practice of medicine
“Patient noncompliance.” I wasn’t very familiar with this term until I started my clinical rotations. But after just the first week, I started noticing that health care providers throw this phrase around all time.
We particularly like using it as an excuse. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? It’s often simply attributed to patient noncompliance.
What bothers me the most about this phrase, though, is how it’s often stated with such disdain. We act as if it’s incomprehensible that someone would ignore our evidence-based recommendations. If the patient would only bother to listen, he or she would get better. If we were patients, we would be compliant.
But that’s simply not true. We are no different from our patients. We practice our own form of noncompliance. It’s called guideline non-adherence.
Despite the fact that many guidelines are created after systematic reviews and meta-analyses – processes we would never have time to go through ourselves – we, like our own patients, are often noncompliant.
Research on guideline adherence has been around since guidelines started becoming prominent in the early 1990s. Despite the many studies and interventions to improve guideline adherence, the rates of guideline adherence still remain dismally low.
I find this particularly disconcerting. Despite my own interest in research, it makes me question the value of research. Why do we spend millions of dollars to find a better intervention that does not change how most providers deliver health care?
Continue reading “Why the Phrase “Noncompliant Patient” Bothers Me, And Should Probably Bother You Too ..”
Filed Under: Physicians, THCB
Tagged: American Resident Project, Choosing Wisely, Elaine Khoong, FutureMed, noncompliance, Physicians, practice of medicine
May 23, 2014
The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.”Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license”.
What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.
So I would like to know, please, when I’ll get to practice at the top of my license?
As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time.
Yet I spend a lot of time performing tasks that could be done by someone with far less training.
Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.
I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.
First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart.
This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.
Continue reading “Scope of Practice: Playing at the Top of My License?”
Filed Under: OP-ED, THCB
Tagged: frontline health workers, Karen S. Sibert, Physicians, practice of medicine, Scope of Practice
May 20, 2014
Writing in the Wall Street Journal (WSJ) Dr. Daniel F. Craviotto Jr. an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR).
As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour.
The article went viral (it has been tweeted nearly 3000 times), though with little virulence. And it is not WSJ’s paywall to blame.
The author might have assumed that most the healthcare community in general and physicians in particular wish to be free from regulations. I have serious doubts that this assumption is correct in the aggregate. The relationship between regulators and physicians is more complex and symbiotic than it first appears.
Some physicians believe in bureaucracy. Rationalism will march us out of our healthcare wilderness. This belief in scientific managerialism, faith in technocracy, is the new theism. The rationale of the new theists is that regulations fail not because they are inherently useless but because there are so few of them, and even fewer that are actually smart.
Like the first religions started with polytheism, the new believers want more agencies, more alphabet soups, more gods.
Continue reading “Doctor Paul Revere Fails to Light the Fire”
Filed Under: THCB
Tagged: health care delivery, ICD-10, Mandates, Outcomes, Physicians, practice of medicine, Quality improvement, Saurabh Jha
May 13, 2014
On April 29, Dr. Daniel Croviotto published an editorial in the Wall Street Journal, “A Doctor’s Declaration of Independence,” in which he argued that it is time to “defy healthcare mandates issued by bureaucrats not in the healing profession.”
Dr. Croviotto does a good job of articulating his frustration with the increasingly burdensome bureaucracy and regulations placed on care. Many physicians and nurses share his frustration. I once did, until I saw a way out of the cynicism and frustration – a way that can improve the quality and lower the cost of care for all Americans.
No matter how misguided we think the federal government is in its electronic health record mandate or other requirements, simply defying mandates as Dr. Croviotto proposes is not likely to accomplish much. Those who signed the Declaration of Independence knew it was only an initial step toward ridding the country of tyranny. They had to create a new vision for a better, more effective government.
Similarly, the medical profession needs to move beyond cynicism to create a vision for a better, more effective healthcare system.
Continue reading “A Declaration of Independence Is Only the Beginning”
Filed Under: OP-ED, THCB
Tagged: frontline health workers, health care delivery, Hospitals, John Haughom, LEAN, Physicians, practice of medicine, process improvement, Quality
May 7, 2014
It’s a strange business we are in.
Doctors are spending less time seeing patients, and the nation declares a doctor shortage, best remedied by having more non-physicians delivering patient care while doctors do more and more non-doctor work.
Usually, in cases of limited resources, we start talking about conservation: Make cars more fuel efficient, reduce waste in manufacturing, etc.
Funny, then, that in health care there seems to be so little discussion about how a limited supply of doctors can best serve the needs of their patients.
hair-brained novel idea making its way through the blogs and journals right now is to have pharmacists treat high blood pressure. That would have to mean sending them back to school to learn physical exam skills and enough physiology and pathology about heart disease and kidney disease, which are often interrelated with hypertension.
