Wednesday, October 16, 2013

Team Huddles Make for a Satisfying Day!

Five minutes before my day begins I discover two patients scheduled for ER followups don't have the hospital records yet in the chart. Can we get those, please? My nurse points out that Mrs. Jones, who just lost her husband, is coming in today. Good to know. My office manager asks if we can work in a late caller from the day before with a rash. Yes, let's do that at, umm, 2 pm. The scheduler says "Mr. Robert's wants to know if he can have his testosterone checked with his regular blood work?" Yes. Anyone else? OK, let's do this!

Sometime in 2012 I heard about using the Huddle Technique in medicine. When The Happy MD's blog post on the Team Huddle hit my mailbox last year I considered trying it but, not having my own medical assistant at the time, I delayed. Several months later at the ACE conference in Chicago, Marijka A. Grey presented on Care Teams using the Huddle and standing orders. I decided to implement them both in my office early September. I've been blown away by how it improves my ability to efficiently provide care. And my staff loves it.

Every morning, I go up front where my office staff is gathered. For about five minutes we inspect the day's schedule, check for issues, make sure we have the necessary referral information, look to see if an appointment's purpose is unclear and generally try to make the day smoother. For the first month, we only huddled in the am. Now my nurse and I meet in the afternoon to review the day and see where we need to follow up with a call to see how the patient is doing in the next day or so.

In regard to standing orders, we have begun slowly. My nurse determines that all patients are up-to-date on their immunizations and if not, offers to provide them with the appropriate vaccine that day. Our Zostavax (shingles shot) rate is up at least 50%. Having her review this information is much more efficient than me trying to remember it along with all the other distractions in the "fifteen minute" visit. Since our EHR is still not capable of "pop ups" that remind us when a patient needs an immunization this is working well. 

As I stated on Twitter--why didn't I think of this 25 years ago?

Saturday, October 5, 2013

The Irony of a Paper TOC Document in an EHR

Over one year ago my office implemented Allscripts Enterprise EHR (Electronic Health Record). I've not done a note on paper since. Last week, a "Transition of Care" (TOC) document was placed on my desk with a sticky note stating: "Dr. Nieder please fill out this form so we can bill a 99496 for your visit with Mrs. Jones yesterday". I pick up two sheets of paper with multiple questions including: 
  • Discharge Medications: (list)
  • Present Medications: (list)
  • Diagnostic tests reviewed/disposition (list)
  • Disease/illness education (discussion documentation)
  • Home health/community services discussion/referrals: (list)
  • Establishment or re-establishment of referral orders for community resources: (list)
  • Discussion with other health care providers: (list)
  • Assessment and support of treatment regimen adherence: (discussion documentation)
  • Appointments coordinated with: (list)
  • Education for self-management, independent living and activities of daily living: (discussion documentation)
Please remember, I am now on an EHR. So I am expected to document in the EHR and THEN fill out these forms. I have no discharge summary yet from the hospital. It may be ready but no one sent it to me and since our hospital is not sync'ed with our ambulatory clinics it didn't seamlessly flow into my patient's chart when she was discharged. When I finally do get it, there is no mention of any referrals given other than with the surgeon she saw in the hospital and me. The discharge medications state "resume pre-admission meds". In order for me to list what tests she had and make sure they are normal I have to return to the hospital portal and look them all up. Some of them have already been scanned into the EHR. I have no idea if there were other referrals made but I doubt it. She had a very straight-forward admission for a small bowel obstruction. She declined to keep the surgeon's appointment since they gave her instructions in her care in the hospital. I concurred about that. She could call them if she needed them. The women is a healthy 65-year-old who still works part-time as an accountant. She travels a lot. 

This TOC visit is paid at a much higher rate than other visits IF the patient does not return to the hospital in the next 30 days. Hence, we hold the billing until that time. 

My understanding of the purpose of this new code is to improve the CO-ORDINATION of care as the patient transitions from the hospital to home. Coordination would imply that there are other individuals involved in giving the patient care and thus we should have improved COMMUNICATION
between us. However, at least in my institution, my staff and I bear the brunt of gathering information (which is what we normally do anyway, so I guess it's nice because now we get paid for it). 

