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Category: Physicians

Behind the Mask

By HANS DUVEFELT

Today I saw a patient I have known for years. He suddenly pulled his mask down and said, “I’d like to know what you think I should do about this”.

On his nose was an 8 mm (1/3”) brownish-red flat spot with a crack or scrape through it.

“How long have you had it?”, I asked.

“Oh, a while now” he answered. That is about the least helpful time measurement I know of. I asked him to pin it down a bit more precisely. He settled for about a year. I prescribed a cream and made a two week follow-up appointment for either cryo or a biopsy. It’s probably just an excoriated, premalignant, actinic keratosis.

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We are Asking Our Physicians to Do Too Much. It’s No Wonder They are Burnt Out.

By GAIL PEACE

We have heard the phrases “physician fatigue” and “burnout” too often in the last year – and for good reason. Covid-19 has placed an incredible burden on our healthcare providers. However, as healthcare professionals, the stats representing physician burnout are not new for us.  

We have seen similar trends and stats for years. Covid-19 did not cause the current state of physician burnout, it has just exacerbated it and further exposed critical issues with the expectations placed on physicians in today’s healthcare system. Ludi conducted a survey of physicians across the country confirming that exact theory:

  • 68 percent of physicians feel pessimistic or indifferent about their occupation
  • 48 percent describe the relationship with their hospital partners/employers as combative or transactional at best

We need to ask ourselves: What is actually causing this dissatisfaction and how can hospitals better align with their physician partners?  

According to the physicians surveyed, 68 percent agreed they have too much administrative burden placed on them. More often than not, our industry blames EHRs for dominating administrative time, but from the physicians we surveyed, EHRs are just part of the problem. In fact, 54 percent of physicians indicated they spend 1-3 hours per day on administrative work outside of EHR time, with another 35 percent spending more than 4 hours per day on similar tasks.

Let’s put that into perspective. On top of seeing patients, charting in EHRs, and all the other things physicians are expected to do to take care of patients, physicians are also spending at least another 1-3 hours per day on “everything else.” This everything else includes meetings, training, compliance, policy, etc.  

We are asking our physicians to do too much. It’s no wonder they are burnt out.

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We Use Too Many Medications: Be Very Afraid of Interactions

By HANS DUVEFELT

I happened to read about the pharmacodynamics of parenteral versus oral furosemide when I came across a unique interaction between this commonest of diuretics and risperidone: Elderly dementia patients on risperidone have twice their expected mortality if also given furosemide. I knew that all atypical antipsychotics can double mortality in elderly dementia patients, but was unaware of the additional risperidone-furosemide risk. Epocrates only has a nonspecific warning to monitor blood pressure when prescribing both drugs.

This is only today’s example of an interaction I didn’t have at my fingertips. I very often check Epocrates on my iPhone for interactions before prescribing, because – quite frankly – my EMR always gives me an entire screen of fine print idiotic kindergarten warnings nobody ever has time to read in a real clinical situation. (In my case provided by the otherwise decent makers of UpToDate.)

I keep coming back in my thoughts and blogging about drug interactions. And every time I run into one that surprised me or caused harm, I think of the inherent, exponential risks of polypharmacy and the virtues of oligopharmacy.

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Medicine is a Moving Missile, Aiming for a Dangerous, Elusive Target

By HANS DUVEFELT

(Desperate times called for desperate measures.)

In the tech world, we have come to expect our devices to become outdated and obsolete very quickly. The biggest tech companies in the world didn’t even exist a few years ago. Bitcoin, a virtual currency which at least I can’t wrap my head around, seems to be more attractive than gold.

I get the sense most people embrace or at least accept the speed of change in tech.

But medical advances that occur rapidly are frightening to many people. Vaccine hesitancy, for example, involves concerns and characterizations like “unproven” and “guinea pigs”.

But can we as a society strive for and reward rapid progress in one area and reject it in another, especially if we feel threatened by outside forces or phenomena – be that a virus, climate change or the collapse of our economy’s infrastructure like supply chains and raw materials.

Tech has its own momentum, more driven by profit motives than altruistism or a desire just to make peoples lives better. Medicine clearly has profit as a driving force, but also a goal of improving life for people. Curing or mitigating disease must rank higher than making life more convenient.

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American Primary Care is a Big Waste of Time (When…)

By HANS DUVEFELT

Before Johannes Gutenberg invented the printing press in 1450, books in Europe were copied by hand, mostly by monks and clergy. Ironically, they were often called scribes, the same word we now use for the new class of healthcare workers employed to improve the efficiency of physician documentation.

Think about that for a moment: American doctors are employing almost medieval methods in what is supposed to be the era of computers. Why aren’t we using AI for documentation?

The pathetically cumbersome methods of documentation available (required) for our clinical encounters is only one of several antiquated presumptions in American healthcare. Other inefficiencies, often viewed as axioms, especially in primary care, make the trade I am in chock full of time wasters.

