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Category: Physicians

Leveraging Time by Doing Less in Each Chronic Care Visit

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.

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What’s on USMLE Step 1?

By BRYAN CARMODY

Recently, I was on The Accad and Koka Report to share my opinions on USMLE Step 1 scoring policy. (If you’re interested, you can listen to the episode on the show website or iTunes.)

Most of the topics we discussed were ones I’ve already dissected on this site. But there was an interesting moment in the show, right around the 37:30 mark, that raises an important point that is worthy of further analysis.

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ANISH: There’s also the fact that nobody is twisting the arms of program directors to use [USMLE Step 1] scores, correct? Even in an era when you had clinical grades reported, there’s still seems to be value that PDs attach to these scores. . . There’s no regulatory agency that’s forcing PDs to do that. So if PDs want to use, you know, a number on a test to determine who should best make up their class, why are you against that?

BRYAN: I’m not necessarily against that if you make that as a reasoned decision. I would challenge a few things about it, though. I guess the first question is, what do you think is on USMLE Step 1 that is meaningful?

ANISH: Well – um – yeah…

BRYAN: What do you think is on that test that makes it a meaningful metric?

ANISH: I – I don’t- I don’t think that – I don’t know that memorizing… I don’t even remember what was on the USMLE. Was the Krebs Cycle on the USMLE Step 1?

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I highlight this snippet not to pick on Anish – who was a gracious host, and despite our back-and-forth on Twitter, we actually agreed much more than we disagreed. And as a practicing clinician who is 15 years removed from the exam, I’m not surprised in the least that he doesn’t recall exactly what was on the test.

I highlight this exchange because it illuminates one of the central truths in the #USMLEPassFail debate, and that is this:

Physicians who took Step 1 more than 5 years ago honestly don’t have a clue about what is tested on the exam.

That’s not because the content has changed. It’s because the memories of minutiae fade over time, leaving behind the false memory of a test that was more useful than it really was.

I’m speaking from experience here.

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Let Patients Lead – Explaining Addiction and Recovery to Families

By HANS DUVEFELT, MD

We knew that the most powerful way to provide substance abuse treatment is in a group setting. Group members can offer support to each other and call out each other’s self deceptions and public excuses, oftentimes more effectively than the clinicians. They share stories and insights, car rides and job leads, and they form a community that stays connected between sessions.

Participants with more experience and life skills may say things in group that we clinicians might hesitate saying, like “Now you’re whining” and “Time to put on your big boy pants”. They can become role models by being further along in their recovery and by at the same time revealing their own fear or respect for the threat of relapse.

What has also happened in our clinic, entirely unplanned, was that after an informational meeting where we explained the group model and had a national expert physician speak about opioid recovery, several parents raised their hand and said there should be a group for families, too.

We listened and within a few months we started such a group and now, a year and a half into it, the group is co-led by a few of our patients, who naturally had become leaders of the patient group earlier.

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How to End Egregious Medical Bills (while minimizing the impact on the provider’s bottom line)

By HAYWARD ZWERLING, MD

I recently saw a patient who received a bill for an outpatient procedure for $333. The Medicare allowable reimbursement for the procedure was $180. I have seen other medical bills where the healthcare provider was charging patients more than 10 times the amount they expected to receive from Medicare or any insurance company.

Another one of my patients had an unexpected medical complication which necessitated a visit to an emergency room. He received a huge bill for the services provided. When I subsequently saw him in my office (for poorly controlled diabetes) he told me he could not attend future office visits because he had so many outstanding medical bills and he could not risk incurring any additional medical expenses. While I offered to see him at no cost, he declined, stating the financial risk was too high.

A patient is required to pay the entire medical bill if they have:

  • no insurance
  • poor quality insurance
  • a bureaucratic “referral problem”
  • an out-of-network provider, which means they have no contractural relationship with the healthcare provider/institution, as might result from an emergency room visit or an unexpected hospitalization.