At what point will it become incumbent upon the hospital, who I work for, to send me the necessary information for treating the patient now that he/she is home again? How does it follow that improving care means the primary care doctor fills out even MORE FORMS ultimately reducing the time spent with the patient? At what point does the operability of two disparate systems (office EHR and hospital EHR) talk to each other and the information I need is already in the EHR? Why isn't all the information the patient needs sent home with her and she is told to bring that with her to her primary care doctor's visit which, oh by the way, should be done within two weeks? Why aren't all appointment made before she walks out the door? 

The form will not keep the patient out of the hospital. Communication will keep the patient out of the hospital. True coordination of care might keep the patient out of the hospital. More busy work for the patient's primary care doctor will not. Since the order of the day is using hospitalists (a discussion on that is a post for another day) it is imperative that we improve our communication systems at the time of discharge and before the patient is seen again in the primary care office. Systems must stop thinking that one more form is going to save the patient. Especially another form on my back.

This post's ending was rewritten on 10-10-2013 to take into account the multi-faceted reasons for the form.

Monday, September 30, 2013

Thoughts on MedX

This morning I sit in my daughter's San Francisco apartment pondering the barrage of information that I was exposed to during the previous three days at the Stanford MedX conference. My mind is full of images that begin with Regina Holliday's beautiful pre-conference canvas
Representation of a part of the canvas

and end with my friends Lisa Fields and Ruth Ann Crystal; relationships made over the internet through Social Media and cemented by meeting IRL (in real life).
Ruth Ann Crystal, myself, Lisa Fields

The conference was a showcase of healthcare innovation and opportunities to network with empowered patients from the Society for Participatory Medicine and other like-minded health professionals. The epatients' stories along with Regina Holliday's exhortations to "change the world NOW" were the most compelling part of the program. Over the next few weeks I hope my mind processes what was learned and results in more ideas for changes that improve patient experience in my practice and, who knows, even in my healthcare system.
Flash mob on stage with Regina Holliday (in red)

At first, when asked by other participants why I came to Stanford, I wasn't immediately sure. I made the reservation out of a gut reaction but by day two my motivation was obvious: MedX provides the energy and focus necessary to change our broken healthcare system. Tim Autrey of the Practicing Perfection Institute commented in his workshop that change must start with the individual. This individual began over a year ago but the MedX conference provided a powerful infusion of energy to improve my personal relationships with patients and exhort my system to do the same. Thank you Dr. Larry Chu, Nick Dawson and the staff who worked so hard to make the conference the success it has become.

Monday, September 2, 2013

Google Glass in Primary Care

Google Glass is in its infancy, with over 8000 "explorers" who are eager to find compelling uses for it. The concept is cool: A hands-free cell phone that is voice activated. A month ago my healthcare social media friend Kathi Browne, who is a Glass Explorer, proposed driving to Louisville from Knoxville to allow me to play with Glass for two days.
Kathi Browne's Google+ site
I was excited to accept her generous offer. She was equally accommodating about spending two days in my home which is presently a construction area with two cats, to which she is allergic. She seemed to tolerate the experience admirably.

As expected with a beta product, we had a few setbacks. We couldn't tether Glass to my iPhone unless I gave up my grandfathered unlimited data plan. That wasn't happening. Next we tried using the local network in my office. When that didn't work we thought we'd found an answer jumping on my MiFi. That was great until Glass went into sleep mode (which is frequent due to a short battery life) which disrupted the MiFi connection and I couldn't get it back online until the battery was taken out of the unit. It isn't easy to remove. Finally Kathi just handed me her phone and I stayed live on her account.

The main advantage over a regular smartphone is how surprisingly unobtrusive the device is, both to you and the patients. It's easy for the wearer to ignore it except when in use. Patients were of three varieties--too polite to ask what was on my head until I brought it up and then not caring, knowing immediately what it was and wanting to play with it, and being unaware of the product but excited to learn about it. No one appeared worried and the first thing I told them on entering the room was that it was not recording.

