Politics in the Exam Room

An ancient maxim  of dinner party etiquette, which  I believe has been proffered  from more than one source,  is “never discuss politics, religion or sex in polite company”. In some ways, for me as a physician, entering the exam room with a patient seems to require some similar degree of discretion. But the consequences of straying outside the bounds of polite discussion in the doctor’s exam room are quite different from any awkwardness that might ensue after a social misadventure.

Dr. Henry Lee, the well-known Connecticut State forensic medicine expert likes to relate a tale of his own introduction to dinner party etiquette, which I will try to relay somewhat faithfully. His English was poor when he arrived in the U.S. and, invited to a party in which guests were seated in the traditional “boy-girl-boy-girl” arrangement, he knew he would be pressed to make conversation with the women on each side of him. A friend reassured him, “You’ll have no problem if you can just get the woman talking about herself and then all you have to do is listen politely. Simply ask  ‘Are you married?’ and then ask “Do you have any children?’. This should get things going just fine.” Armed with this strategem, Dr. Lee was seated and turned to an attractive young woman on his left and asked if she was married. She replied “No”. So of course, he went on to the next question, “Do you have any children?”. He was surprised when she reacted with a look of indignation and quickly turned her attention to the guest on her other side. Puzzled at her reaction, he surmised that he must have gotten the sequence out of order. Trying out the other way around, he turned to an older woman on his right and asked confidently if she had any children. “Three!”, she replied happily. Delighted with his progress, he then inquired if she was married. Dr. Lee says he spent the dinner conversing with his soup and salad.

I have also had exam room encounters come to grief because of sex, politics and religion, but nothing has caused me more regret than politics. I will explain.

Sex is not taboo. In fact, it is something I am expected to inquire about as part of the medical history.  A sexual history is essential if one is concerned about infectious diseases, reproductive health, domestic abuse, and even what drugs are prescribed and which are proscribed. I was taught even back in the dark ages of medical education in the 70′s that one should take a careful “non-judgmental” stance in taking a history. Students are taught to ask first, “Are you active sexually?” If the answer is yes, we ask “Do you have sex with men, women, or both?”. Then the question is asked in a way that allows the patient to discuss past behavior that he or she might be ashamed of: “In the past, did you…?”

Nonethless, if at all possible, I avoid asking about sexual activity as part of a history unless it is essential to the diagnosis. Why? Because I have only so much time to see the patient, and time spent on sex is time lost to discussing bowel habits, which is essential if you are a gastroenterologist. A few years ago it was found that women with irritable bowel syndrome (IBS) have an increased incidence of childhood abuse, emotional or otherwise. We were encouraged to add that element to our discussion about emotional factors in IBS.  I found that a colleague at the other practice in our hospital added that question to his interviews, at least for a time, because I had the pleasure of having to review the charts of several of his former patients who took offense to that line of questioning. Even if sexual abuse was an easy topic to discuss, I would not want to go there. If I did I would have become a Freudian psychiatrist. It’s tedious enough as it is, listening to detailed descriptions of stool from people who think they are suffering from a rare and unusual type of excretory syndrome, not to add to it tales of childhood trauma.  In sum, discussions of sex are appropriate in the exam room, but I avoid them because they take too much valuable time.

On the opposite end of the scale, religion is no problem because it is rarely a necessary aspect of the medical history unless it has some bearing on dietary habits. I like to know if my patient is a Hindu and follows a vegetarian diet. If my patient is a worried older Jewish woman, I like to blame her symptoms on having eaten trafe (spelling?), i.e. non-Kosher food, just to get a laugh and break the ice. But as far as I know, the Presbyterian diet is not too different from the Episcopalian, and beyond that I really have no interest. I never bring up my patient’s religion unless it is germane to our discussion, as in “Are you certain your communion wafer is gluten-free?”.  Occasionally a patient will ask me if I happen to be Jewish. When I say “Yes, although not very observant.”, they will sometimes even betray that they subscribe to an old prejudice that is as amusing as it is false: “Jews make the best doctors, you know.” I reply that good doctors come in all shapes, sizes and colors. So much for religion.

But politics in the exam room, that’s a pitfall and a booby trap that makes me wary as soon as I sense the subject is about to come up! I try to avoid politics whenever I can, because it is the biggest time-waster of all when it comes to getting through my day. It would only take three minutes per patient to set me back 30 minutes by the end of the morning, and that would be in addition to the extra 5 minutes taken up by additional unexpected complaints and reports about my patients’ jobs, families, social lives and other circumstances which are the glue that holds our relationships together in a way that simply prescribing medications cannot. Keeping on time is already a challenge I have described in my last post, and politics is yet another impediment.

Even so, politics comes up. Mostly it is because my patients want to know my political opinion. They especially want to know what I think about medical care and how our elected (and don’t forget, appointed!) officials are handling it.  Many of my patients want to discuss “Obama-care” and my attitude toward how it will affect me, although I think their concern is  how it will affect our relationship. Some of my patients want to discuss “socialized medicine”, or how care is delivered in Canada. Some just want to know who I plan to vote for, or who I think will win the Republican primary. Maybe they want to get to know me better, or maybe I am the first person they have encountered since they read the morning paper and they want to air their strong feelings about who said what.  Whatever the reason, if I allowed myself to be drawn into political discussions, my schedule would be an even greater disaster than it often is.

Suprisingly, many of my patients assume my politics are conservative because I am a doctor. Because so many doctors are Republicans they assume I am too. Many patients assume that I am fiercely opposed to socialized medicine, since surely I don’t want to be told how to practice or what I can earn. Some people even presume that I must be angry at the government laying claim to such a large share of my income.  When they bring it up, I never hesitate to tell them that I think the financing of medical care in this country is a disgrace and we should have a single-payer system.  Some people react with shock. A doctor in favor of socialized medicine?!  I confess, when I get that reaction I take a certain amount of malicious amusement in following up by a provocative statement such as medical care in Canada has a great deal to recommend it and we might be better off here if we adopted such a system.  I am especially amused at the story of the Tea Partier who held up a sign at a rally two years ago, “Government Hands off Medicare!”. For all its faults, I tell my patients, Medicare is the most generous insurance plan out there. Why not extend it to everyone? Of course, we would have to control utilization. Upon hearing that, some of my patients seem almost apoplectic.

It doesn’t much matter whether my political opinions agree or disagree with those of my patient; either way it’s a sticky wicket. Some will be particularly eager to have a discussion especially if they find the least suggestion I share their beliefs. Who better to lend a sympathetic ear to your opinions on the absurdity of the term “death tax” than your doctor? After all, doesn’t he have  an intimate acquaintance with life and death? Who better to unburden your political prejudices to than the person who is paid and obligated to listen to your most intimate fears and anxieties about life? Surely your doctor would lend you a sympathetic ear, right?

Thus I have learned over the years that it is best to keep politics from intruding into my medical encounter, but recently I encountered a patient’s political views in a way I could not avoid. I was glancing through the letters-to-the-editor page of our local small town gazette when I came across a letter submitted by one of my patients who I have attended to for many years. He is a very pleasant, intelligent and appreciative gentleman in all respects and we have had many conversations about his career, family, hobbies and retirement pursuits. The letter was prompted by some issue about the town budget, if I recall correctly. I was dismayed to find it proceded to a reactionary and bigotted diatribe against immigrants, poor people, liberals, our President and his party, so laden with half-truths, vitriol and outright nonsense that even a Rush Limbaugh could not have concocted it! I could hardly believe it was written by my very same patient. I wondered immediately how that might affect the care I provide him in the future. Will I be less sympathetic? Will I unconciously skew my use of healthcare resources on his behalf? Will my advice regarding end-of-life issues be influenced by his views on the “right to life”?  Should I recuse myself from his care? But that would constitute a form of retaliation to someone who has entrusted me with his life, and what sort of person would I be if I only plied my skills with those I agree with? In fact, wasn’t it part of my Hippocratic oath not to be swayed by such considerations?  I have a few times cared for criminals and felt as though I was doing my duty, and they presumably havve committed far more egregious offenses than were committed by my patient.

In the end I decided to file it away and never mention I had seen the letter. But my relationship will never be quite the same, in the same way that one might be put off to find that someone we respect has committed some act that betrays  that respect. Sometimes patients find that their doctors have feet of clay, but it is a rude shock for me to learn that my patient is not all the man I thought he was. I guess this is just something else I have to accept: I have to maintain my role as a healer regardless of whether I have contempt for a patient’s substance abuse, legal problems, sexual misconduct, or abhorrent political attitudes. Somehow the last one feels uniquely difficult today.

