By ANISH KOKA, MD
It took some doing, but I had finally
made it to Bobby’s home.
It was a rowhome tucked into one of those
little side streets in the city that non-city folks wouldn’t dream of driving
down. As I step in, I’m met by the usual set up – wooden steps that hug the
right side of the wall leading up to the second floor. Bobby certainly hasn’t made it up to the
second floor in some time. At the moment she is sitting in her hospital bed in
the living room. The bed is the focal point to a room stuffed to the gills with
all manners of stuff. At least three quarters of the stuff seems to be food.
Cinnamon buns, Doritos, donut holes, chocolate frosted Donuts, crackers,
Twinkies. The junk food aisle at Wawa would be embarrassed by the riches on
Bobby weighs in at four hundred pounds, 5
foot 5 inches. She has a tracheostomy from multiple prior episodes of
respiratory failure that have required ventilatory support. I’m here at the
request of a devoted primary care physician that still makes home calls. I’ve
looked through the last number of hospital stays. The last few discharge
summaries are carbon copies of each other. Hypoxemic respiratory failure
related to pulmonary edema complicated further by morbid obesity. Time on the
vent. Antibiotics. Diuretics. Home. Return to the hospital 2 weeks later. The
last echocardiogram done was 3 admissions ago. A poor study. Not much could be
seen due to ‘body habitus’.
I sit on the side of the bed trying to acquire my own images of her heart. I talk to her as I struggle. Bobby is 58, the youngest of three sisters, and the only surviving member of the family. Her elder sisters died of respiratory complications as well. They both died with tracheostomies. The conversation is circular. The problem according to Bobby is the tracheostomy. Everything was fine before that. I explain that a prolonged period of time on the ventilator on a prior admission prompted the tracheostomy, and that the multiple recent admissions to the hospital that required a ventilator seemed to validate that decision. She doesn’t waver. Both her sisters died shortly after they got tracheostomies. Bobby thinks the physicians taking care of her sisters had a hand in their demise. “They didn’t care.” “We told them they were sick.”
By AMITA NATHWANI, MA
This week’s impeachment hearings show what a crisis of trust we live in today. 69% of Americans believe the government withholds information from the public, according to recent findings by Pew Research Center. Just 41 % of Americans trust news organizations. We even distrust our own health care providers: Only 34% of Americans say they deeply trust their doctor.
One important way doctors can regrow that trust is to become educated about the types of medicine their patients want, including alternative therapies.
People are seeking new ways to care for their health. For instance, the percentage of U.S. adults doing yoga and mediating—while still a minority– rose dramatically between 2012 and 2017, according to the CDC’s National Center for Health Statistics. Likewise, the number of Americans taking dietary supplements including vitamins, minerals and natural therapies like turmeric, increased ten percentage points, to 75% in the past decade, according to the Council for Responsible Nutrition. As Americans increasingly seek out non-pharmaceutical ways to address wellness, they need doctors who can talk to them about such alternatives.
Unfortunately, this is rare. As a provider of an holistic approach to health called Ayurvedic Medicine, I often see people who tell me their physician dismissed them when they asked about treatments they’d read about on the internet. In many cases, clients tell me their doctor has actually chastised them for entertaining an alternative approach to their existing illness. This leaves them disempowered. They wanted to make choices to improve their own health, but found they were not acknowledged, supported or even understood by the doctor.
By HANS DUVEFELT, MD
At the end of the year my patients and I will start over. That is what changing EMRs does to us. I have mixed feelings about data migration, if it even happens.
I will move into a new virtual environment and my patients will take on slightly different appearances, maybe even alter their medical histories. Some will perhaps be asking me to edit diagnoses that have haunted them since we went from paper to computer records almost a decade ago.
With our first EMR, we scanned in a few things from patients’ paper records – sometimes only a few pages from years or decades of first handwritten and later typed notes. Much got lost, because we were doing something we never really had thought through, and we had to do it with a clock ticking: “Hurry, before the Federal incentives go away”. The Feds wanted EMRs because the vision was that more data would help research and population health and also reduce medical errors.