While it's easy to understand how surgeons, teaching physicians or ER personnel might use Glass, its implications in the primary care office are less clear. A few thoughts:

  • Glass is much less obtrusive than the laptop I carry or even the chart I used to carry. If I could dictate into the EHR this could enhance communication with patients.
  • Having a projection screen that would show the patient what I was looking at could be used for education, the way I sometimes use my iPad now. For instance, I had a patient with shingles on her back and I could project her rash or a reference rash for comparison. I can do that with my iPad now but that involves carrying an iPad and a laptop. I don't use the laptop for education because the screen is awful.
  • On the down side, there is no unobtrusive way to Google a question using voice activation. My patients would know exactly how dumb I am. Wait, I already do that with them on the laptop so with Glass I could look cool and dumb. 
  • In a rural setting, sending a picture or a video from the exam room to a specialist would be advantageous but no more than telemedicine could do.
  • Calling up an examination video for something I don't do a lot of, like a specific orthopedic exam, could be helpful but I'm not sure about the patient's reaction. They usually prefer to think their doctor is well-versed in such things. Back to cool and dumb.
  • It's quicker to Google with Glass, an advantage over a cell phone. 
  • The voice recognition is amazing. Odd names and medical terms were usually nailed on the first try. However, there didn't seem to be a way to correct recognition mistakes.
  • I suppose patients would get used to it, but would they worry that I was secretly recording them?
  • As Clive Thompson commented in today's New York Times[1], using Glass is uncomfortable enough that constantly looking at the little screen is not an option. That could improve communicating time instead of the way the EHR takes away from it. 
  • How about an app in Glass that would identify a rash within certain parameters of likelihood? That is, a Watson for Glass. This was also suggested by Melissa McCormack of Software Advice in the Profitable Practice blog.
What I enjoyed most was the shear delight of several patients who wore it for a few moments. They were so excited by the device and its possibilities. Whether it will prove of use in the everyday practice of the primary care doctor remains to be seen.

1. Googling Yourself Takes on a Whole New Meaning 

Post was edited 9-4-2013 by request of Ms. McCormack to better describe her blog.

Monday, August 26, 2013

The Trouble with Physician Email

There are many articles on why physicians won't use email to communicate with patients, such as the lack of remuneration, liability fears, HIPAA concerns and time constraints[1,2,3]. The fact is, physicians don't read their email or respond to anyone. Seriously. Here's a typical scenario: as physician champion for the EHR in our local system I hold once monthly sessions to trade tips & tricks and answer questions. Doctors rarely show up. Recently one of the physicians emailed me a recommendation that he thought would be of benefit to the providers (I was excited to get an email from him). "Why don't you hold a monthly tip & trick session and everyone could share?" Wow. What a great idea. How come I never thought of that? After seething for a good five minutes I sent back an email and said "I've been offering this for almost a year now. Obviously I'm not communicating it well enough to the doctors since the email announcement several days before each session isn't working. Do you have any suggestions on how to improve my communication?" The returned response was, "I guess I don't read my emails very often." You think?

The same week my manager got an email from our PR department requesting her to tell me something. When I inquired as to why they didn't send the email directly to me their response was "Because doctors never read their emails." Fair enough. But I do. 

Yes, writing this rant in a blog is singing to the choir. If you read blogs I'll bet you keep your email correspondence up-to-date, but seriously doctors: YOU HAVE TO READ YOUR EMAILS in this day and age. It is part of your job. To those of you who are tasked to communicate with physicians, even if they don't read their emails, it is your job to send them. Don't remove responsibility from the doctors' shoulders by never sending the information to begin with. You can copy the manager but you still have to email the doctor.

Our inboxes are crammed full of unimportant things so get the friendly IT guy to create filters for you. Fewer irrelevant things will be delivered to your inbox. Don't feel the need to respond to every email. Most people don't need to be thanked or even acknowledged, and they don't want more extraneous emails in their inbox either. Establish a "throw away" email address on Google or elsewhere to give out when you buy something. Unsubscribe to sites that send you stuff. For more in-depth writing on the subject I recommend the Asian Efficiency website, especially this guide on emails.

OK, back to my inbox. There is probably some mail I need to respond to.

1. Weill Cornell Medical College. The Doctor Will Email You Now
3. Wall Street Journal January 23, 2012  Should Physicians Use email to Communicate with their Patients?