Not only would this cause fragmentation of care, but it would probably soon take up enough of our pharmacists’ time that we would end up with a serious shortage of pharmacists.
Within medical offices there are many more staff members who interact with patients about their health issues: case managers, health coaches, accountable care organization nurses, medical assistants and many others are assuming more responsibilities.
We call this “working to the top of their license.”
Doctors, on the other hand, are spending more time on data entry than thirty years ago, as servants of the Big Data funnels that the Government and insurance companies put in our offices to better control where “their” money (which we all paid them) ultimately goes.
In primary care we are also spending more time on public health issues, even though this has shown little success and is quite costly. We are treating patients one at a time for lifestyle-related conditions affecting large subgroups of the population: obesity, prediabetes, prehypertension and smoking, to name a few that would be more suitable for non-physician management than hard-core hypertension.
It is high time we have a serious national debate, not yet about how many doctors we need, but what we need our doctors to do. Only then can we talk numbers.
Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes where this piece originally appeared.
Filed Under: Physicians, THCB
Tagged: doctor/ patient relationship, Hans Duvefelt, Physicians, Population Health, practice of medicine, primary care, Quality
Apr 22, 2014
Would allowing patients to read their mental health notes provide more benefits than risks?
In a recent article in JAMA my colleagues and I argue that it would. While transparent medical records are gaining favor in primary care settings throughout the country through the OpenNotes initiative, there has been reluctance to allow patients to see what their treaters say about their mental health issues. While this reluctance is understandable and deserves careful consideration, we suggest that several benefits could result from patients reading their mental health notes.
First of all, accuracy would be enhanced by allowing patients to cross-check what their clinicians say about their symptoms, medication doses, and so forth. Second, allowing patients to review assessments and treatment decisions privately might help to promote a richer dialogue between patient and clinician. Third, patients might learn that their clinician sees them more as a complete person, rather than as a collection of symptoms.
Many patients silently fear that their treater “will think I’m crazy/whining/lazy/boring”; seeing in print that the treater does not see them that way—and in fact recognizes and documents their strengths—can be an enormous relief and might therefore enhance the therapeutic alliance.
Clinicians have their own worries about transparent mental health notes that must be considered. Will patients feel objectified by the medical language commonly used in documentation? Will they break off treatment if they don’t like what they read? Will too much time be spent wrangling over details of what has been documented? Will vulnerable patients be psychologically harmed by reading their notes? Although our article briefly addresses these issues, only a trial of transparent mental health notes will provide the data needed to assess them.
Such a trial has just begun at the Beth Israel Deaconess Medical Center in Boston. Culminating many months of careful planning by my colleagues in the ambulatory psychiatry clinic, the Social Work department, as well as the OpenNotes team, we began a pilot project of transparent notes in our psychiatry clinic on March 1. So far almost all clinicians have chosen to participate in the project, and have identified 10% of their caseloads to be included. It’s too early to gauge results yet, but we hope to more fully evaluate the effects of making mental health notes fully transparent to our patients.
Michael W. Kahn, MD is an assistant professor of psychiatry at Harvard Medical School and Harvard Medical Faculty Physician at Beth Israel Deaconess Medical Center (BIDMC).
Filed Under: THCB, The Vault
Tagged: BIDMC, Clinical Documentation, doctor/ patient relationship, FutureMed, Mental Health, Michael Kahn, Open Notes, patient engagement, personal health records, practice of medicine, Psychiatry
Apr 11, 2014
Is this a good time to be a physician? Absolutely! In fact, I believe there has never been a better time to practice medicine. I hold this belief despite the barrage of negative comments and predictions from doomsayers remarking on the sorry state of health care in its current state.
Before I tell you why I’m so optimistic, I’d like to acknowledge one fact: practicing medicine is more complex and difficult than ever, however, this fact doesn’t dampen my enthusiasm. There is no doubt that over the past two decades a great many changes in the health care environment have consumed doctors’ time, distracted us from our core task of providing care, and impacted our incomes.
Meanwhile, patients’ expectations of the health care industry and of their physicians are changing. An increasing number of people want more involvement in their own health care and want to partner with their physician. So it is not hard to understand how practicing medicine can feel more challenging than ever.
For example: results from a national survey reported in the Archives of Internal Medicine in 2012 indicated that US physicians suffer from more burnout than other American workers.
Burnout, in this report, was defined by “loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment”; 45.8% of responding physicians had at least 1 of these symptoms.
So why am I so optimistic?
Because when I read these survey results, and others like them, bureaucracy and complexity are often cited as the reasons why physicians are unhappy. Not patient care.