This time, another factor is pushing us forward: The EMR we have will no longer be supported after a certain date, and for an EMR that requires continuous tinkering in order to do basic tasks consistently, that is an untenable scenario. Only yesterday, I was suddenly unable to send prescriptions electronically and it took the national headquarter’s involvement to get me up and running again.
By ANISH KOKA, MD
No one likes getting bills. But there is something that stinks particularly spectacularly about bills for healthcare that arrive despite carrying health insurance. Patients pay frequently expensive monthly premiums with the expectation that their insurance company will be there for them when illness befalls them.
But the problem being experienced by an
increasing number of patients is going to a covered (in-network) facility for
medical care, and being seen by an out-of-network physician. This happens because
not all physicians working in hospitals serve the same master, and thus may not
all have agreed to the in-network rate offered by an insurance company.
This is a common occurrence in medicine. At any given time, your local tax-exempt non-profit hospital is out of network of some low paying Medicaid plan or the other.
In this complex dance involving patients, insurers and doctors, Patients want their medical bills paid through premiums that they hope to be as low as possible, Insurers seek to pay out as little of the premium dollars collected as possible, and Doctors want to be paid a wage they feel is commensurate to their training and accumulated debt.
Insurers act as proxies for patients when
negotiating with the people that actually deliver healthcare – doctors.
Largely, the system works to funnel patients to ‘covered’ doctors and
hospitals. Patients that walk into an uncovered facility are quickly
redirected. But breakdowns happen during emergencies.
There are no choices to make for patients arriving unconscious or in distress to an emergency room. It suddenly becomes very possible to be seen by an out of network physician, and depending on the fine print of the insurance plans selected, some or none of these charges may be covered.
By HANS DUVEFELT, MD
It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word.
This has been the bread and butter of counselors for years. People will faithfully attend and pay for weeks, months and even years of therapy visits just to have an attentive and active listener and to feel like they have an ally.
We also have data that shows that adherence to treatment plans is dependent on how patients feel about their provider. One problem solved can build an ally for life
Primary care medicine is a relationship based business. I don’t know how often that basic fact is overlooked or denied. Whether you are trying to get another person to alter their lifestyle, take expensive medicines according to inconvenient schedules or even just trust and accept your diagnosis, you have to “earn” the right to do those things. Our titles and medical accoutrements give us a foot in the door, but they don’t usually get us all the way into peoples inner circles of trusted advisers.
In this age of corporate medicine, there is a belief that patients attach themselves to institutions and networks because of their trust in the organizations, and that therefore the connection with their individual providers is secondary.
By BRYAN CARMODY, MD
“YOUR LIKELIHOOD OF SECURING RESIDENCY TRAINING DEPENDS ON MANY FACTORS – INCLUDING THE NUMBER OF RESIDENCY PROGRAMS YOU APPLY TO.”
So begins the introduction to Apply Smart: Data to Consider When Applying to Residency – a informational campaign from the Association of American Medical Colleges (AAMC) designed to help medical students “anchor [their] initial thinking about the optimal number of applications.”
In the era of Application Fever – where the mean number of applications submitted by graduating U.S. medical students is now up to 60 – some data-driven guidance on how many applications to submit would be welcome, right?
And yet, the more I review the AAMC’s Apply Smart campaign, the more I think that it provides little useful data – and the information it does provide is likely to encourage students to submit even more applications.
This topic will be covered in two parts. In the first, I’ll explore the Apply Smart analyses and air my grievances against their logic and data presentation. In the second, I’ll suggest what the AAMC should do to provide more useful information to students.
Introduction to Apply Smart
The AAMC unveiled Apply Smart for Residency several years ago. The website includes lots of information for students, but the piece de resistance are the analyses and graphics that relate the number of applications submitted to the likelihood of successfully entering a residency program.
By HANS DUVEFELT, MD
I scribbled my signature on a pharmaceutical rep’s iPad today for some samples of Jardiance, a diabetes drug that now has expanded indications according to the Food and Drug Administration. This drug lowers blood sugar (reduces HbA1c by less than 1 point) but also reduces diabetes related kidney damage, heart attacks, strokes and now also admission rates for heart failure (from 4.1% to 2.7% if I remember correctly – a significant relative risk reduction but not a big absolute one; the Number Needed to Treat is about 70, so 69 out of 70 patients would take it in vain for the heart failure indication. The NNT for cardiovascular death is around 38 over a three year period – over a hundred patient years for one patient saved). There are already other diabetes drugs that can reduce cardiovascular risk and I see cardiologists prescribing them for non-diabetics.