The Doctor Will See You Later…

Like most doctors, especially us subspecialists, I see my patients by appointment. For many reasons, some sensible and some foolish, our patients’ satisfaction seems greatly influenced by how long after the appointed hour they actually get to see the doctor. Many people think that we doctors care little for how long they have to spend in our waiting room. Nothing could be farther from the truth. Actually, I spend a great deal of my day thinking about just that. So I decided that the topic was worth a bit of contemplation and frank discussion.

Of course, there are other ways of allotting a physician’s time to achieve the greatest efficiency. Many primary care practices have taken to abolishing appointments altogether, relying on the “law of averages” that a large enough patient panel will generate a relatively stable volume of patient visits from day to day. In fact, this is not a new concept; many old time “G.P.’s” scheduling regimens consisted only of the rule of “first come, first served”. My late father-in-law, whose presence remains in my conscience years after his departure, had a busy general practice in Brooklyn. His office opened promptly at eight AM when he would return from his morning hospital rounds. His secretary/receptionist/medical assistant/office Czar would open the door at the strike of 8 to admit a queue of patients who were literally “presenting” themselves with their complaints. The beauty of the system was that the places toward the front of the line were usually occupied by those most deserving immediate attention, since those in the greatest distress usually had the greatest incentive to arrive earliest.

Priorities were assigned by the sign-in sheet and the waiting room would immediately fill to capacity. Everyone got seen eventually, sometimes after waiting two or three hours, without a grumble and with gratitude for the doctor’s seemingly inexhaustible capacity for the application of his healing art and his labor to their problems. I was not there to witness this, but my wife, who served as an office assistant during summers when she was in high school, tells me that there would often be 40 people crowded into the waiting room with half as many chairs. No one resented the wait, because they knew that there was no better doctor to be found in all of Brooklyn, NY than he. And I myself believe that to be true.

Fast forward to 2012. I have a morning full of procedures and some time to grab a bit of lunch, then start seeing office patients shortly after 1 PM. I allot 15 minutes for a follow-up visit for a GI patient, 20 minutes for my few remaining internal medicine patients, and half an hour for a new consultation. I rarely see more than 12 people in an afternoon. My encounters are punctuated by telephone calls from other doctors who I have left messages for to call me about patients we both care for. I am interrupted by calls from radiologists, pathologists, laboratory staff, nurses on the hospital floors, patients whose problems cannot wait until after office hours, and my own staff who need decisions made about day-to-day matters that can’t wait until I finish the patient encounters because some of the staff leave before that time. Even my wife, who tries not to bother me, sometimes calls on matters that can’t wait. Sometimes I am called to the hospital  or the emergency room to rescue patients who appear to be trying their level best to bleed to death from one orifice or another. My ever-sympathetic and saintly receptionist spends time mollifying the waiting crowd and offering her best E.T.A. (estimated time of arrival).

Meanwhile, during their time with me, the patients I see offer complaints that they failed to mention to staff when they made their appointment, or forgot about until they got in the exam room, or thought they would bring up only when they saw me.  The classic schedule-killer is known as the hand-on-the-doorknob remark: “Oh, by the way, Doctor, I’ve been getting these funny pains in my chest when I go out walking in the cold.”  So the 15-minute visit becomes 20. The 20-minute visit becomes 40. And the half hour consult becomes an hour. By the end of an afternoon, I am running an hour behind.

So why not just schedule fewer patients? For one thing, I am already having to defer or turn away people anxious to see me and me alone. I would have to delegate them all to my junior partner, who is himself harried,  or ask my primary care patients to find a new primary care doctor. Existing patients with urgent problems end up being “squeezed in” to the schedule at times. And yet not infrequently, patients fail to show up without the courtesy of even a phone call, leaving me unexpectedly idle, knowing that I will still be pressed to accommodate the people scheduled later in the session. Of course, I can use the “down time” to catch up on phone calls and paperwork, but every 15 minute slot that lies idle means some other patient has been made to wait longer than needed and I am bearing the cost of keeping an office open with a staff of 10 people and a large rent with no revenue to support that.

And if I am fortunate, I might find the time to make a few calls to attend to my own personal needs, such as my own care and maintenance and that of my family.

Many people seem to think that doctors have no regard or respect for their time. They write in smug tones in chat rooms about how they presented their doctor with a bill for the time they spent in the waiting room. Some take their delay to mean that I think I am more important than them. Some schedule other engagements an hour after their appointment time and expect to be seen by me in time to travel half an hour by car to get to them. Accustomed to getting a Big Mac and fries within 5 minutes of driving up to the order window, our patients sometimes fail to comprehend that my office is not on par with a McDonald’s restaurant. (No disrespect; I envy their efficiency.)

I see Medicare beneficiaries in their 80′s who are indignant that I am keeping them from their important pursuit of watching their favorite television show.  Some older patients retain a great respect for the healing profession and make no complaint but others, perhaps disinhibited by their age, are downright rude.   My wife has a theory that some older patients, even though they have no pressing tasks that I am keeping them from, are annoyed that I have wasted the dwindling time they have remaining on this earth.

Not everyone is put out by waiting to see me. Occasionally, I do encounter patients who conclude from their long wait that I am very busy and thus I must be a very good doctor. Many of my patients have learned to bring a book. The e-reader has been a boon to quite a few. Others relish the chance to read trash magazines and celebrity weeklies they would otherwise not feel a legitimate use of their time. I find some patients happily doing crosswords, Sudoku or checking email on their smart phones when I enter the room.

I assure you, I am mindful of my patients’ concerns and their own oftentimes equally busy schedules.  There is no satisfaction in entering an exam room an hour after the patient’s appointment time to find him or her tapping her feet, looking immediately at her watch, and then at me with a sullen stare or daggers in the eyes. The bolder folks verbalize their frustration or annoyance immediately; others say nothing but are clearly resentful enough to be distracted from getting down to business for the first few minutes.  A colleague described the feeling as “fighting the clock” all day long. Another tells his patients, “I’m pedaling as fast as I can!” I usually tell people immediately that I recognize that they have been waiting a long time or I apologize and explain the reason. Sometimes, though, when the patient remains unforgiving and I am running way behind and feeling overly harassed by demands from all sides, I am tempted to say, “I can do it fast or I can do it right! Which do you want?!” I never say it but I often think it.

But I will be honest: I could arrange it so that no one would ever have to wait more than 5 minutes to see me. I would schedule an hour visit for each patient and allow half an hour between visits for miscellaneous eventualities. I would see 6 patients in a day. I would dismiss 90% of my existing patients and see only consultations. I could see people only at their initial consultation and hire a physician’s assistant to see every one for their follow-up. I could take a huge pay cut. Or I would charge each patient 4 times as much and not accept insurance.  Don’t think it hasn’t been tried! Some primary care doctors have formed “concierge” practices. They offer their services on retainer for a sum of several thousand dollars yearly and limit their panel to no more than 250 well-off people. But clearly this would not work for the vast majority of Americans occupying the “99%” status in the economy.

I could see my 6 patients a day for the same fees that I now receive. I would still be working an eighty hour week including nights and weekends and simply content myself with the income of the average starting mail carrier, only without pension or health benefits provided to me by my employer, instead having to fund these entirely on my own.

Even then, at the end of the day, if all of us doctors decided to practice that way, we would find that the supply of doctors is grossly mismatched to the demand, and people would not have access to care without waiting months, except for the few who could afford to pay large sums out of pocket.

Which is why my discussion, like many discussions of healthcare in the U.S., ends up leading to one fundamentally about money. What kind of healthcare delivery workforce can we afford? How do we balance quality and quantity? Do we ramp up our medical schools to turn out 4 times the number of trainees we do now? We might be able to do this in a decade or two with a crash program, but unless the government is prepared to make medical education free, most will graduate with over a quarter million dollars of indebtedness, and how many of us would make a bargain to start our career at age 33 on the salary of the average postman only without the benefits. OK, so do we make the training free and pay every doctor a good salary commensurate with the many years of hard work and study and deferment of life’s pleasures? Get ready to ante up, folks, because there are some 600,000 of us last time I counted, and if we had 2.5 million doctors earning $200 K yearly, that’s $500 billion yearly in salary. Five trillion in a decade? So much for balancing the federal budget.

