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Category: Medical Practice

‘I Apologize for What You Are About To See’

By HILARY HATCH, PhD

The growing movement to include the patient voice in medicine through Motivational Interviewing, patient-reported outcomes, social determinants of health and shared decision-making

One day in 2011, as a part of my research on ways to improve patient-provider communication about health behaviors, I was shadowing Dr. G., a talented young internist with a cheerleader demeanor. He marched through 12 afternoon patient appointments with confidence and purpose. But when he saw the name of the last patient on his schedule, he turned pale, faced me and said, “I apologize for what you are about to see.”

I must have looked confused. He repeated, “I apologize for what you are about to see.”

We walked into the exam room. I’m not sure either one of us knew what to expect. The patient, a white, obese man, was seated, doubled over. He had a wad of paper towels jammed in his mouth. He threatened to pull out his own, presumably abscessed, tooth. He refused to see a dentist because he had no dental coverage, no money and no one to borrow money from. He said he would use pliers to pull his tooth, but stayed put, rocking in his seat. At the computer, the young doctor’s white-knuckled hand gripped his mouse. Click. Click. Click. He searched the patient’s chart aimlessly for help. Alerts kept popping up about the patient’s missing A1C results. It took two minutes, but it felt like 20.

Dr. G. left the room and came back a few minutes later. He gave the patient the name of a dentist who would see him at no cost. I suspected Dr. G. had called the dentist and said he would pay for the appointment out of his own pocket. The patient hugged Dr. G. He only wanted help, and Dr. G. wanted to help. The tension was resolved for the moment.

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HardCore Health Podcast| Episode 3, IPOs, Privacy, & more!

On Episode 3 of HardCore Health, Jess & I start off by discussing all of the health tech companies IPOing (Livongo, Phreesia, Health Catalyst) and talk about what that means for the industry as a whole. Zoya Khan discusses the newest series on THCB called, “The Health Data Goldilocks Dilemma: Sharing? Privacy? Both?”, which follows & discuss the legislation being passed on data privacy and protection in Congress today. We also have a great interview with Paul Johnson, CEO of Lemonaid Health, an up-and-coming telehealth platform that works as a one-stop-shop for a virtual doctor’s office, a virtual pharmacy, and lab testing for patients accessing their platform. In her WTF Health segment, Jess speaks to Jen Horonjeff, Founder & CEO of Savvy Cooperative, the first patient-owned public benefit co-op that provides an online marketplace for patient insights. And last but not least, Dr. Saurabh Jha directly address AI vendors in health care, stating that their predictive tools are useless and they will not replace doctors just yet- Matthew Holt

Matthew Holt is the founder and publisher of The Health Care Blog and still writes regularly for the site.

Are Radiologists Prepared for The Future?

By ALEX LOGSDON, MD

Leave your bias aside and take a look into the healthcare future with me. No, artificial intelligence, augmented intelligence and machine learning will not replace the radiologist. It will allow clinicians to.

The year is 2035 (plus or minus 5 years), the world is waking up after a few years of economic hardship and maybe even some dreaded stagflation. This is an important accelerant to where we are going, economic hardship, because it will destroy most radiology AI startups that have thrived on quantitative easing polices and excessive liquidity of the last decade creating a bubble in this space. When the bubble pops, few small to midsize AI companies will survive but the ones who remain will consolidate and reap the rewards. This will almost certainly be big tech who can purchase assets/algorithms across a wide breadth of radiology and integrate/standardize them better than anyone. When the burst happens some of the best algorithms for pulmonary embolism, stroke, knee MRI, intracranial hemorrhage etc. etc. will become available to consolidate, on the “cheap”.

Hospitals can now purchase AI equipment that is highly effective both in cost and function, and its only getting better for them. It doesn’t make sense to do so now but soon it will. Consolidation in healthcare has led to greater purchasing power from groups and hospitals. The “roads and bridges” that would be needed to connect such systems are being built and deals will soon be struck with GE, Google, IBM etc., powerhouse hundred-billion-dollar companies, that will provide AI cloud-based services. RadPartners is already starting to provide natural language processing and imaging data to partners; that’s right, you speak into the Dictaphone and it is recorded, synced with the image you dictated, processed with everyone else to find all the commonalities in descriptors to eventually replace you. It is like the transcriptionists ghost of the past has come back to haunt us and no one cried for them. Prices will be competitive, and adoption will be fast, much faster than most believe.

Now we have some patients who arrive for imaging, as outpatients, ER visits, inpatients; it does not matter the premise is the same. Ms. Jones has chest pain, elevated d-dimer, history of Lupus anti-coagulant and left femoral DVT. Likely her chart has already been analyzed by a cloud-based AI (merlonintelligence.com/intelligent-screening/) and the probability of her having a PE is high, this is relayed to the clinician (PA, NP, MD, DO) and the study is ordered. She’s sent for a CT angiogram PE protocol imaging study. This is important to understand because there will be no role for the radiologist at this level. The recommendation for imaging will be a machine learning algorithm based off more data and papers than any one radiologist could ever read; and it will be instantaneous and fluid. Correct studies will be recommended and “incorrectly” ordered studies will need justifications without radiologist validation.

