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Tag: Rob Lamberts

Bad Directions

• 11

By Rob Lamberts, MD

I love the GPS analogy for health care.  Patients need a GPS for their health, showing them the reality of their past, present, and future health.  The analogy has not only shown me how I want to give care for my patients, it has also given me insight into the pitfalls of automated medical care.

Way back in the days when GPS was new, the rental care company Hertz advertised “NeverLost,” a GPS on your dashboard (if you forked out the extra money for it).  I was asked to give a talk in Oregon, and decided I would try out this cool new technology (since others were picking up my bill).  While I found it overall very useful, there were a couple of times it didn’t work as advertised.

  • I needed a sweatshirt, so  I used the NeverLost for directions to a Wal-Mart.  It worked!  It gave me flawless directions to a Wal-Mart store…in Las Vegas (over 1000 miles away).  I stopped at a gas station and they told me that there was actually a Wal-Mart 1/2 mile down the road.
  • Then, when I was trying to get to Crater Lake, “Never Lost” repeatedly directed me down dirt roads, some of which had trees fallen across their path.  NeverLost was quite perturbed when I didn’t follow its direction, nagging me to make an immediate u-turn back toward the tree in the road.

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Us and Them-Ism

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By Rob Lamberts, MD

Us and Them
And after all we’re only ordinary men

The wanna-be congressman appeared with his neat hair and pressed suit, a competent yet compassionate expression on his face.  ”The first thing I am going to do when I get to congress is to work to repeal Obamacare,” he said, expression growing subtly angry.  ”I will do everything I can to give you back the care you need from those who think big government is the solution to every problem.”

My wife grabbed my arm, restraining me from throwing the nearest object at the television.  I cursed under my breath.

No, it’s not my liberal ideology that made me react this way; I’ve had a similar reaction to ads by democrats who demonize republicans as uncaring religious zealots who want corporations to run society.  I am a “flaming moderate,” which means that I get to sneer at the lunacy on both sides of the political aisle. I grew up surrounded by conservative ideas, and probably still lean a bit more that direction than to the left, but my direction has been away from there to a comfortable place in the middle.

It’s not the ideology that bugs me, it’s the use of the “us and them” approach to problem solving.  If only we could get rid of the bad people, we could make everything work.  If only those people weren’t oppressing us.  If only those people weren’t so lazy.  It’s the radical religious people who are the problem.  It’s the liberal atheists.  It’s the corporations.  It’s the government.  All of this makes the problem into something that isn’t the fault of the person making the accusation, conveniently taking the heat off of them for coming up with solutions to the problems.

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The Problem with Transformation

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By Rob Lamberts, MD

Eric Topol wrote a post recently put up on THCB where he looks to a future enabled by emerging technology.

Just as the little mobile wireless devices radically transformed our day-to-day lives, so will such devices have a seismic impact on the future of health care. It’s already taking off at a pace that parallels the explosion of another unanticipated digital force — social networks.

Take your electrocardiogram on your smartphone and send it to your doctor. Or to pre-empt the need for a consult, opt for the computer-read version with a rapid text response. Having trouble with your vision? Get the $2 add-on to your smartphone and get your eyes refracted with a text to get your new eyeglasses or contact lenses made. Have a suspicious skin lesion that might be cancer? Just take a picture with your smartphone and you can get a quick text back in minutes with a determination of whether you need to get a biopsy or not. Does your child have an ear infection? Just get the scope attachment to your smartphone and get a 10x magnified high-resolution view of your child’s eardrums and send them for automatic detection of whether antibiotics will be needed.

Now, I am the first to confess my infatuation with technology.  I am also a very big believer in patient empowerment, which could be the one force strong enough to overcome the partisan politicians and corporate lobbyists resisting any positive change.  But there are several problems I see with this kind of empowerment with technology.