OK, so we train a whole bunch of what are sometimes called “health care extenders” or “providers”. You don’t get to see the doctor unless someone realizes you might just have an out-of-the-ordinary disease or you are clearly dying. Otherwise, an APRN or PA will be your provider. They seem to be content with salaries in the $100 K range, knowing that they can work 9 to 5 or if not strictly a day job, at least a guaranteed 40-hour work week, maybe a few 12-hour shifts sometimes overnight. Mark that cost down from $500 billion to only $250 billion yearly, assuming we retire most of the doctors.

Oh, but by the way, a lot of us doctors are going to retire in the next decade. To begin with, we have a disproportionate number of “baby-boomers” in our ranks who are now approaching a retirement age of 70 or so. (Used to be 65 but the recession did a number on a lot of people’s pension plans, so they will still be working a while longer, but not forever.) And the latest news is that Congress is planning to cut our reimbursement for seeing Medicare patients by about 25% as of January 1. They usually rescind the cut by March but this time they supposedly mean business. A lot of doctors will decide they can no longer make a decent living practicing with a quarter of their revenue lost coming from the patients who lay claim to the greatest amount of their time. Some will just stop caring for Medicare patients. Some will only allow time to address one problem per visit and have you return every other week if you have multiple problems. I may be able to continue subsidizing my office practice with reimbursement for procedures, which is only being whittled away more slowly.

So if you think you are waiting too long to see the doctor, don’t worry. Soon you will be waiting just as long to see the APRN. But if you can’t stand waiting, I hear there are now some web sites where for a fee, you can chat with a real doctor. Maybe I’ll try my hand at that next.

There has GOT to be a better way to allocate doctors’ time. I plan to reflect on solutions in another post.

The Last Six Months of Life: The Last Place to Look for Savings?

This discussion was inspired by the two women I owe my  life to: my mother and my wife.

I cannot identify the citation for this factoid, but the assertion has become engrained in the lore of medical urban myth: “50% of healthcare costs are incurred in the last 6 months of life.” (or some similar figure)  There are other less arresting but more concrete statistics to be found. For example, according to Health Affairs,  July 2001  vol. 20  no. 4  188-195, one quarter of Medicare outlays are for the last year of life. Another more recent discussion concerned the various factors that influence that spending in the last 6 months. An article in the Annals of Internal Medicine for February 15, 2011   vol. 154 no. 4   235-242  describes determinants of healthcare spending and points out that regional variation in medical care does not account for as much variation as is sometimes pretended.

A concise summary of that article by one consulting firm states “Individual characteristics such as black or hispanic race, severe functional impairment, having Medicare Supplement coverage, suffering from certain chronic diseases or from four or more, were associated with higher spending.  Others, such as having a relative live nearby or having dementia, are associated with lower spending.  And some, such as having an advance directive, sex, marital status, education, net worth, or religiosity, appeared to have no relationship.  Altogether, patient characteristics account for 10% of the variation in spending in the last 6 months of life.”  (Quoted from Kevin Roche at vitaadvisors.com)  Yet even with all this taken into account, patient and regional factors accounted for only 15% of the variation.

There seems to be a major subtext to all of this discussion about the last six months of life, whether the topic is cost, ethical issues, quality of life, or whatever. The unstated message is “WE ARE WASTING MONEY ON FUTILE CARE!”.  The implication seems to be, “couldn’t we devote these scarce medical resources to more beneficial use?” and “Why are we prolonging suffering and poor quality of life at such great expense to so little gain?” I ask myself these same questions whenever I walk down the corridor of the ICU to see a consult, past room after room of people on ventilators, bloated, mittened and tubed beyond our ability to recognize them as the same individuals seen in the photos I sometimes see pasted to the wall opposite the bed. “Don’t we know”, I ask,  ”when to cease and decist?”

But how DO we know when it is time to cease and decist?. My wife recently posed the question another way. She pointed to a commonly ridiculed question : “Why do you always find things in the very last place you look?” ”Well, stupid,” is the rejoinder, “because you stop looking after that!” But, she observed, the question really contains an ellipsis: you find things in the last place you think to look. And viewed that way, it is an entirely sensible question. Retrospective data from Medicare rolls are all well and good, but it is entirely different matter  forecasting when to start that 6-month countdown clock ticking!

The question was brought home to me when last spring my widowed mother at age 85 went into acute congestive heart failure after rupturing a mitral valve. At first it seemed a simple matter: a minimally invasive repair by a trusted cardiac surgeon at a nearby hospital known for cardiac care. But a pre-operative angiogram revealed a 95% narrowing of her left main coronary artery. Minimally invasive was no longer an option. She needed valve surgery AND a bypass graft. My mother was not medically sophisticated enought to weigh risks of surgery versus anticipated length and quality of life, even without the further impairments of disorientation during a 48-hour sojourn in the ER holding unit awaiting a bed. So the call was essentially mine.

I am not a surgeon, but I am a great believer in seizing the opportunity that surgery affords us to cure what can only be palliated by medications. I knew the quality of life and the prognosis with a flail mitral leaflet was not a good one.  I told my mother and her surgeon, “Go for it!” Mom was really too confused to argue or question.

The surgery was more complicated than anticipated; she needed a reconstruction of a myxomatous degeneration of one leaflet (i.e. there was nothing even left to sew back together) using Gor-tex. The surgeon assured me she would be  off the ventilator in a few days. Instead, she spent 3 weeks in the surgical ICU relying on what lay people refer to as “life support”. There was nosocomial pneumonia and central venous catheters. She was delerious and fighting the vent and the nurses for much of that time. When she was coherent again but still not able to be taken off the breathing machine, she wrote on the pad I held for her “What am I doing here? Why are these nurses torturing me? These tubes are killing me! Why did you do this to me?  I can’t take more of  this!”

More than once during those 3 weeks, my wife asked me, “David, are you sure you did the right thing?” Even her brother, a research cardiologist with advanced angiographic skills, asked me if I had not been overly agressive in pushing her into surgery. My confidence did not waver. I told them I have seen many patients sicker than her spend twice as much time in ICU’s on ventilators and return to my exam room after their ordeal, their health restored and their loved ones grateful.

My mother did recover, albeit very slowly. Six months later she is now living in a one-bedroom apartment at a wonderful assisted-living community nearby. She is happier and leading a fuller life than she was before the surgery.  We received the Explanation of Benefits from Medicare a month after her hospital discharge. The bill was $300,000. (Of course, that was retail. Medicare pays the hospital a substantially lower fraction of the list price.) Last time I went to visit her, I couldn’t find my mother anywhere in the faciltiy; she blithely told me later she had gone for a walk. Perhaps my mother will enjoy another 5 or 10 years.

Was it worth the cost? If you ask me, emphatically, yes! But what would we all have said if one complication had followed another and her course had been inexorable deterioration and ultimately a decision to halt aggressive care. It could have easily turned out that way. We would all bemoan the futile waste and  unnecessary sufffering for a patient in the last six months of her life.

My point is not that we should always be aggressive in caring for the elderly and the chronically ill. The point of the story is that we have such inadequate means of predicting who shall live and who shall die. Some patients like to say it is all in the hands of God and we have no way to do so. (“who by fire and who by water, who by war and who by famine…”) But my tradition urges us to pray as if all depends on God but act as if all depends on us. My argument is that we can and we must devise better prognostic measures, to guide us in our advice to patients and their families and to inform their decisions along the course of an acute illness.

Which brings me back to the question with which I began this essay: can we save money and precious resources with such tools? Suppose we could predict the likelihood of survival within 5 percentage points of confidence? Suppose we could tell the family, “Grandma has a 20% chance of surviving this hip fracture, pneumonia and sepsis and a 7% chance of returning to a normal existence”. Would there be less futile care? I’m not so sure.  There are so many ethical, cultural and economic factors involved. At my hospital, I am accustomed to seeing rooms occupied by an extended family keeping vigil over a clearly moribund loved one and upon leaving the room I am assailed by the relatives: “Doctor, isn’t there anything more you can do??”. Families cling to hope and reject any suggestion of “comfort measures only”. They even have paralyzing disputes over these issues.

So unless we are prepared to exert some control, i.e. dare I say it, “rationing”, it will take more than good prognostication to provide rational, efficient, safe, sane and humane allocation of scarce human and monetary resources. The furor over the imaginary “death panels” concocted by reactionary Republicans illustrates the political problems inherent in such efforts. Maybe it’s time we change the terms of discourse and start talking about “life panels”. My wife says wants to know how she can join one; she has a few acquaintances she might want to weigh in on the deliberations. I never cease to marvel at her resourceful talent for devising ways to save money!