It’s a bit of a head scratcher and it makes me think of the recently re-emerged interest in the notion of a “Polypill” with several ingredients that together reduce heat attack risk. The tested Polypill formulations are all very inexpensive, which is a big part of their attraction. Jardiance, on the other hand, costs about $400 per month.
The “rep” asked whether this medication would be something I’d be likely to discuss with my diabetic patients.
“Well, you know I’ve only got fifteen minutes…” dampened his expectations. But I told him about the Polypill studies. I think patients are still not ready to make the distinction between on the one hand medications that treat a more or less quantifiable problem like blood sugar levels, blood pressure or the much less straightforward lipid levels and on the other hand ones that only change statistical outcomes. Most of my patients have trouble wrapping their head around taking a $400 a month pill that doesn’t make them feel better or score a whole lot better on their lab test but only changes the odds of something most people think will never happen to them anyway.
By LISE ALSCHULER, ND, FABNO
I am a naturopathic doctor, and because I operate outside of insurance-based medicine, I have, what most healthcare providers would consider, lots of time with my patients. My typical first patient appointment is 90 minutes long and my follow-up visits are 30 minutes long.
What, you may ask, do I do with all this time? I get to know my patients by listening to their stories, their concerns and their hopes. We delve into their health concerns, we review their medical records, and we explore lifestyle-based strategies to optimize their healing and wellbeing.
In short, I listen and apply what I know in partnership with each patient with the goal of empowering them towards greater wellness. Over and over, I hear from my patients how unusual this is. They speak about the 5-minute visits with their doctors that feel rushed and disconnected. They express frustration and dismay about being a diagnosis, not a person, when seeing their healthcare providers.
A recent survey conducted by the New York Times found that two-thirds of Americans support some form of change to the current healthcare system and favor moving towards greater insurance coverage for all. My experience for almost 25 years leads me to conclude that underlying this vision of healthcare is a deep-seated desire for patients to be cared for and listened to.
By HANS DUVEFELT, MD
In medicine, contrary to common belief, it is not usually enough to know the diagnosis and its best treatment or procedure. Guidelines, checklists and protocols only go so far when you are treating real people with diverse constitutions for multiple problems under a variety of circumstances.
The more you know about unusual presentations of common diseases, the more likely you are to make the correct diagnosis, I think everyone would agree. Also, the more you know about the rare diseases that can look like the common one you think you’re seeing in front if you, rather than having just a memorized list of rule-outs, the better you are at deciding how much extra testing is practical and cost effective in each situation.
Not everyone with high blood pressure needs to be tested in detail for pheochromocytoma, renal artery stenosis, coarctation of the aorta, Cushing’s syndrome, hyperaldosteronism, hyperparathyroidism or thyroiditis. But you need to know enough about all of these things to have them in mind, automatically and naturally, when you see someone with high blood pressure.
Just having a lifeless list in your pocket or your EMR, void of vivid details and depth of understanding, puts you at risk of being a burned-out, shallow healthcare worker someday replaced by apps or artificial intelligence.
By HANS DUVEFELT, MD
So many primary care patients have several multifaceted problems these days, and the more or less unspoken expectation is that we must touch on everything in every visit. I often do the opposite.
It’s not that I don’t pack a lot into each visit. I do, but I tend to go deep on one topic, instead of just a few minutes or maybe even moments each on weight, blood sugar, blood pressure, lipids, symptoms and health maintenance.
When patients are doing well, that broad overview is perhaps all that needs to be done, but when the overview reveals several problem areas, I don’t try to cover them all. I “chunk it down”, and I work with my patient to set priorities.
What non-clinicians don’t seem to think of is that primary health care is a relationship based care delivery that takes place over a continuum that may span many years, or if we are fortunate enough, decades.