While these factors (bureaucracy and complexity) can momentarily take physicians away from their passion of practicing medicine, it is the passion of a physician, precisely, that fuels my optimism for the state of health care today.
Continue reading “Actually, It’s a Great Time to Be a Doctor”
Filed Under: THCB
Tagged: Burnout, Jeffrey Weisz, Physicians, practice of medicine
Mar 26, 2014
I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?
In thinking about this, I reflected on how far we have come on quality measurement. A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse. Yet, in the last decade, we have seen a sea change.
We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay. But the unease with quality measurement has not gone away and here’s why. If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria: good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes.
Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.
So where’s the disconnect? What does make a good doctor? Unsure, I asked Twitter:
Over 200 answers came rolling in.
Continue reading “What Makes a Good Doctor? And Can We Measure It?”
Filed Under: Physicians, THCB, The Vault
Tagged: Ashish Jha, Physician Quality Reporting System, Physicians, practice of medicine, Quality
Mar 22, 2014
Once-upon-a-time, when a patient said they were taking a vitamin, most doctors would simply shrug their shoulders and say, “well, I guess its OK, it couldn’t hurt.” There was little research to judge the affect of vitamin supplements, so there was no reason to take a stand. That is no longer true.
Now we have published data on many vitamins and we can say that for most people they do not work. More importantly, there is increasing research that says manufactured, chemically synthesized nutriment compounds in a pill, can be deadly.
For this reason, I am likely to ask my patients if they are taking a vitamin and, if so, which fabricated additive and how much. Therefore, I asked Bill, while he was in the office receiving chemotherapy for Hodgkin’s disease, what alternative therapies he was using.
When he informed me that he swallowed a multivitamin (MVI), large doses of Vitamins C and E, as well as a B complex preparation, I advised him to stop.
To my astonishment he responded, “Well, you only want me to do that because you make a lot of money on chemotherapy, and vitamins might put you out of business.”
Bill’s response, he lack of trust in my advice, disturbs me at several levels. He fails to understand and does not wish to learn the present state of science regarding nutrition. In addition, there is a major problem regarding his perception of my motivations and therefore the veracity of my guidance.
Let us be clear; in the absence of malnutrition, malabsorption and a few uncommon medical conditions, there is absolutely no reason to take a multivitamin. They do not prevent or fix anything. Originally developed for starving populations and hungry soldiers during the Second World War, they have no place in a society with access to a broad range of foods.
More importantly, there is increasing data that people taking a multivitamin may become less healthy.
Continue reading “That Vitamin There Could Kill You”
Filed Under: OP-ED, THCB
Tagged: alternative medicine, Cancer, doctor/ patient relationship, James Salwitz, multivitamins, practice of medicine, Wellness
Feb 25, 2014
Here is a sweeping generalization: When doctors write for the lay public they tend towards tiresome self-flagellation.
Samuel Shem’s House of God is an exception; a refreshing read.
Perhaps he wrote for physicians so he wrote with such open face honesty.
In today’s politically correct world, Shem would have been castigated as an ageist for his brilliant acronym, GOMER (Get out of My Emergency Room), for peri-ninety year olds with advanced dementia who are skirting that narrow zone between St. Peter’s Gate and fractured ribs post-CPR.
Time for a pronouncement for medical students: There are two things you must do before starting your internship. Pass your USMLEs and read House of God.
I have read Shem’s classic twice. I remember the Rules of House of God more reliably than I recall the names of the carpal bones.
My first read was a few days in to my internship in elderly care medicine. The hospital was a rickety establishment in Britain’s National Health Service, not quite the Best Medical School that Shem described. But I seemed to share the same clinical experiences as Roy Basch, Shem’s Gomer-phobic protagonist.
There was a deluge of Gomers on New Year’s Eve; the old practice of granny dumping. I had to justify admission by finding nitrates in their urine for suspected urinary tract infection (grandson attending New Year’s bash still does not have an ICD code), or the vaguest T wave changes on EKG (unstable angina is a useful bet in a 90 year old).
If medical taxonomy could not be clinically justified there was always “acopia.”
Shem was remarkably prescient.
Take rule 13: “The delivery of good medical care is to do as much nothing as possible.” This was before statins reached their zenith of irrelevance; before physicians were inserting stents through rock hard femoral arteries to give patients an aggregate of two extra hours of survival.
Basch’s elderly patients would do the best precisely because his caring was the least aggressive. He would occasionally forget to prepare them with laxatives for a barium enema, saving them from dehydration and its cascade.
If Shem realized in the seventies that nothing was more futile than an investigation leading to a futile treatment, God knows what he would have written today.
Continue reading “Ode to the Fat Man”
Filed Under: THCB
Tagged: House of God, Physicians, practice of medicine, Samuel Shem, Saurabh Jha
Feb 11, 2014