What Doctors Think, Part 1

A number of years ago, Dr. Jerome Groopman published a wonderful book for the benefit of patients and their physicians, entitled How Doctors Think. It is an excellent description, illustrated by anecdotes, of the cognitive processes by which doctors arrive at diagnoses, and the pitfalls that are inherent in such calculations owing to the inherent strengths and weaknesses of human thought processes. For example, our tendency to consider conditions that we have seen recently, or those for which can easily imagine examples, is one habit discussed in some depth. It is a fascinating read (or in my case, listen, as I heard it on a CD in my car over the course of a couple of weeks.)

So Dr. Groopman has exposed well how doctors think. But how often do we reveal just what we are thinking? No more often, in my opinion, than we reveal our inner thoughts to friends and relatives in our personal lives – and in fact, considerably less often if we value our professional success. We occasionally let slip our attitudes in a moment of carelessness, a gesture, or the infrequent loss of temper. But for the most part, we try to embody the ideal of “equanimitas” that was advocated by one of our icons of modern medicine, the great doctor William Osler. There have been many learned treatises on this quality as to its benefits to a physician and his patients, and I have little of great insight to add on that topic.

But wouldn’t it be nice to occasionally allow ourselves to express what we really think?  I always enjoy arriving home  - usually somewhat later than I promised – to relate some of the triumphs and tragedies of the battles of the day. And this, of course, is when I get to say what I really think. It has occurred to me that I might even collect enough material to publish my own book, What Doctors Think.  My wife suggested an alternative or a sequel entitled Do Doctors Think? I am choosing to ignore the suggestion for the purposes of this post.

I recently receive a letter from another specialist I had occasion to consult. It was an excellent evaluation, clearly dictated, and in a style not yet of the computer-generated boilerplate type that is becoming commonplace now that the electronic medical record is taking hold. It began with a “thank you” for the referral, a glowing description of the “delightful” character of the patient, and ended with another expression of gratitude for the opportunity to assist in her care. In other words, the same sort of letter I always send to my referring physicians. It struck me, as it always has, how stereotyped these phrases are, so that they, too are really just insincere pleasantries. I am especially amused when I know full well that my patient is anything but delightful and his next visit with my consulting physician will not likely be greeted with delight. The fact is, we all need to be stroked, and being commended for sending a patient will very much increase the likelihood that I will send another. Of course the converse is true. It led me to wonder what sort of letter I might write if I truly expressed my opinion.

So during a tedious session at my laptop during a weekend getaway marred by bad weather, I found my mind wandering from the editing of office notes and reviewing of labs I was doing remotely. In a moment of malicious glee, I started to compose the following consultation note as a parody of everything I have ever been tempted to dash off to my referring physicians. It soon finished itself. For the non-physician readership, please be advised that the following does not represent the actual views and attitudes  of the writer, the American College of Gastroenterology, the various instituitons that will disavow any connection with me, or those of the medical profession in general.

Dear Jerome,

I am not sure how to  thank you for asking this most unpleasant gentleman to see me for colorectal cancer screening. So I won’t.

Although the patient appears to be entirely well, he offers a litany of gastintestinal complaints that might not have occupied me for the better part of an hour had he not had an unfortunate tendency to veer of onto other concerns both political, economic and pertaining to the general state of mankind , not to mention the unfair manner in which the world has treated him personally.   Even after returning to the topic of his GI tract, I was unable to determine whether he was magnifying the  severity of his symptoms, except in regard to his complaint of excessive flatulence, which became more and more verifiable as our interview proceeded.

The past medical history was obtained with some difficulty, the patient insisting that there was nothing really wrong with him and all of his current diagnoses had been made up by the 6 or 7 previous physicians who had attended him, none of whom was fit to care for his cat.

His medication list  consists exclusively of herbal and natural remedies that he is prescribed by his chiropractor, naturopath, personal trainer and his reiki therapist. He insists that they have done him more good than that penicillin some quack he recently saw had wanted to give him for some imaginary condition, that he thinks was called “STD”.

He reports having had allergic reactions to cortisone, prednisone, benadryl and all foods that begin with the letter “R”. He is intolerant but not allergic to foods that conclude with the letter “L”.

He has a 40 pack-year smoking history which he incurred during his 2-year stint in the Congolese mercenary army; he no longer smokes. He proudly informs me that his alcohol intake has recently diminished to only two 6-packs of beer a day at the advice of his naturopath, who has sold him an amazing product that when consumed at 3 quarts daily has had a miraculously salutory effect on diminishing his capacity for beer.

The surgical history includes traumatic amputation of the right 3rd digit in a barroom accident, multiple fractures of  the lower extremities, and a circumcision that occurred in the course of his 9th and most recent sexual relationship.

The family history is largely unavailable, as he is estranged from his parents, his siblings, his children, and a large number of people who only vaguely remind him of other family members.

The social history is significant. Although the patient stated he was unemployed and unmarried on our intake form, he was accompanied in the exam room by two young women who appeared to be under the age of 16. Also noteworthy is that he has no insurance and insisted on paying in cash, but only after inspecting our waiting room and my exam room as if he was looking for something.

Physical Examination:

The vital signs were unremarkable except that we were unable to weigh the patient due to his inability to balance himself on the scale.

He is a somewhat easily distracted gentleman in no acute distress who was found looking through the supply drawers when I entered. He appeared resentful and malodorous. He is wearing an exam gown over his clothes.

HEENT: Muddy sclerae and muddy cap with logo “I’m with stupid”.

Neck: Unable to find

Chest: Dullness with diminished breath sounds due to increased soft tissue. When asked to inhale he had to be reminded to exhale as well.

Heart: Sounds obscured by scratchy noises from hair on chest during respiration and patient insisting on speaking during exam

Abdomen: Upon lifting pannus it revealed a bottle cap and  a large cast brass belt buckle showing a pair of young female silhouettes back to back.

Genito-urinary: deferred and denied

Extremities: Tattoos on the extensor surfaces of proximal phalanges spelling “Joann” on the left hand and “Tr_sh” on the right. (missing letter and finger; patient says it was an “i”). I decided against having him remove his boots.

Skin: Multiple tattoos some of which appeared to have been professionally done but distorted by body habitus.

Neurologic: Sluggish pupils and sluggish in general. Startled easily by ring-tone on his phone despite 3 signs in room asking patients to place their phones on vibrate.

Impression:

This gentleman has attained the age of 50 years in spite of multiple risk factors for death by tobacco, alcohol, firearms and trauma, and one might argue that having navigated circumstances that would have put a period to a less fortunate soul, he can only be described as “lucky” and therefore in need of no preventive measures. Guidelines do, however, call for colorectal cancer screening  at his age. On the other hand, one might also argue that the patient’s pre-test probability of demise in the next 10 years is great enought that his post-test probability would not be significantly affected by cancer prevention. On the other hand, if I recommend against doing a colonoscopy, I am sure you will refer him to some other gastroenterologist who will  be happy to do one. Thus, the benefits for me of the procedure greatly outweigh the risks to me. I am not greatly worried about the patient’s risk, as it is well known that God protects children, drunkards and fools.

 Recommendations:

I have discussed the rationale for colorectal cancer screening and the benefits, alternatives, techniques and risks of colonoscopy in detail, including but not limited to bleeding, infection, perforation, surgery, colostomy, stroke with temporary or permanent loss of function, heart attack, death, aspiration pneumonia, drug allergy, phlebitis, motor vehicular accident due to absconding after the procedure having falsely claimed to have a ride home,  need to reschedule as a result of factors such as failure to follow prep instructions with inadequate prep, blizzard, hurricane, earthquake, other acts of God, spontaneous combustion, and The Rapture. The patient had an adequate opportunity to ask questions. His only inquiry was, “I’m not going to know nothin’, Doc, RIGHT!?” Accordingly, a procedure has been arranged.

I can only hope that the next patient you send this way will offer me the  honor and a privilege of participating in the care of a somewhat more pleasant gentleman.

Sincerely,

David M. Sack, MD

I can’t wait to hear back from my referring physicians what they really think of my consultation notes!

The Cost of Medical Malpractice: Part 2

My last post was about medical malpractice and what it costs us in dollars. This time I want to take up a different cost: the human one. This post is not going to be easy.