Whereas in most other “industries”, people talk about reach, scale, leverage and automation, primary care is still doing things one patient at a time. The automation in our field is not one where processes happen without human involvement according to preset patterns. Instead, it is an ongoing effort to make medical providers behave in automatic fashion with patients on a one-on-one, one visit at a time basis. The value of one-on-one is when you individualize, give unique advice considering multiple individual parameters; saying “in your particular case”, rather than “everybody should eat a healthy diet”.

Primary care here is wasting time in many ways:

When health maintenance and disease prevention is done by physicians. I keep writing about this, but a standing order to offer pneumonia or shingles shots, diabetes or lung cancer screenings and so many other things to people over a certain age or with certain risk factors can be handled by non-physicians. This would keep the six figure problem solvers doing what only they can do. It would also (a not-so-wild guess) probably double physician productivity.

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I Am a Decision Maker, Not a Bookkeeper

By HANS DUVEFELT

Perhaps it is because I love doctoring so much that I find some of the tools and tasks of my trade so tediously frustrating. I keep wishing the technology I work with wasn’t so painfully inept.

On my 2016 iPhone SE I can authorize a purchase, a download or a money transfer by placing my thumb on the home button.

In my EMR, when I get a message (also called “TASK” – ugh) from the surgical department that reads “patient is due for 5-year repeat colonoscopy and needs [insurance] referral”, things are a lot more complicated, WHICH THEY SHOULDN’T HAVE TO BE! For this routine task, I can’t just click a “yes” or “authorize” button (which I am absolutely sure is a trackable event in the innards of “logs” all EMRs have).

Instead, (as I often lament), I have to go through a slow and cumbersome process of creating a non-billable encounter, finding the diagnostic code for colon cancer screening, clicking on REFERRAL, then SURGEON – COLONOSCOPY, then freetexting “5 year colonoscopy recall”, then choosing where to send this “TASK”, namely the referral coordinator and , finally, getting back to the original request in order to respond “DONE”.

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A Man With Sudden Onset of Gastroparesis

By HANS DUVEFELT

Leo Dufour is not a diabetic. He is in his mid 50s, a light smoker with hypertension and a known hiatal hernia. He has had occasional heartburn and has taken famotidine for a few years along with his blood pressure and cholesterol pills.

Over the past few months, he started to experience a lot more heartburn, belching and bloating. Adding pantoprazole did nothing for him. I referred him to a local surgeon who did an upper endoscopy. This did not reveal much, except some retained food in his stomach. A gastric emptying study showed severe gastroparesis.

The surgeon offered him a trial of metoclopramide. At his followup, he complained of cough, mild chest pain and shortness of breath. His oxygen saturation was only 89%.

An urgent chest CT angiogram showed bilateral pulmonary emboli and generalized hilar adenopathy, a small probable infiltrate, a small pulmonary nodule and enlargement of both adrenal glands, suspicious for metastases.

He is now on apixiban for his PE, two antibiotics for his probable pneumonia and some lorazepam for the sudden shock his diagnoses have brought him.

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As Doctor Burnout Climbs, Can We Save Primary Care?

By RONALD DIXON

Week after week, I hear from colleagues in diverse specialties about how exhausted they are from practicing medicine.

It’s no surprise that they are looking for careers outside of medicine. The demands and strain are unsustainable.

So it’s also no surprise that a recent survey showed 40% of primary care clinicians are worried that their field won’t exist in five years and that 21% expect to leave primary care in three years as a result of COVID-19-related burnout. 

While COVID-19 is the tipping point, this burnout is the result of the relentless and mounting administrative burden placed on us by electronic medical records (EMRs), coding and billing requirements and prior authorizations. And then it is exacerbated by uncertainty mounting in the primary care field, with new medical care entrants popping up everywhere — from retail pharmacies to digital health startups — aiming to create their own primary care model, replacing rather than working with existing ones.

Where it All Began

The roots of this burden began three decades ago with the advent of an acronym that few outside of the healthcare world know of today — the resource-based relative value scale (RBRVS). This payment system, launched in 1989 and subsequently adopted by Medicare in 1992, led to what we know now as the foundation of the U.S. healthcare payment system.  

The RBRVS system assigns procedures a relative value which is adjusted by geographic region. Prices are based on physician work (54%), practice expense (41%) and malpractice expense (5%).

Since the initiation of the scale, the relative value of specialist work has remained much higher than primary care. This disparate compensation, in combination with most health maintenance and patient supportive tasks delegated to primary care, has led to significant fatigue. 

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Anxiety, Worry or Fear? Disappointment, Grief or Depression?

By HANS DUVEFELT

Especially in these strange and uncertain times, many people feel uneasy. Some of them come to us with concerns over their state of mind.