First off, the goal is not to find technologies that simply transform, but ones that move care to a better place.  Right now our system is running aground for one reason: we spend too much money.  Patient empowerment that improves efficiency of care is good, while empowerment that increases consumption or decreases efficiency is to be avoided if at all possible.  The technology mentioned in the article is predominantly data-gathering technology, increasing the amount of information moving from patient to physician.  The hope is that this will enable faster and better informed decisions, and perhaps some of it will.  But I can see harm coming out of this as well.

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A Funny Thing Happened on the Way to Meaningful Use

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By Rob Lamberts, MD

This July will mark the 16th anniversary of the installation of our electronic medical record.

Yup.  I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care.  I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red.  I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue.  I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care.  I heard people say primary care doctors couldn’t afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time.  To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka “meaningful use” criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it.  I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind.  No, I didn’t stop thinking that EHR was a very powerful tool that could transform care.  I didn’t pine for the days of paper charts (whatever they are).  I certainly didn’t mind it when I got the check from the government for doing something I had already done without any incentive.  What changed was my belief that government incentives could make things better. They haven’t.  In fact, they’ve made things much worse.

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Finding a Good Doctor – A Doctor’s Notes

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By ROB LAMBERTS, MD

My in-laws are in town for my daughter’s graduation.

When I came home yesterday I was greeted with a big smile and vigorous handshake from my father-in-law.  ”I just want to thank you,” he said, standing up from his chair, “for finding us a good doctor.  The one you found for us is wonderful.”

My wife smiled at me warmly.  I just earned myself big points.  Yay!

Her parents and mine are both in their 80′s and are overall in remarkably good health.  When I called my father after he had a minor surgery over the summer, my mother told me he had a ladder and was “on a bee hunt.”  It’s a blessing to have them around, especially having them healthy.

My parents have a wonderful primary care physician, which takes a whole lot of pressure off of me to do family doctoring, and puts my mind at ease.  I’ve only personally contacted him once when my dad had a prolonged time of vague fatigue and body aches.  I try not to use the “I’m a doctor, so I am second-guessing you” card that I’ve had some patients’ children pull.  I called his doctor more as a son who wanted a clear story about what was going on than as a physician with thoughts on the situation.

“I first want to say that I am very grateful my parents have gotten such good care from you,” I said at the start of the conversation.  ”It’s nice to not have to wonder if they are getting good care.”Continue reading…

Z-Packing

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By Rob Lamberts, MD

It was during my residency that the first indication of heart toxicity of antibiotics affected me personally.  The threat was related to the use of the first of the non-drowsy antihistamines – Seldane – in combination with macrolide antibiotics, such as Erythromycin causing a potentially fatal heart arrhythmia.  I remember the expressions fear from other residents, as we had used this combination of medications often.  Were we killing people when we treated their bronchitis?  We had no idea, but we were consoled by the fact that the people who had gotten our arrhythmia-provoking combo were largely anonymous to us (ER patients).

Fast forward to 2012 and the study (published in the holy writings of the New England Journal of Medicine) that Zithromax is associated with more dead people than no Zithromax.  Here’s the headline-provoking conclusion:

During 5 days of therapy, patients taking azithromycin, as compared with those who took no antibiotics, had an increased risk of cardiovascular death (hazard ratio, 2.88; 95% confidence interval [CI], 1.79 to 4.63; P<0.001) and death from any cause (hazard ratio, 1.85; 95% CI, 1.25 to 2.75; P=0.002).  Patients who took amoxicillin had no increase in the risk of death during this period. Relative to amoxicillin, azithromycin was associated with an increased risk of cardiovascular death (hazard ratio, 2.49; 95% CI, 1.38 to 4.50; P=0.002) and death from any cause (hazard ratio, 2.02; 95% CI, 1.24 to 3.30; P=0.005), with an estimated 47 additional cardiovascular deaths per 1 million courses; patients in the highest decile of risk for cardiovascular disease had an estimated 245 additional cardiovascular deaths per 1 million courses. (Emphasis Mine).

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Shame

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By Rob Lamberts, MD

I saw a gentleman in my office recently.  He was having severe pain radiating from his lower back, down to his calf.