As a physician, being sued for malpractice is a concern that enters my mind at least fleetingly on a daily basis. A recent article from the the Aug. 18 issue of the New England Journal of Medicine is being widely quoted. Surveying claims data and a national databank of malpractice data, the study reported that by the age of 65 years, three quarters of doctors in “low-risk” specialties had faced a malpractice claim, and nearly all physicians in high-risk specialties had been exposed. They estimated that nearly half of us would be sued by the age of 45 years. Each year, an average of 7.4% of physicians had a malpractice claim filed against them. But according to the study a little more than three quarters of all claims did not result in payments.

The threat of medical malpractice suits has an incalculable effect on the way doctors practice medicine in this country.  I have already talked about the numerous unnecessary tests ordered by doctors practicing “defensive medicine”. I have already talked about the way in which we are advised to obtain “informed” consent by scaring our patients  half to death just by discussing every conceivable risk of even the most minor intervention. But I have not talked about the profound effect a malpractice suit has on the individual who is sued and the ripple effect it has on his patients. This post is about the effect it has had on me.

I am in what might be considered high-risk specialty.    In other words, if I make a mistake somebody could conceivably be seriously injured or die as a direct result .  Fortunately, such opportunities are a rather small part of my professional life in the same way that although driving to the grocery store is not considered a high-risk activity , there is always the possibility of going through a busy intersection and making a monumentally wrong maneuver and killing someone.   In specialties that consist mainly of prescribing medication , medical misadventures are rarely immediately apparent, whereas in procedural specialties such as my own it becomes quite obvious if there is a mishap.  So it is  inevitable  that someone like me will eventually be sued for malpractice. I don’t think about auto accidents much, perhaps because I have thus far been lucky enough not to be in one. That was my attitude about malpractice.

A few years ago I was named in a suit involving a patient whose care I participated in and who had an “adverse outcome”. She died. In spite of two years of diligent testing, and treatment by her physicians, we failed to recognize one of the less common but serious health consequences that her particular habits had led to. The patient’s family blamed the primary care doctor, the consultants, and the first surgeon that was called to treat her.   Perhaps all would have been forgiven if the second surgeon involved in the case, by which time the diagnosis was quite obvious in hindsight,  had not told the family ” if only they had sent the patient to see me sooner I could’ve done something “. I don’t think any of us was negligent or did not live up to the “standard of care” but that is what we were sued for.

I had never been sued before. I had attended a number of seminars over the years on how to avoid being sued when there is an adverse outcome.    One of the most frequently repeated messages was the importance of maintaining a good relationship with the patient’s family.  Numerous examples were given of doctors who were sued only because they had made the patient or family angry even though their care has been exemplary.   There were numerous other anecdotes about patients who might justifiably have sued their physician but chose not to because they had a very good relationship .  I pride myself on nurturing my relationships with my patients, communicating well, and maintaining what patients usually call a good “bedside manner”. I even took what I now realize was a foolish pride  in the fact that I had never been sued.  I know now I had merely been lucky.

One day I was in my consulting room , in between patients, when my secretary buzzed in to say that there was a sheriff’s deputy there to see me.  I have occasionally been asked to provide legal documents for patients but on this occasion I couldn’t imagine what was the purpose of the visit.  I welcomed the gentleman into my office and his first words were “Doc, I’m really sorry because I have heard that you are really good doctor but I have to serve you with this.  “  He handed me a thick envelope and with a few further apologies promptly took his leave.  I opened it. Inside was an offical court document informing me that in essence, I was being sued for malpractice in the matter of a particular patient and a list of allegations  of various ways that I had failed to meet the standard of care  for doctors in my specialty.

Althouugh the implications are not nearly as serious,  the initial sequence of emotions one goes through on receiving such news is not unlike people’s reaction on learning that they have a diagnosis of cancer. I couldn’t believe it. I was shocked.  Then I was angry that I was unjustly “accused”.  But after that the sequence diverged from the Kubler-Ross “death-and-dying” progression. I didn’t bargain. I set to thinking about what I might possibly have done wrong or could have done differently in that patient’s care.  I engaged in self-recrimination. I was angry at myself for having allowed this to happen; I must have done something wrong.  This was the topic that was preoccupy me for the next few days and even weeks.  Like many doctors, I am perfectionistic and compulsive.  After all,  wasn’t I was one of the select few talented enough to be granted the honor of great responsibility? Didn’t I always get A’s?  I expect my work to be perfect, and although I don’t often consciously think it, I expect at some level that I will in fact earn a perfect score as a doctor.  It is a great blow to think that one might have injured someone because of having made a mistake.

Of course my first response was to notify the risk management office at my insurance company. The attorney in charge there gave me my first of many legal instructions: don’t discuss anything about this matter with anyone at all, not even – and especially – not the other doctors named. I was offered a list of defense attorneys to choose from.  I asked around as discreetly as I could and chose one well known to be a skilled defense lawyer. His first advice was: “Don’t discuss anything about this matter with anyone at all, not even…”

When misfortune strikes us, one of the greatest consolations is the emotional support we get from other victims. I would have yearned to compare notes with my colleagues who were also named. There were only two people I could look to for support whose testimony could not be discovered and presented as evidence for the plaintiff: my lawyer and my wife. Both were sympathetic and suportive. But only my wife got to share the emotional burden.  My wife has always been a fantastic cheerleader but I knew she was somewhat biased in my favor and so I did not feel completely bolstered by her encouragement. But that would have to do;  there was to be no support group of my peers.

The next step was a deposition. This is a legal proceeding where the attorneys get to question the potential witnesses about all aspects of their involvement in the case, including their knowledge of their specialty, the diseases involved, the nature of their practice, their credentials, their attitudes, and anything else that might conceivable have any bearing in a trial.  For the attorneys, it is like dealing the first two cards in a game of Texas hold’em poker. The information might be useful in a  trial, but it might also be useful in guaging the relative strenth of one’s oppenent and  bargaining to settle the case rather than go to court.

A deposition usually starts out with routine questions and works its way to the most critical examination of what actions or inactions are alleged to have been a breach of adequate care. As the line of inquiry proceeds, it becomes increasingly stressful. The aim of the plaintiff’s attorney is to get the doctor into a rapid-fire rhythm of responding to questions without careful forethought and to lure him into offering more information that was required to answer the question.  My deposition was definitely stressful. I had never been deposed. I was apprehensive. On the way there I kept thinking of the concluding scenes in an episode of Perry Mason when the guilty party succumbs to a withering cross-examination.  The deposition room proved to be a rather comfortable non-threatening environment. All were introduced and pleasantries exchanged.  The questions began. The opposing attorney was alternately pleasant and then condescending and pugnaceous. My lawyer called for “time outs” when he saw I was losing my cool. The session continued and broke for lunch. The questions became more and more critical  Finally, the plaintiff’s attorney shrugged and led me to think his questioning was concluded only to turn and say, “Oh, by the way…”.  Then came the really accusatory series of questions.  Somewhere along the way, it became clear that even if he was unable to get me to admit to some negligence on my own part,  there was a potential I could be called as an “expert witness” and compelled  to testify on behalf of the plaintiff that my colleagues had commited malpractice!  Among the emotionally stressful experience in my life, this one ranks well up there; I even find my pulse quickening just writing about it.

I returned home exhausted and relieved to have gotten through it. My wife offered me a Martini. I knew that the next step in the process was a trial, which was not to take place for some time, so I returned to the usual cares and pleasures of work and family. But there ware always occasional reminders of the situation that would hit me in the middle of my workday. And there was a definite change in my medical practice.

With every test I ordered and every drug I prescribed, a host of potential risks and side effects came to mind, even the remote ones, and I felt compelled to enumerate tham in a way I never did before.  My usual confidence in knowing the proper course of managment was shaken. I  began to view every patient I was trying to help as a potential adversary in a suit. I even began to look at each of my oldest patient relationships with different eyes. “I know this person loves and trusts me, but might they change their mind and sue me if I make a mistake?” I asked myself. An invisible emotional curtain descended between my patients and me.

