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Category: Physicians

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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Health Insurance is a Stumbling Block in Many Patients’ Thinking

By HANS DUVEFELT

I have a patient with no health insurance but a brand new Mercedes. He says he can’t afford health insurance. He cringes at the cost of his medications and our office visit charges. His car cost a lot of money and I know that authorized Mercedes dealers charge around $140/hour for their technicians’ (not mere mechanics) time. A routine service costs several hundred dollars, which he seems more okay with than the cost of his own healthcare visits.

His new Mercedes is under warranty, but his body is not. He is risking financial disaster if he gets seriously ill with no insurance coverage.

I have another patient who needed a muscle relaxer for a short period of time. His insurance wouldn’t cover it without a prior authorization. The cash cost was about $14. We suggested he pay for the medication and told him his condition would have resolved by the time a prior auth might have been granted. He elected to go without.

The brutal truth is that a primary care doctor’s opportunity cost, how much revenue we can potentially generate by seeing patients, is around $400/hour or $7/minute. There is no way I could request a prior authorization in under two minutes. So it would have been more cost effective to pay for his medication than to do the unreimbursed paperwork (or computer work, or phone work) on his behalf. But, of course, we can’t do that.

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EHRs Are Workarounds, Rerouting the Way Physicians Work

By HANS DUVEFELT

IT GUY: Hey, Doc, don’t make up workarounds, use the EHR the way it was designed.

DOCTOR: Listen, your whole EHR is a workaround itself – around the way medicine is practiced.

– Hans Duvefelt, MD

This was a tweet I posted a while ago. I expected it to either go viral among doctors or catch the ire of administrators and IT folks. Neither happened. So I’m back on my soap box:

Imagine creating a computer simulation or video game that people expected to prepare them for or refine their skills in any given sport. Then, assume that this game altered the rules of the game – using a volley ball instead of a hockey puck, scoring goal attempts rather than goals, rewarding slowness rather than speed and so on.

Then, imagine you, the programmers/code writers, went to the team owners and proposed athletes and coaches should abandon the time-honored rules of the game and instead play like it plays out on the pixelated imitation you just created. And just to be clear: You, the programmer, actually never played the game yourself.

You’d get shown the door and sent back to the digital drawing board.

But that’s not what is happening in medicine.

FIRST: Is finding the clinically relevant information easier than, or at least as easy as, the regulatory information? (The cumbersome ways we have to enter information is a big topic, better covered separately.)

Here’s a silly example: One of the EMRs I work with displays prominently that the smoking assessment requirement has been satisfied, but I’ll be darned if I can see whether the patient smokes or not. Whom does the Holy Grail serve here?

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Morning Distort

By MARTIN A. SAMUELS

A 35-year-old woman complains of weakness of the right side of her face and pain behind the right ear.  She lives in an urban environment and denies any recent illnesses.  She is not vaccinated against COVID-19 but is COVID negative. 

What do you think, I was asked at our Morning Report?  Well, I said, it sounds like a straightforward Bell palsy.  The pain around the ear suggests swelling of the VIIth cranial nerve in the facial canal and the stylomastoid foramen, a very common historical point, I opined; so much so that its absence would make me doubt the diagnosis and make me consider other causes of facial palsy such as sarcoidosis or Borreliosis, though the urban environment argues against that tick born disease.  Then we went around the room, expanding the differential diagnosis (as this exercise is often called) to include tumors of the parotid gland, leptomeningeal metastases and many more.  At one minute before the end of the thirty- minute conference, a photo of the patient was shown.  There was only one problem.  There was no facial weakness, but rather she had a definite Horner syndrome on the right with a smaller pupil and subtle ptosis due to weakness of the Muller muscle, a small circular sympathetically innervated muscle that acts as a minor controller of the palpebral fissure.  The patient’s pupils were not tested in bright and then dim light, nor was sweating tested because why would one do those things in someone with facial weakness and pain around the ear.  In fact, this patient had nothing like a Bell palsy but rather Raeder syndrome, a painful oculosympathetic (Horner) syndrome, which implicates a disease of the carotid artery.  Once this was discovered it was learned that the patient had hyperextensibility of the joints and hadn’t suffered any neck trauma.  Now a spontaneous dissection of the right carotid artery becomes the focus of thought with a very different implication for therapy and prognosis.