Hospitals, physicians and other healthcare providers usually do not know what they are going to get paid for any given service as they contract with many insurance companies, each of which has a different contracted payment rate. Healthcare providers and institutions typically set their fee schedule at a multiple of what they expect to get paid from the most lucrative payer so as to ensure they capture all the potential revenue. In the process, they create an economically irrational fee schedule which is neither reflective of a competitive marketplace nor reflective of the actual cost of the services provided.

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Training the Modern Physician: A Call to Incorporate Finance and Law into Medical Education

By SAI BALA, JD

The United States medical education system is heralded as one among the top in the world for medical training. Given the strict standards of education, multiple licensing boards, and continuous oversight by governing bodies, getting a placement to train in the US is extremely competitive.  In 2017 alone, nearly 7000+ non-US citizens (commonly referred to as “foreign medical graduates”) applied to compete with 24,000+ US citizens for American residency spots to pursue specialty training. The reasons for this competitiveness are simple. The vast majority of medical institutions in the US boast a comprehensive curriculum that entails basic sciences, clinical principles, practical and hands-on didactics, and enriched exposure to the clinical aspects of patient care. This training produces astute clinicians that are capable of resolving the most complex diagnoses while providing comprehensive patient care.

However, it is high time to recognize that being a shrewd clinician is no longer a sufficient product for the demands of the healthcare market today. That is to say, the scope of medicine today for a physician has gone far beyond resolving complex medical problems, but demands a higher understanding of multidisciplinary skillsets, most important of which are finance and legal theory. In these aspects, the US medical education system direly underprepares physicians, and thus, requires a thorough reevaluation.

The art of medicine, as much as it was originally developed to be purely about the betterment of patient health, has become yet another siloed service industry. Simply put, patients are customers, and physicians are increasingly held accountable for the financial metrics and revenue their work produces. Compensation models are increasingly favoring productivity based payment methods, such as the relative value unit (RVU) system, and are moving away from the traditional, salaried physician. This has resulted in increased pressure on physicians to become more efficient with their workload and patient docket, while managing the often turbulent and contradictory interests of insurance, patients, and hospital administration.

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The Rise and Rise of Quantitative Cassandras

By SAURABH JHA, MD

Despite an area under the ROC curve of 1, Cassandra’s prophesies were never believed. She neither hedged nor relied on retrospective data – her predictions, such as the Trojan war, were prospectively validated. In medicine, a new type of Cassandra has emerged –  one who speaks in probabilistic tongue, forked unevenly between the probability of being right and the possibility of being wrong. One who, by conceding that she may be categorically wrong, is technically never wrong. We call these new Minervas “predictions.” The Owl of Minerva flies above its denominator.

Deep learning (DL) promises to transform the prediction industry from a stepping stone for academic promotion and tenure to something vaguely useful for clinicians at the patient’s bedside. Economists studying AI believe that AI is revolutionary, revolutionary like the steam engine and the internet, because it better predicts.

Recently published in Nature, a sophisticated DL algorithm was able to predict acute kidney injury (AKI), continuously, in hospitalized patients by extracting data from their electronic health records (EHRs). The algorithm interrogated nearly million EHRS of patients in Veteran Affairs hospitals. As intriguing as their methodology is, it’s less interesting than their results. For every correct prediction of AKI, there were two false positives. The false alarms would have made Cassandra blush, but they’re not bad for prognostic medicine. The DL- generated ROC curve stands head and shoulders above the diagonal representing randomness.

The researchers used a technique called “ablation analysis.” I have no idea how that works but it sounds clever. Let me make a humble prophesy of my own – if unleashed at the bedside the AKI-specific, DL-augmented Cassandra could unleash havoc of a scale one struggles to comprehend.

Leaving aside that the accuracy of algorithms trained retrospectively falls in the real world – as doctors know, there’s a difference between book knowledge and practical knowledge – the major problem is the effect availability of information has on decision making. Prediction is fundamentally information. Information changes us.

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Academic Medicine and the Peter Principle

By BEN WHITE, MD

Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.

The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”

In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.

The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).

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Primary Care Is at the Center of a Health Revolution

By KEVIN WANG, MD

If our urgent-care-as-healthcare culture isn’t killing us, it’s certainly wasting our time and resources. 