I was about to describe my plan to him when he interrupted me saying, “I know, Doc, I am overweight.  I know that this would just get better if I lost the weight.”  He hung his head down as he spoke and fought off tears.

He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds.  On the other hand, I don’t know of any studies that say obesity is a risk factor to ruptured vertebral discs.  Besides, he was in significant pain, and a lecture about his weight was not in my agenda.  I wanted to make sure he did not need surgery, and make him stop hurting.

This whole episode really bothered me.  He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him.  He was living in shame.  Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character.  After all, losing weight is as simple as exercise and dietary restraint, right?

Perhaps I am too easy on people, but I don’t like to lecture people on things they already know.  I don’t like to say the obvious: “You need to lose weight.”  Obese people are rarely under the impression that it is perfectly fine that they are overweight.  They rarely are surprised to hear a person saying that their weight is at the root of many of their problems.  Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.

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Behind the New Autism Numbers

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By Rob Lamberts

Yes, I am going to talk about…autism.  The last time I did so I was inundated with people trying to convince me of the dangers of immunizations and their causal link to autism.  I really, really, really don’t want to go anywhere near that one.

No, I am not going to talk about the cause of autism; I am going to talk about my observation of the rise of the diagnosis of autism, and a plausible explanation for part, if not most of this fact.  The thing that spurs me to write this post is a study by the CDC which was quoted in the NY Times:

The new report estimates that in 2008 one child in 88 received one of these diagnoses, known as autism spectrum disorders, by age 8, compared with about one in 110 two years earlier. The estimated rate in 2002 was about one in 155.

The rise in numbers is cited as one of the main evidences for some external source – a new thing in our environment – that is causing this rise.  The article, however, gives another clue:

The frequency of autism spectrum diagnoses has been increasing for decades, but researchers cannot agree on whether the trend is a result of heightened awareness, an expanding definition of the spectrum, an actual increase in incidence or some combination of those factors. Diagnosing the condition is not an exact science. Children “on the spectrum” vary widely in their abilities and symptoms, from mute and intellectually limited at one extreme to socially awkward at the other.

Children with such diagnoses often receive extensive state-financed support services — which some experts believe may have contributed to an increase in numbers.

That last sentence holds the golden ticket.  What would make me think this?  My experience.

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Patient Rights

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By Rob Lamberts

I was talking to a patient a few days ago who was raving about a local grocery store.

”They get it,” she said. ”They understand how to take care of their customers.”

It made me think about how far medicine has drifted away from the same idea. Ironically, despite the fact that our “customers” (people who pay us for our services) are seeking us so we can “take care of” them, we do a lousy job of taking care of our customers. It has been an obsession of mine since I started practice, but it has been something that has been increasingly difficult to accomplish. I now have to fight against the need to meet “meaningful use” criteria so that I can have time to make the record meaningful and useful to my patients. I have to fight against the need to conform to “medical home,” criteria so that I can make my practice the place my patients see as their ultimate medical haven.

The more the government and insurance industries push me toward focusing on my patients, the less time I have for my patients because of the need to meet criteria proving that I am caring for my patients. It’s a mess.

So I went back to my roots. What do I really think should be the rights of my patients? Here is a list that I made:

Patients have the following rights:

The right to have access to care when it’s needed
This does not mean the care is done in the office either. It can be done over the phone or via computer.
The schedule of the office should accommodate the patients’ needs as much as is reasonable to expect.
The right to have care that is convenient
They should not have to wait to be seen or wait on the phone to be heard

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Meaningful Meaningful Use

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By ROB LAMBERTS, MD

Quiz:

What does the term “meaningful use” mean?

a.  Using something in a way that gives life purpose and leads to carefree days of glee.
b.  It depends on your definition of the word “term.”
c.  It is not mean.  It is really nice.
d.  A large number of rules created by the government to assess a practice’s use of electronic medical records so that they can spur adoption, give criteria for incentive rewards, and have physicians in a place where care can be measured.
e.  Job security for those making money off of health IT.

The answer, of course is d and e.

Meaningful Use, in the eyes of many is seen as curse words, especially doctors.Continue reading…