This experience vividly emphasizes two traps in the diagnostic process:  thinking fast and framing.  As Daniel Kahneman and the late Amos Tversky have articulated and summarized in their book, Thinking Fast and Slow, there are two subsystems within the nervous system that they dubbed system one and system two.  System one is a very rapidly acting, involuntary system which estimates the likelihood of a given circumstance and reacts to it.  System two is a voluntary, tedious, slow system that weighs evidence, considers the frequency of a likelihood in the environment according to The Reverend Bayes’s prior probability.   In neurology, system one is the autonomic nervous system (or the reptilian brain as it was called by the late Paul MacLean in his triune brain).  System two is the cerebral cortex with its complex networks that facilitate various aspects of awareness, an aspect of consciousness.   Neither system is good nor bad, as both have their place.  The first presumably survived the rigors of evolution because it allowed our ancestors to react to potential threats rapidly (i.e. a movement in peripheral vision is not analyzed; it is rather escaped as if it were a snake, even though Bayesian reasoning would predict that it was probably a stick).  System two allows for more accurate conclusions in less time sensitive circumstances.  What happened to me in the conference was that my system one rapidly generated a theory, but this was based on incorrect data (it was a snake; not a stick).  If a mistake is made early in the diagnostic process, the processes thereafter are all distorted and there is virtually no way to reach the correct answer.  Recall Conrad Waddington’s epigenetic landscape, wherein he used a metaphor (marbles rolling down a hill) to describe how mistakes early in a developmental process have enormous effects on the ultimate outcome, whereas errors later in the process are less destructive.   In addition to my system one error, I was also taken in by the framing shortcut (heuristic).  The person who presented the case had a theory of his own, which was promulgated in the headline:  a woman with a painful facial palsy.  In fact, it was a woman with a painful Horner syndrome.  The moral of the story is that I should have looked at the photograph first.  That would have avoided the futile task of elaborating an expanded differential diagnosis which, after all, is a nothing but a list of wrong answers followed by the right answer. 

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“This Doesn’t Usually Hurt that Much”: Patients With Fibromyalgia Spectrum Disorder

By HANS DUVEFELT

Specialists in orthopedics and general surgery often want us, the primary care doctors, to manage postoperative pain. I don’t like that.

First, I don’t know as much as the surgeons about the typical, expected recovery from their procedures. My own appendectomy in Sweden in 1972 was an open one that I stayed in the hospital for several days for (and nobody mentioned that there were such things as pain medications). I’m sure a laparoscopic one leaves you in less pain, but I don’t personally know by how much.

Postoperative pain could be an indicator of complications. Why would a surgeon not want to be the one to know that their patient is in more pain than they were expecting?

Pain that lingers beyond the postoperative or post-injury period is more up to us to manage. I accept my role in managing that, once I know that there is no complication.

I have many patients who hurt more that most people every time they have an injury, a minor procedure or a symptom like leg swelling, arthritis flare or toothache. The common view is that those people are drug seekers, taking every chance to ask for opiates.

I believe that is sometimes the case, but it isn’t that simple. I believe that people have different experiences with pain. We all know about fibromyalgia patients or those with opioid induced hyperalgesia, but pain is not a binary phenomenon. Like blood glucose, from hypoglycemia, through normoglycemia to prediabetes and all the degrees of diabetic control, pain experience falls on a scale from less than others to more than others.

I reject the notion that pain is a vital sign. When I was Medical Director in Bucksport I discouraged the use of numeric pain ratings. But I did encourage talking about the experience of pain as a subjective, nuanced and very valid consideration. We started a comprehensive pain education module for all our chronic pain patients.

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The Call to Be a Primary Care Doctor

By HANS DUVEFELT

I suspect the notion of calling in narrower specialties is quite different from mine. Surgeons operate, neurologists treat diseases of the nervous system, even as the methods they use change over time.

Primary care has changed fundamentally since I started out. Others have actually altered the definition of what primary care is, and there is more and more of a mismatch between what we were envisioning and trained for and what we are now being asked to do. Our specialty is often the first to see a patient and also the last stop when no other specialty wants to deal with them.

We have also been required to do more public health, more clerical work, more protocol-driven pseudo-care and pseudo-documentation like the current forms of depression screening and followup documentation. And don’t get me started on the Medicare Annual Wellness Visit. How can we follow the rigid protocol and be culturally and ethnically sensitive at the same time?

We are less and less valued for our ability – by virtue of our education and experience – to take general principles and apply them to individual people or cases that aren’t quite like the research populations behind the data and the guidelines. The cultural climate in healthcare today is that conformity equals quality and thinking out of the box is not appreciated. The heavy-handed mandates imposed on our history taking and screening constantly risk eroding our patients’ trust in us as their confidants and advocates. The finesse and sensitivity of the wise old fashioned family doctor is gradually being squeezed out of existence.

The call to primary care medicine, if it isn’t going to pave the road straight to professional burnout, today needs to be a bit like the call to be a missionary doctor somewhere far away:

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