Consider these facts highlighted by Advanced Medical Reviews, based on various studies: 

  • U.S. physicians report that more than 20 percent of overall medical care is not needed.
  • The Congressional Budget Office recently estimated that up to 30 percent of the costs of medical care delivered in the U.S. pay for tests, procedures, doctor visits, hospital stays, and other services that may not actually improve patient health.
  • Unnecessary medical treatment impacts the healthcare industry through decreased physician productivity, increased cost of medical care, and additional work for front office staff and other healthcare professionals.

Most of today’s primary care is, in retail terms, a loss leader — a well-oiled doorway to the wildly expensive sick care system. For decades, practitioners have been forced into production factories, seeing as many patients, ordering as many tests, and sending as many referrals as possible to specialists. Patients, likewise, have avoided going in for regular visits for fear of the price tag attached, often waiting until they’re in such bad shape that urgent (and much more expensive) care is necessary.

The system as it stands isn’t delivering primary care in a way that serves patients, providers, employers, or insurers as well as it could. To improve health at individual and population levels, the system needs to be disrupted. Primary care needs to play a much larger role in healthcare, and it needs to be delivered in a way that doesn’t make patients feel isolated, neglected, or dismissed. 

Luckily, primary care is making a comeback — the kind that doesn’t just treat symptoms, but sees trust, engagement, and behavior change as a path to health.  

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Ordering Tests Without Using Words: Are ICD-10 and CPT Codes Bringing Precision or Dumbing Us Down?

By HANS DUVEFELT, MD

The chest CT report was a bit worrisome. Henry had “pleural based masses” that had grown since his previous scan, which had been ordered by another doctor for unrelated reasons. But as Henry’s PCP, it had become my job to follow up on an emergency room doctor’s incidental finding. The radiologist recommended a PET scan to see if there was increased metabolic activity, which would mean the spots were likely cancerous.

So the head of radiology says this is needed. But I am the treating physician, so I have to put the order in. In my clunky EMR I search for an appropriate diagnostic code in situations like this. This software (Greenway) is not like Google; if you don’t search for exactly what the bureaucratic term is, but use clinical terms instead, it doesn’t suggest alternatives (unrelated everyday example – what a doctor calls a laceration is “open wound” in insurance speak but the computer doesn’t know they’re the same thing).

So here I am, trying to find the appropriate ICD-10 code to buy Henry a PET scan. Why can’t I find the diagnosis code I used to get the recent CT order in when I placed it, months ago? I cruise down the list of diagnoses in his EMR “chart”. There, I find every diagnosis that was ever entered. They are not listed alphabetically or chronologically. The list appears totally random, although perhaps the list is organized alphanumerically by ICD-10, although they are not not displayed in my search box, but that wouldn’t do me any good anyway since I don’t have more than five ICD-10 codes memorized.

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I Have a Strong Relationship with my Bank but I Almost Never Go There. How Could this Translate to Primary Care?

By HANS DUVEFELT, MD

Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch – and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.

Of course that’s not how banks operate. There are small ongoing charges (or margins off the interest they pay you) for keeping your money and for making it possible to do almost everything from your iPhone these days. Yes, there may be additional charges for things that can’t be done without the bank’s personalized assistance, but those things happen at your request, not by the bank’s insistence.

Compare that with primary care. The bulk of our income is “patient revenue”, what patients and their insurance companies pay us for services we provide “face to face”. We may also have grants if we are Federally Qualified Health Centers, mostly meant to cover sliding fee discounts and what we call “enabling services” – care coordination, loosely speaking.

Only a small fraction of our income comes from meeting quality or compliance “targets”, and those monies only come to us after we have reached those goals – they don’t help us create the needed infrastructure to get there.

Then look at how medical providers are scheduled and paid. We all have productivity targets, RVUs (Relative Value Units – number and complexity of visits combined) if our employer is paid that way and usually just straight visit counts in FQHCs (because all visits are reimbursed at the same rate there). Sometimes we have quality bonuses or incentives, which truthfully may be the combined result of both our own AND other staff members’ efforts.

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