In primary care, our job is in large part to perform triage. We strive to identify patients who need referral, medication or further evaluation. We also strive, or at last should strive, to reassure those patients whose reactions are normal, considering their circumstances.

A set of emotions we consider normal during the first weeks of the loss of a loved one may constitute pathology of protracted or if there is no apparent trigger.

But what is normal in today’s reality?

People today often have a low tolerance for deviations from the mean. They measure their heart rates, sleep times, steps taken, calories eaten and many other things on their smartphones. They compare their statistics to others’ or to their own from different circumstances.

Is it normal to sleep less when the last thing you do before bed is take in the latest disaster news? Is it normal to have a higher resting heart rate when you are threatened by eviction? Is it normal to feel sadness that life as we knew it doesn’t seem to be within our reach right now?

The worst thing we can do is tell people there is something wrong with them if we see them doing and hear them expressing what many other people also do.

It’s bad enough to feel bad, but even worse if you think your reaction is a sign of psychiatric illness or psychological or constitutional inferiority.

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Does Our Healthcare System Work for the Most Vulnerable Americans?

By DEBORAH AFEZOLLI, CARL-PHILIPPE ROUSSEAU, HELEN FERNANDEZ, ELIZABETH LINDENBERGER

“Why did you choose this field?” Most physicians are asked this question at some point in their early careers. We are geriatrics and palliative medicine physicians, so when that question is posed to us, it is invariably followed by another: “Isn’t your job depressing?”

No, our job is not depressing. We are trained in the care of older adults and those with serious illness, and we find this work very rewarding.  What truly depresses us is how many vulnerable patients died during the pandemic, and how the scourge of COVID-19 revealed the cracks in our health system. Never before in modern times have so many people been affected by serious illness at the same time, nor have so many suffered from the challenges of our dysfunctional health system. Our nation has now witnessed the medical system’s failure to take comprehensive care of its sickest patients.  This is something those in our own field observed long before the pandemic and have been striving to improve.

All of us practicing geriatrics and palliative care have had a loved one who has been challenged by aging, by serious illness, or indeed by the very healthcare system that is supposed to help them. As medical students and residents, we personally confronted these systemic deficiencies and wondered about alternatives for those patients with the most complex needs. We chose fellowships in geriatrics and palliative medicine because we wanted to try and make a difference in the healthcare that is offered to our most vulnerable patients.

During the New York City surge in the spring of 2020, we were front line workers at a major academic medical center. While the global pandemic took us all by surprise, our clinical training and passion for treating vulnerable populations left us feeling capable and ready to serve. Due to the urgent needs of overwhelming numbers of extremely sick patients, our Department was charged with rapidly expanding access to geriatrics and palliative care across our seven hospitals. We were embedded in Emergency Departments (EDs), hospitalist services, and critical care units.  We roamed the hospitals with electronic tablets and held the hands of dying patients, while urgently contacting families to clarify goals of care.  For those who wanted to receive care in the community, we scrambled to set up telehealth visits and coordinate the necessary support. Way too often we could not meet their needs with adequate services, forcing them to visit overwhelmed Emergency Rooms.

While we helped individual patients and eased some of the strain on our hospitals, our system was overwhelmed and mortality numbers continued to steadily rise. Within our hospitals, staff were redeployed to care for the most critically ill in the emergency departments and intensive care units.  In this frantic time, we were fortunate that our hospitals had sufficient medical resources to care for the sickest patients and for the staff.  However, the sub-acute nursing facilities (SNF) and long-term care facilities strained to protect their residents and their employees. Shortages of PPE, staff, space, testing supplies, and funding all contributed to the high mortality numbers we saw in many NYC facilities and across the nation. There were also limited resources allocated to delivering outpatient care in our patients living in the community.  The rapid shift to telehealth was not feasible for many of our older patients, and even when it was possible, the delivery of diagnostic and therapeutic care was limited and suboptimal.

Data now shows that older adults and those with underlying chronic illnesses were disproportionately affected by the COVID-19 pandemic, experiencing higher hospitalization rates as well as higher death rates. Although adults 65 and older account for only 16% of the US population, they represent 80% of COVID-19 deaths. Residents of nursing homes, the frail homebound, and older people of color were the hit the hardest. Thirty-five percent of the deaths in the US from March-May 2020 occurred among nursing home residents and employees. Nationally, over 600,000 nursing home residents were infected with COVID-19 and over 100,000 died from the disease. These data are underestimates and the death toll is likely higher. We cannot explain why older Black Americans were 1.2 times more likely to die than white Americans nor why the odds of dying from COVID were nearly two times higher for persons living in South Dakota as compared to Wyoming or Nebraska. Often, the paid caregivers for these vulnerable patients were themselves vulnerable underpaid women of color who were at higher risk of contracting COVID.

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