I had previously had contempt for other doctors who seemed to be practicing defensive medicine. There was a colleague whose patients occasionally came to me for a second opinion or because they didn’t get along. I would review his notes and see how  he documented two paragraphs of all conceiveable risks and complications; I thought it was a completely misplaced sense of priorities.  My attitude changed; now I understood.  Now I found myself  ordering more CT scans and bloodwork. The radiology report that said “consider follow-up MRI to further characterize the lesion”, which I used to dismiss when it was clearly an artifact or an incidental finding, now merited that follow-up as recommended. After all, even if the procedure was expensive, uncomfortable, anxiety-provoking and the  chance one in a thousand that there was something serious there, why should I be the one to take the risk of a lawsuit.

I am sure my patients suffered from my experience during that time. I was more distant. I was depressed. I felt “burnt out”.  I was not my complete empathetic self. I put my patients through tests that were probably “overkill”. I did not spread optimism and confidence with every encounter. I left home in the morning not looking forward to the day and came home tired and unfulfilled.  Fortunately, I eventually got over it, but not for some time. Here’s  how:

Mainly, to my great relief, the suit never came to trial.  It was settled within the next year.  I don’t know what it cost my insurance company. My lawyer advised me it was in my best interest not to know for how much and what was my share of the settlement.  I also had to agree never to discuss the particulars of the case or the nature of the settlement with anyone, ever (except of course my attorney and my wife).  The emotional ordeal was over. That was when the healing started. But it still took months for me to get past some of the consequences of my experience.

And only now, a few years later, this is the first time I find myself able to discuss it. Was writing this post cathartic? No, not really.  I have already made my own peace with myself. But perhaps it will help someone else.

At least it can’t hurt??

One of the things that constantly amuses me is how frequently I hear from patients that their other doctor told them there was nothing wrong with them using this or that home remedy or so-called natural treatment or some other form of complementary or alternative therapy, saying “well, at least it can’t hurt.”   Coming from a medical professional, ostensibly having been educated in the scientific method and the value of randomized controlled studies, such remarks to me bespeaks a surprising degree of either naïveté, lackadaisical attitude, denial, or an  understandable wish to gain the patient’s trust and not to take away the placebo value of the treatment  that the patients feel to be helping them.  In my more cynical moments I sometimes suspect that the other doctor is really trying to dismiss the patient’s enthusiastic recitation of the vitamin or natural remedy that they are taking so they can get on with the office visit  without undue delay.

The first thing that I find so surprising about this is that  so few people imagine that something they believe capable of causing significant good would be capable of causing some harm or side effect.  Patients are very quick to ask if me there are any possible side effects or risks to taking medications that I recommend but they rarely ask if  there  could be any side effects to this or that vitamin or “colon cleanse” or “detoxifier”. Frequently they are under the misimpression that as long as something is “natural” that it must be safe.  My late father-in-law, who was a family practitioner in Brooklyn, used to become incensed at that suggestion.  ”Why, cholera is natural!”  he would exclaim.  He knew whereof he spoke as he had seen cholera epidemics firsthand in the ghettos of Poland. My family recalls fondly the shocked stares he drew when he expressed his outrage about this notion at the top of his lungs while shopping in the natural foods market in Berkeley California with my wife.

But the thing that I find most surprising is that so many of my colleagues do take it for granted that all of these complementary and alternative medications are probably safe simply because they regard them as placebos.  It seems to me a matter of logical necessity that anything capable of having an effect may cause either good or bad effects or both.  Yet when I point this out to my patients they usually respond with quizzical looks.  Then some of the more thoughtful ones see the point.  If I have the time I relate the story of my father-in-law and how “Cholera’s natural!”.

I’m not saying that complementary and alternative therapies don’t work.  I am seeing they usually do – but not necessarily in a positive fashion.

Who Pays for Medical Malpractice Litigation?

The short answer: you do. Here’s why.

Ask any doctor – at least any one who has been out practicing clinical medicine for some time – how much the threat of a malpractice suit influences their behavior and odds are, they will tell you “a lot!”.  While the degree may vary depending on your specialty, your years in practice, your patient clientele, your prior malpractice history, and the anecdotes you have heard from colleagues, you cannot be immune to the influence of malpractice law as it exists today in the US. I had intended to talk about how healthcare costs are influenced by malpractice, but it is impossible to take up that subject without touching on how my own practice has been affected.  And how this directly affects the kind of care I offer my patients.

It has been observed that while most people have negative perceptions of lawyers, most will tell you that their lawyer is a great person. The same  has been found true of peoples’ attitudes towards doctors, plumbers, auto mechanics and other members of service professions. (Car salesmen, to their misfortune, don’t even enjoy that consolation.) Thus it is for malpractice attorneys: doctors despise plaintiffs’ attorneys and look favorably on defense attorneys. hardly a surprise. And as part of their job, many defense attorneys are engaged by malpractice insurance companies and hospitals not simply to defend malpractice cases after the fact, but to practice “preventive medicine” for malpractice suits. These take the form of lectures and workshops, sponsored by malpractice insurance companies or hospitals, educating us on how to avoid being sued. We listen carefully to the advice of people who make it their profession to defend us. They are the “good guys”.

Let me say at the outset that all malpractice defense attorneys will agree and counsel that the best defense is not to commit malpractice in the first place. But they will tell you that the many of the unfavorable judments they see are not the result of medical errors themselves, but rather errors in patient relations, documentation, office management and other factors that might have easily averted a suit. In fact, they tell us that there are frequently judgments against physicians where the weight of the evidence and overwhelmingly common sense would argue otherwise, due to discrepancies in the way the patient or their family recalls the events.  And so we are instructed from time to time on how to do a better job attending to all these factors so as not to leave ourselves open to charges of failing to live up to what is called the “standard of practice”.

The last lecture of this sort that I attended began with a recitation of what you might think were preposterous jury verticts. In one case, a patient was told she needed a test because she might have cancer. She refused it. She went on to get a serious incurable cancer. She sued the doctor  for failing to inform her fully of the need for the test. Her reason: “He never told me that cancer could kill me!”.  Then there was the patient who was told that his brain surgery for a life-threatening blood vessel problem carried a risk of stroke. He sued because, unfortunately, his surgery was complicated by a stroke. His complaint: “He never informed me that a stroke means a partial paralysis!”.

Following a series of such cautionary tales, the defense attorney proceded to instuct us on how we might best avoid such scenarios. An example: 99.9% of all headaches are not due to brain tumors. Numerous scholarly articles in the medical literature have shown how unproductive and wasteful it is to do CAT scans on everyone with a headache. But if the one person in a thousand decides to sue, the plaintiff’s attorney will ask, “Doctor, did you know that there was a chance that the patient’s headache was due to a brain tumor?”. If you start to say, “Yes, I did, but the chances of that were…”, you will be cut off immediately with “Thank you very much, doctor. So you knew that there was a risk he had a tumor and yet you didn’t order a CAT scan, is that right?”. So what are we supposed to tell our patients to insure we don’t get sued for failing to inform them of the risk?

The attorney told us that if we thought there was even an infinitesimal chance that a patient’s complaint might be a symptom of a cancer, and they ask us, “Doctor, could this be due to a cancer?”, we are obliged to tell them “Yes.”, no matter how remote the possiblility and no matter what affect that answer might have on the patient’s emotional state.

What might be the effect of our heeding this advice? I’ll leave you to wonder until the next entry.

A Death Well Spent

I was going to start the second installment of my ongoing discourse about healthcare costs, which was to be about the impact of malpractice litigation on current medical practice and the extent to which it is raising the cost of healthcare in the United States, but it occurred to me that this will be a long discussion and runs the risk of reaching the level of a rant.  So before I indulge in what might be anticipated to be a self-serving diatribe against malpractice suits and the plaintiffs attorneys who reap huge profits from them (such as the now disgraced Jonathan Edwards), I thought I would take a break and talk about a patient who I’ve been seeing this week.

One of my patients who I have cared for for many years has been slowly declining due to chronic pulmonary disease and is now in the hospital dying .

She was an inveterate smoker and continued to smoke cigarettes even when she reached the point that she could barely breathe when she walked and needed to wear oxygen at home. She was tethered to an oxygen tube while at home and it was only when she became dependent upon portable oxygen to get out of the house that she finally gave up cigarettes altogether.

She belongs to a class of patients who I’ve come to think of as the “smoking coffee drinkers”.  They are thin, older women with gravelly voices and outgoing personalities.    They usually cosume 6 cups of coffee a day and smoke a pack a day of cigarettes, and try as they might , are completely incapable of quitting smoking, even though they know perfectly well that is going to kill them.  Most of them are complete teetotalers and hardly the type of people that you would expect to be substance abusers.    Nonetheless, they are as addicted to nicotine as any heroin addict is to narcotics.