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Telemedicine is a Tool, not a Panacea, to Reach Underserved Communities

Sam Aptekar
Phuoc Le

By PHUOC LE, MD and SAM APTEKAR

Kijan ou ye? How are you?” I asked my patient, a fifty-five year-old Haitian-American woman living in Dorchester, Massachusetts. It was 2008. I had been her primary care doctor for two years and was working with her to reduce her blood pressure and cholesterol levels. “Papi mal dok– I’m doing ok doc.” We talked for 15 minutes, reviewed her vital signs and medications, and made a plan. I then electronically transmitted a new prescription to her pharmacy. The encounter was like thousands of others I’d had as a physician, except for one key difference– I was in Rwanda, 7,000 miles away from Dorchester and 6 hours ahead of the East Coast time zone.

At the time, I knew that telemedicine – the practice of providing healthcare without the provider being physically present with the patient – was a resourceful means of working with rural populations that have limited access to healthcare. However, I had no idea that just ten years down the road, many health professionals and policymakers would laud the emerging tech field as the answer to inaccessible healthcare for rural communities. While I’m aware of telemedicine’s promising benefits, I’m certain that it cannot, on its own, solve the most pressing issues that continue to afflict the rural poor and underserved.

https://news.ihsmarkit.com/press-release/design-supply-chain-media/global-telehealth-market-set-expand-tenfold-2018

Ever since the invention of the telephone, providers have been practicing telemedicine. However, not until the advent of advanced technologies such as high-speed internet, smartphones, and remote-controlled robotic surgery, has the field of telemedicine started to beg the question: “Do we still need in-person interactions between patient and doctor to provide high quality healthcare?” This question is particularly important for patients who live in rural areas, where a chronic shortage of providers has existed for decades.

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“Thanks for Your Time”: Einstein’s Relativity in the Clinical Encounter

By HANS DUVEFELT, MD

In business literature I have seen the phrase “getting paid for who you are instead of what you do”. This implies that some people bring value because of the depth of their knowledge and their appreciation of all the nuances in their field, the authority with which they render their opinion or because of their ability to influence others.

This is the antithesis of commoditization. Many industries have become less commoditized in this postindustrial era, but not medicine. Who in our culture would say that a car is a car is a car, or that a meal is a meal is a meal?

The differences between services with the same CPT code for the same ICD-10 code aren’t, hopefully, quite that vast. But they’re also not always the same or of the same value. There is a huge difference between “I don’t know what that spot is, but it looks harmless” and “It’s a dermatofibroma, a harmless clump of scar tissue that, even though it’s not cancerous, sometimes grows back if you remove it, so we leave them alone if they don’t get in your way”.

I always feel a twinge of dissatisfaction when, after a visit, a patient says “Thanks for your time”. It always makes me wonder, on some level, “did my patient not get anything out of this other than the passage of time, did we not accomplish anything”?

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Healthcare IT Has Failed Providers, but It’s Not Too Late to Redeem Ourselves

By GUS MALEZIS

It’s no secret that healthcare providers are among the hardest working of all professionals – their skill and intelligence are matched only by their creativity and commitment to their patients. But the healthcare IT sector, while it has made an effort to assist, has failed to support our providers – doctors, nurses and caregivers – with technology solutions that meet the increasing demands for better, faster, more efficient patient healthcare delivery. Instead, we have cast these providers in the dark, forcing them to function blindly, devoid of necessary information, pushing many of them to the brink of what they can withstand as professionals, pushing them to burnout.

The thing about providers is that, in addition to being hardworking, dedicated, and outstanding professionals, they are incredibly creative and innovative, willing to embrace new technologies and workflows – as long as they can add value to their patients. So how about we – the broader healthcare IT solutions vendor community – focus on delivering technologies that don’t force them to compromise care and efficiency for the sake of security, or compliance and access to data?

We need to do so to address an industry crisis. Physician burnout is on the rise, and it’s increasingly clear that overworked providers have reached the breaking point. They spend valuable minutes battling technology on virtual desktops, mobile devices, biomedical equipment, and clinical SaaS applications – typing in usernames and passwords, loading various apps, and more. All the while, standing beside a patient that is desperately seeking their assistance.

Right now, nearly one-half of all physicians (44 percent) report having feelings of burnout (according to Medscape‘s 2019 National Physicians Burnout & Depression Report). While these numbers should alarm everyone, what the healthcare IT industry should be especially concerned about is that a leading cause of this physician burnout are tools that hinder provider productivity. Instead of simplifying work for doctors and nurses, technology tools are having the opposite effect. Isn’t technology supposed to make things easier?

