primary physician would not be involved in her hospital care. She had always assumed that she would be able to rely on their longstanding relationship for counsel and support. She imagined that if she were facing some really important decision, such as whether or not to proceed with a risky operation or how to manage her own end-of-life care, it would make a huge difference to know that she could count on a physician she knew well. Instead her hospital-based physician was a complete stranger.
Mrs. Jones’ experience is far from unique. In the past 15 years or so, medicine has seen the birth of hospitalists, a new breed of physicians who care only for hospitalized patients. There are now over 30,000 hospitalists in the US. From a patient’s point of view, such physicians offer a number of advantages. In many hospitals, a specialist in hospital medicine is always on duty, day or night. Moreover, because such physicians work only in the hospital, they are often more familiar with the hospital’s standard procedures, information systems, and personnel.
It is not difficult to see why hospital medicine might be so attractive to young physicians. For one thing, it provides them with a high degree of control over their working hours. They come on and off shift at regular times, and do not bear patient care responsibilities outside these hours. In addition, they are usually employed by the hospital, which means that they do not need to attend to a host of practice management issues that self-employed physicians confront. They can also focus on acute-care, in-hospital medicine, avoiding the challenges associated with long-term care of chronic-disease patients.
Some non-hospitalist physicians also find the rise of hospital medicine attractive. They do not need to travel to one or more hospitals each day to see patients, which takes considerable time and generates little revenue. They do not need to work so hard at staying abreast of changes in hospital procedures and technologies, which often vary from institution to institution, as do requirements for acquiring and maintaining hospital medical staff privileges. And finally, they can focus their energies on outpatient care, avoiding the more acutely life-threatening and complex situations associated with hospitalization.
Continue reading “The Rise of the Hospitalists”
Filed Under: OP-ED, Physicians, THCB
Tagged: doctor/ patient relationship, hospital medicine, Hospitalists, hospitalization, inpatient care, outpatient care, practice of medicine, Quality, Richard Gunderman
Aug 4, 2013
Consider the doctor’s office: the sanctum of care in American medicine, where a patient enters with a need — a question or an ailment or a concern — and leaves with an answer, a diagnosis or a treatment. That room, with its emblematic atmosphere of exam table and tiny sink and bottles of antiseptic, is in many ways the engine of our health care system, the locus of all our collective knowledge and all our collective resources. It’s where health care happens.
But in a less sentimental light, the doctor’s office doesn’t seem so exalted. Yes, it remains the essential hub for clinical care. But what occurs in that room isn’t exactly ideal, nor state-of-the-art. The doctor-patient encounter is fraught with tension, asymmetrical information, and flat-out incomprehension. It is a high-cost, high-resource encounter with surprisingly limited value and limited returns. It is too cursory to be exhaustive (the infamous fifteen-minute median office visit), too infrequent to create an honest relationship (one or two times a year visits at best), and too anonymous to be personal (the average primary care doc has more than 2,300 patients).
At best, it offers a rare personal connection between doctor and patient. At worst, it is theater. The doctor pretends she remembers the patient, and that she has actually had the time to read the patient’s chart in full; the patient pretends that he hasn’t spent hours on the Internet trying to diagnosis himsef, half-admitting what he’s really doing day to day, and pretending he won’t second- guess the doctor’s orders the moment he gets back to a computer.
As woeful as that sounds, we know that there’s real value here. This encounter can be meaningful; it should and must be meaningful. The doctor is a necessary interface to medicine, and his office is a source of care, expertise, and trust. The patient is eager and receptive to learning, primed for guidance and direction. Pragmatically, the doctor’s visit is a powerful part of modern medicine. The problem is that we, collectively, are not optimizing this resource; we have not reconsidered and re-evaluated how we might exploit the visit to its full advantage.
So how can we improve this situation? How can we fix this thing?
Continue reading “Flipping the Doctor’s Office”
Filed Under: Tech, THCB
Tagged: Betty Irene Moore School of Nursing, Camden Coalition of Healthcare Providers, clinicians, FutureMed, Khan Academy, Medical Education, Patient-centered care, Patients, practice of medicine, RWJF, Thomas Goetz, UC Davis
Jul 17, 2013
Every now and then the title of a book influences your thinking even before you read the first page.
That was the case for me with Thomas Moore’s “Care of the Soul” and with “Shadow Syndromes” by Ratley and Johnson. The titles of those two books jolted my mind into thinking about the human condition in ways I hadn’t done before and the contents of the books only echoed the thoughts the titles had provoked the instant I saw them.
This time, it wasn’t the title, “Cultivating Chi”, but the subtitle, “A Samurai Physician’s Teachings on the Way of Health“. The book was written by Kaibara Ekiken (1630-1714) in the last year of his life, and is a new translation and review by William Scott Wilson. The original version of the book was called the Yojokun.
The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.
The translator, in his foreword, points out the ancient sources of Ekiken’s inspiration during his long life as a physician. Perhaps the most notable of them was “The Yellow Emperor’s Classic on Medicine”, from around 2500 B.C., which Ekiken himself lamented people weren’t reading in the original Chinese in the early 1700′s, but in Japanese translation. One of his favorite quotes was:
“Listen, treating a disease that has already developed, or trying to bring order to disruptions that have already begun, is like digging a well after you’ve become thirsty, or making weapons after the battle is over. Wouldn’t it already be too late?”
Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:
“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.
Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference toarchetypal or somatic medicine.)
The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.
If you restrain the inner desires, they will diminish.
If you are aware of the negative external influences and their effects, you can keep them at bay.
Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”
On the topic of Restraint, the Yellow Emperor text states:
In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more.
Continue reading “The Samurai Physician’s Teachings on the Way of Health”
Filed Under: Physicians, THCB
Tagged: Country Doctor, Disease Management, Personal responsibility, Physicians, practice of medicine, prevention, The Yellow Emperor's Classic on Medicine
Jul 17, 2013