When I ask them how much they are smoking lately, they nearly always say that they’ve “cut down” since their last visit, without answering the question directly .   But when pressed, they always report a daily consumption that is no fewer than the amount they admitted to at the last visit, not recalling that  they said the very same thing  last time I saw them: “only a few”.  Once in a while they will even tell me they have given up the habit, but on closer questioning they admit it has only been for the past two days or some such painfully brief interval, and not in any premeditated fashion .

I have tried every trick I know to help them quit.  Medications such as nicotine patches, Zyban, Chantix, antianxiety agents and antidepressants are more often than not either ineffective or result in intolerable side effects in this type of patient.  Or she is unwilling to try them because she is afraid of possible adverse reactions, or because her friend tried it and “went bonkers” or had some other dire result.  Motivational tricks are equally ineffective.  “You wouldn’t believe how many of my pateints have succeeded in quitting!” I tell them.  “Well, if you were able to quit for a week last year, that proves you are strong enough to do it again!”   A rare few have tried hypnosis without success.  Even my constant efforts at counseling from the point of view of my – admittedly,remote -  and brief experience with quitting smoking in college, and the techniques that I was able to use, always come to nought.

Of course, as physicians, we are instructed always to gently mention at every visit, “Have you thought about quitting lately?”. Usually they say they have, but in the same labored breath, that they are not ready or don’t think they can, or that they want to, but their life has been too stressful lately to do so.

Thus they all progress more or less gradually in the direction of what was once called chronic bronchitis and emphysema before I entered medical school. Shortly before my medical education began, someone decided that “COPD” was a better all-encompassing term.  I have always felt that it serves only as a blander shorthand with less stigma and threat attached to it than the frightening word “emphysema”.

Trying to halt their slide toward becoming pulmonary cripples is a frustrating and discouraging endeavor, requiring that I  periodically rescue these women from their intermittent bouts of acute exacerbation of their chronic bronchitis.  Inhalers and cortisone medications are helpful and antibiotics occasionally have some value, but after several years, the repeated bouts and continued smoking take their toll.  The decline is inexorable.  I watch them graduate from home oxygen to portable oxygen.  Oftentimes, the end is a three-week stay in the intensive care unit on a respirator while pneumonia finally puts a period to it.

What is remarkable about the patient I am caring for at the moment has been her incredible determination in clinging to life, in spite of respiratory disability, as stubbornly as she had formerly clutched her pack of smokes. She treasured her ability to bake an apple pie for her grandson and was heartbroken when she no longer had the strength to roll the dough. But she hung to life fiercely so that she could be with her family to the last moment – and then, without hesitation, decided  it was time to call it quits.

Her last month was spent in a pulmonary rehabilitation hospital, but even that was to no avail.  She had reached the point that even with all of the oxygen supplementation available, her lungs were incapable of excreting the carbon dioxide that her body would generate.  This condition is called  hypercarbia and results in lethargy, stupor, and ultimately, near-coma.  I only learned that she had been readmitted to the hospital when her family member called me the following day.  At that point, he related that she had had a frank discussion with the hospitalist responsible for her and had made the decision that she didn’t wish any further efforts to keep her going and she would absolutely not accept being intubated.  She had emerged from her stupor long enough to make clear her wishes: was adamant that there should be no further efforts. She had had enough.

The decision having been made, in order to keep her from feeling short of breath she was receiving an intravenous morphine drip and the maximum possible oxygen.  By the time I came to visit her, she was already essentially unresponsive.

For the past five days, her husband and children have been keeping vigil by her bedside 24 hours a day.  Her husband has been sleeping on a futon sofa bed that the nurses make available to family members.  He has been going home for an hour every day so he can take a shower and change his clothes.  Her children and grandchildren are all by her side.  Everything that there is to say has already been said and they are just being with her at this point.  Their only concern is that the morphine drip is adequate to be sure that she is comfortable.

What strikes me about her situation is the profound sense of appropriateness in her family’s acceptance of the inevitability of her passing and the fact that they are all in agreement about how it should go.  She has already expressed her wishes as to the disposal of her remains and what sort of service she wants.  There has been no acrimony.  There have been no demands of “isn’t there anything else you can do, doctor.?”.  There is no attitude of “spare no expense!”.  There is only love and grief.

To visit this hospital room gives me a very old-fashioned a sense of rightness. It is an all-too-rare experience for me lately. I have watched over the years as death has  become protracted, agonizing and expensive. This one is by no means cheap. But it is well worth it.

All about the Electronic Medical Record (EMR) also known as the Electronic Health Record

If you have been following this blog, you will recall that the first entry was an introduction to an ongoing essay on Healthcare costs in the US and how we can restrain them. To see where this is all going, I highly recommend you go to the archive and start with that first entry introducing the series.

Today’s entry:   a somewhat preliminary stab at the topic of electronic medical records with respect specifically to their impact on cost of providing care.

The new Obama healthcare legislation includes provisions to encourage me and other doctors to adopt an electronic chart by 2015.  Known as the HITECH act, the legislation establishes a set of monetary rewards for early adopters and ultimately, monetary penalties for hold-outs.  All this will be costing our Medicare program a lot of money. The folks who devised this scheme are hoping this will save even more money in the long run.  There are many reasons to convert our outmoded paper system of medical records to a digital one, but is it realistic to expect to save money?   The answer is much more complex than anyone at CMS (the Center for Medicare Services) or the current administration would have you believe.  I’d like to think the answer will turn out to be a “yes” but the evidence of my eyes and of published studies is not overwhelmingly convincing.

Let’s look at a typical medical practice using a typical EMR (electronic medical record).  I have been using an electronic medical record in my office for nearly 10 years, having experimented with them for even longer than that before I adopted one. There are a lot of things it does really well, and unfortunately, a great many that it doesn’t do nearly as well or not at all.   But when it comes to saving money, the chief deficiency of all electronic health records is not what they fail to do for the individual doctor trying to provide good care to his patient, but rather that so few of them talk to one another.  In fact, even two practices using the same software may be unable to share data if they are not part of a single organization! I might have the “latest and the greatest ”  electronic chart that money can buy – and by the way, they can run into a LOT of money – and I could send you to see a consultant across town who uses the same product, but unless we both belong to a large group practice, I might end up receiving the results of your encounter there in the form of a paper document and printed lab reports, or an image of them, which is not much more useful.

The new health regulations provide rewards for adopting EMR’s, but only for those capable of “Meaningful Use”. The government’s definition of meaningful use keeps shifting, but over the past two years it has been diluted down to the point that I wonder how meaningful it is. My own system does not qualify for “meaningful use” in one respect among many because it relies on my computer sending a fax to the fax machine at the patient’s pharmacy to transmit our prescriptions.  We are being asked to eliminate the fax machine and go directly via the Web.   Why might doing it by internet make a difference? Well, for one thing, the pharmacy might be able to keep better statistics on what is being prescribed to the patient population in general, and keep better track of what medications an individual patient has been prescribed.  This might avoid waste, duplication and medical errors.  But in case you haven’t noticed, your local CVS or Walgreen’s has a record of every prescription you have been given for the past 5 years. And much to my dismay, the pharmacies are selling that info to the drug companies! Looks like we don’t need the internet for the pharmaceutical industry to keep tabs on us. Moreover, that information is also readily available from claims data that the health insurance companies have. So much for that aspect of meaningful use!   And as it is, I am already being deluged with notifications from pharmacies and insurance companies on what conflicts there are among the drugs my patient is taking and what cheaper generics I might be able to substitute. Even a paper prescription ends up entering the data repository these days.  So where’s the savings?  Maybe they will get better at it. Maybe we’ll save some paper. But it looks like I’m going to be junking a perfectly good system that I have devoted ten years to learning, tweaking and perfecting. Now I am on the hunt for the electronic “Mr/Ms Right”.