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Doctors Will Vote With Their Patients

By MIKE MAGEE, MD

As Robert Muller’s testimony before Congress made clear, we owe President Trump a debt of gratitude on two counts. First, his unlawful and predatory actions have clearly exposed the fault lines in our still young Democracy. As the Founders well realized, the road would be rocky on our way to “a more perfect union”, and checks and balances would, sooner or later, be counter-checked and thrown out of balance.

On the second count, Trump has most effectively revealed weaknesses that are neither structural nor easily repaired with the wave of the wand. Those weaknesses are cultural and deeply embedded in a portion of our citizenry. The weakness he has so easily exposed is within us. It is reflected in our stubborn embrace of prejudice, our tolerance of family separations at the border, our penchant for violence and romanticism of firearms, our suspicion of “good government”, and –unlike any other developed nation – our historic desire to withhold access to health services to our fellow Americans.

In the dust-up that followed the New York Times publication of Ross Douthat’s May 16, 2017 article, “The 25th Amendment Solution for Removing Trump”, Dahlia Lithwick wrote in SLATE, “Donald Trump isn’t the disease that plagues modern America, he’s the symptom. Let’s stop calling it a disability and call it what it is: What we are now.”

Recently a long-time health advocate from California told me she did not believe that the majority of doctors would support a universal health care system in some form due to their conservative bend. I disagreed.

It is true that, to become a physician involves significant investment of time and effort, and deferring a decade worth of earnings to pursue a training program that, at times, resembles war-zone conditions can create an ultra-focus on future earnings. But it is also true that these individuals, increasingly salaried and employed within organizations struggling to improve their collective performance, deliver (most of the time) three critical virtues in our society.

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Health Reform Job One: Stop the Gouging! | Part 3

By BOB HERTZ

We Need Legal Assaults On The Greediest Providers!

When a patient is hospitalized, or diagnosed with a deadly disease, they often have no choice about the cost of their treatment.

They are legally helpless, and vulnerable to price gouging.

We need more legal protection of patients. In some cases we need price controls.

In the final part of this series, I discuss how we need to empower patients by allowing them to challenge their medical bills in courts.

Assault Phase Four – Binding Arbitration of Medical Bills

 We must allow patients to challenge their medical bills in expanded ‘Health courts.’

Patients should be able to contest any bill over $250,  especially if they have not given ‘informed financial consent’ to the provider.

Such ‘consent’ would require that if a procedure can be scheduled in advance, it can also be quoted in advance. If the patient requests an estimate, they must be notified in writing at least seven days in advance. This would allow the patient to request a different provider, or to investigate other alternatives. If an estimate is requested but never produced, the patient has no liability. (That will shake up the providers rather quickly.)

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Health Reform Job One: Stop the Gouging! | Part 1

By BOB HERTZ

We Need Legal Assaults On The Greediest Providers!

When a patient is hospitalized, or diagnosed with a deadly disease, they often have no choice about the cost of their treatment.

They are legally helpless, and vulnerable to price gouging.

Medicare offers decent protection — i.e. limits on balance billing, and no patient liability if a claim is denied.

But under age 65, it is a Wild West — especially for emergency care, and drugs and devices. The more they charge, the more they make. Even good health insurance does not offer complete financial insulation.

We need more legal protection of patients. In some cases we need price controls.

‘Charging what the market will bear’ is inadequate, even childish, when ‘the market’ consists of desperate patients. Where contracts are impossible and there is no chance for informed financial consent, government can and should step in.

This series describes the new laws that we need. Very little is required in tax dollars….but we do require a strong will to protect.

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Zeev Neuwirth Reframes Primary Care…Brilliantly

By AL LEWIS

I would urge THCB-ers to read Reframing Healthcare by Dr. Zeev Neuwirth. While much of the territory he covers will be familiar to those of us with an interest in healthcare reform (meaning just about everyone reading this blog), Chapter 5 breaks new ground in the field of primary care.

Primary care is perhaps the sorest spot in healthcare, the sorest of industries. Primary care providers (PCPs) are underpaid, dissatisfied, and in short supply. (The supply issue could be solved in part if employers didn’t pay employees bonuses to get useless annual checkups or fine them if they don’t, of course.) 

They are also expected to stay up to date on a myriad of topics, but lack the time in which to do that and typically don’t get compensated for it. Plus, there are a million other “asks” that have nothing to do with seeing actual patients.

For instance, I’ve gone back and forth three times with my PCP as she tries to get Optum to cover 60 5-milligram zolpidems (Ambien) instead of 30 10-milligram pills. (I already cut the 5 mg. pills in half. Not fair or good medicine to ask patients to try to slice those tiny 10 mg pills into quarters. And not sure why Optum would incentivize patients to take more of this habit-forming medicine instead of less.)

This can’t be fun for her. No wonder PCPs burn out and leave the practice faster than other specialties. What some of my physician colleagues call the “joy of practice” is simply not there.

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