So drug costs are one area we hope the EMR will save money. How about allowing doctors to work more efficiently? Do more in less time? Enter the date with the click of a mouse or stroke of a stylus on tablet, instead of laboriously writing out notes? Use voice-to-text instead of dictating notes to a typist?  Well, don’t get your hopes up!. In fact, be afraid. I have spoken with dozens of colleagues about their new EMRs and they all say the same thing.  ”At first, it really slowed me down so much I had to see only half the patients I usually saw in a day, but after a couple of weeks, I got better at it, and I was seeing only a couple less a day, and now I am nearly back to seeing as many as I used to before I computerized.”  Guess what?  Entering patient date into a computer requires capturing far more information that just jotting a note, and putting it in with a mouse or a stylus may approach but will never beat paper for speed. The promise of the EMR is not that it will let me do my job faster, but just do it better. And that might save money in other ways…

Avoiding medical errors? Imagine the savings just from preventing the untold number of medical mishaps that occur yearly in the US. Complications resulting in repeated visits, hospitalizations, unnecessary surgeries, even deaths!  The Institute of Medicine notoriously estimated about 10 years ago that medical errors in this country result in 100,000 deaths annually, if my memory serves me. (I might need to correct that figure.)  Their methodology can be questioned, and I suspect they are.  But wait just a minute, friend. No doubt we will save a lot of mortality and morbidity due to any number of advantages to a computerized record. But one aspect of it has been found to be a less than unalloyed boon: computerized order entry. The hope has been that doctors will write clearer prescriptions, hospital doctors will omit fewer important orders, that clinical algorithms will be adhered to, and therefore uniformly improved care will be delivered. But the empirical evidence is actually conflicting. A study of residents and interns at a major teaching hospital in Boston failed to demonstrate improved safety. (I plan to add citations and will welcome comments/corrections).  I’ll tell you what I see at my hospital: it appears that the hospitalists are ordering more interventions at the click of a mouse than we used to see when orders were handwritten. It takes only a keystroke to order that my inpatient have a blood count daily for the next week, where previously we had to order it a la carte and think beforehand if it was really needed that day. There has been too much blood and not enough ink spilled on this phenomenon.

Another interesting phenomenon is the advent of “boilerplate” in medical records, or “charting by exception”, primarily to document  something we call “level of service”.  As it currently stands, doctors are paid by piecework, i.e. by the individual service performed. A doctor visit is billed to the insurance company or to Medicare or Medicaid on the basis of the amount of work done. Sounds reasonable so far? But “if it wasn’t documented, it wasn’t done” from the point of view of the payers. So to justify having billed for a particular level of service, we doctors have to generate a note documenting the visit. Well, it’s a whole lot easier to do that with the click of a mouse than with a note written longhand, or even a series of check-boxes on paper. So that’s what we do!  Now the vast majority of us have found that computer documentation more accurately captures the multiple observations and judgments we make each time we see a patient, and therefore allows us to be paid more fairly for our work. But there is always the temptation to click a few more boxes to make that Level 4 office visit a Level 5. In fact, salesmen for EMR’s often point out that the ROI(return on investment) on an EMR more than outweighs its cost because of better billing.  I like to think it is making things fairer. But it clearly doesn’t make them cheaper!

There must be other ways the EMR will save money,  and in fact there are quite a few

Probably the most important way that an EMR could save money is if it is linked to all the other offices where my patient has been seen. There is a huge amount to be saved by cutting out duplication and waste in medical testing, and our inability to obtain the results of previous tests such as blood tests and x-rays ordered by other physicians  leads to  an immense amount of  redundant studies. It is a daily struggle for my staff to acquire the results of tests that have been done on my patients by other consultants or primary care doctors. We find ourselves calling laboratories, waiting for results to be faxed. We have to call other offices where the beleaguered staff regard our inquiries as a nuisance and act like THEY are doing US a favor to send us their doctor’s notes and studies, even when the doctor there has asked for MY help! The staff at other offices are overworked and are not paid to provide information to another doctor at a moment’s notice, and even my referring doctors sometimes think it is adequate for them to send me only the patient’s most recent blood test and the most recent illegibly scrawled progress note. This happens even if there are typed notes from other consultants, x-ray reports and procedure notes in their charts that are crucial to my making a good assessment. And frequently the patient him/her self forgets to mention that they had other tests, or forgets when and where they were peerfomed.  We are fortunate that in many cases we can call our hospital’s radiology group for results and get x-ray reports that way, but oftentimes we call the same laboratory that we ourselves use and they refuse to give us results without a signed release from the patient for fear of violating HIPPA regulations. (I can explain that one later). Then there is the interminable wait for the fax machine while the patient sits and I fume. Is it any wonder that it is easier just to repeat a blood count than to get a report from the one done a week ago elsewhere? Worse still, I may order an x-ray that would have been unnecessary had I known of information that would lead my investigation in another direction!

What a boon it would be to be able to go into my computer and have all that information at my fingertips! You can call an airline reservations desk anywhere in the world and find out what seat on what flight you  have reserved and what is the status of that flight. You can even get it over the internet. But the unfortuanate state of our medical information systems is analogous to the state of the newfangled railways of the 1840′s where each one had a different guage of track and passengers had to disembark from one train and board another several times just to make a single journey. We were lucky in many ways that our telephone system evolved in the first 100 years of its existence as a monopoly: at least a phone plug fits a phone jack anywhere in the country and the letters on the keypad of the touchtone phone are all the same. (Ever notice that the arrangement of the numbers on your phone is opposite that of the keypad of your computer? That was one opportunity for standardization that got away!)  But in the world of medical software, there are hundreds of companies to choose from. Even with the constant process of market shakeout, mergers and acquisitions, new ventures seem to pop up as fast as old ones disappear.

When it comes to communication, the best we have so far is a loose connection of geographically close practices using what is called a “healthcare information hub” or some similar name.  All it amounts to is that some of the labs, radiology offices and practices agree to upload their data and make it available to other practices attached to that hub. It has promise, but we are only in the infancy of this organization in most parts of the country.

One work-around that is being proposed is for each of us to carry a copy of our full medical record on our person to bring to all doctor visits, in the form of a CD-ROM or a flash drive. This system has great potential, but to be useful, a large number of patients would need to do this. And to be truly useful, the information should not just be in the form of text and images, but a form  that can be imported into any EMR.  There is a supposed standard for medical software to communicate to other software by. It was agreed to nearly 20 years ago and is called HL-7. Too bad it doesn’t really go very far. It is as if all the software programmers agreed that our software would use a Roman alphabet, but left the decision as to what language to speak up to the individual.

So there is much money to be saved by computerizing medical records, but only when we have a nationwide network! What might bring that about? A subject for later intense debate: single payor or the marketplace!

Next: Malpractice Reform…

The truth about healthcare costs

Everyone is  concerned about the cost of healthcare  in the United States.  The cost of healthcare delivery is having a profound effect on our nation’s health, our economy, and our national debt. No wonder so much as been writen about it. It has been estimated that healthcare takes up  approximately 16% of her national gross domestic product and disfigures  increasing yearly. (Citation pending). So what can we do about it? And what are we doing about it?

Numerous solutions have been proposed to try to rein in these  ballooning costs. Each one has it’s merits. I intend to reflect on some of the following in my next few posts:

• Electronic medical records
• Accountable care organizations
• Best practices
• Comparative effectiveness research
• Enforcing use of generic drugs
• Curbing approval of new devices and procedures
• Market competition and health insurance excahanges
• Tort reform and defensive medicine
• End of life issues and palliative care
• Allocation of scare medical resources

There is money to be saved by attacking each of the areas I have listed, but some are much less likely than others to yield real savings, and the most efficacious of the remedies above may be the one most difficult to achieve. The obstacles are huge!   They include:

• Entrenched politicalinterests
• Powerful commercial interests
• Public demands based on promotion rather than real value of drugs, devices and procedures
• Public ignorance or denial
• Lack of uniform yardsticks
• Disagreement about the facts
• Insufficient data and statistics

NOTE: Each of the above proposed solutions and obstacles is worthy of an essay in itself, and I intend to tackle them one post at a time. Opinions expressed in the blog are those of the writer and any resemblance to actual fact is intended and (as far as I am concerned), absolutely congruent and accurate.

Another aspect of this issue is not just the cost of healthcare, but who is paying for it, where does the money come from, and where does it go?  It seems a truism that somehow, the burden of healthcare costs is on all of us here in the US, but how is this burden divided?  And if there is money to be saved, who will reap the benefits? Taxpayers? Employers contributing to healthcare coverage? Employees share  premium costs themselves? Insurance company stockholders? Not so clear. Recently, two major pharmacy benefits management companies announced plans to merge. It will be interesting to see who benefits from the economies of scale. Financing healthcare is a larger issue that is a challenge for the most sophisticated economists, and I leave that to them. But remember: ultimately the cost of your healthcare comes from you!