Sunday, August 18, 2013

A * Readable * Usable * Patient Note

It's not just the clicks. It's creating a Readable.Usable.Note.[1][2] It is embarrassing to look at a patient chart and read: "Your HDL (good) cholesterol is excellent but your LDL (bad) cholesterol is too high. I would recommend trying to reduce sure fact food intake." What? Oh, yeah, reduce your fatty food intake. Or worse: "She wanted me to know that she had a laparoscopic hysterectomy and in for reck to me over the summer." That one took a while to figure out. What I dictated was "she had a laparoscopic hysterectomy and oopherectomy over the summer." Ouch. I read over my notes before I sign them but between the rush of seeing patients and the problem with editing your own notes within the horrible output that electronic records produce, it's easy to miss your own mistakes.

The notes are built to maximize the billing that we do. But frankly, even though I revisit a patient's chart and check their past medical history, update their meds, update their family history, review their social history, etc. IT DOESN'T NEED TO BE REPEATED IN THE NOTE! However, if I don't rewrite all that, Medicare or the insurance company doesn't believe I did it and I can't charge for it. As a consequence everything is repetitive and finding the little gem of information one needs to care for the patient becomes more and more difficult. As anyone who has ever received the reams and reams of paper from an ER with an electronic health record (EHR) that has no discernible font changes or indentation can tell you, it is next to impossible to determine why the patient was there, what treatment they received and what followup they need. 

To counteract this I dictate my medical reasoning in the discussion box at the end of the note. Next visit that's where to look to find the important stuff. Of course this increases the amount of time documenting, taking away more precious moments I have to spend with the patient creating inelegant notes that are one step away from being worthless for subsequent treatment.  

What if we could create two notes for every patient. One that went in to the billing records for auditing purposes and one culling the important stuff into a true "patient care note". Surely there is software that could help us with that.

To quote Dr. Vartabedian: What do you think?

1. We need to reassess the patient note.
2. The doctor will see your medical record now.

Tuesday, July 16, 2013

The Importance of Being on the Same Page

No doctor is perfect. My guess is that orthopedic surgeons are as tired of talking about the importance of weight loss and exercise as I am to what seems to be deaf ears. Worse, it's unprofessional to complain about other specialists[1], but my last two weeks have been a bit frustrating. 
  • Patient was seen two years ago with "mild arthritis" in a joint. She was told by two orthopedic specialists that she didn't need surgery. Neither of them recommended physical therapy or for that matter, any movement whatsoever. Apparently that's what she didn't do--move (or so I've been told by a friend). Now she's scheduled for a joint replacement having never been offered the option of physical therapy. I cannot help but think her inactivity accelerated her joint problem.[2]
  • I encourage my patients with knee and hip pain to exercise and especially to lose weight. If I send them to an orthopedist they come back to me and deny that the orthopedist recommended weight loss. I think they just didn't hear what they don't want to hear but many times, there is nothing in the referral note indicating that they were told to lose weight. 
  • Last week two patients came to me after they saw their orthopedic surgeons asking ME to send them to physical therapy. Why? Because the surgeon didn't recommend it. 
Several years ago a friend of mine was sitting in an orthopedist office. After looking around the orthopedic's waiting room, she began a diet and exercise program the next morning. She told me "Except for the athletes, every person over 50 in that office was at least 30 pounds overweight. How can you miss the message there?" At that time she was in her early forties. Now ten years later she has kept the 10 pounds she shed off and exercises at least four times weekly.

Day in and day out I understand how frustrating it is to try to motivate patients to exercise and lose weight. Many of my orthopedic colleagues DO emphasize these things and my sense is that they are improving in that regard. In a society where obesity is ever more the norm, we've all got to be on the same page to help patients make changes, especially if you are the expert in the patient's eyes.[3] 


Saturday, June 29, 2013

A Personal Moment

Rarely do I take two week vacations, but my adult daughters have begun their own lives, very separate from mine. This was the last chance to take one together so my husband and I indulged. Tickets were bought last September. My mother, at 84, was doing well enough though she showed signs of some memory loss.

As her memory loss became more apparent, we decided it was time for a retirement community. I began the process and as luck would have it, my vacation fell smack in the middle of planning her move, trying to sell her condo and all the attendant details involved in that. She fell apart.

Weeks before I left she began calling me five to twelve times a day. She couldn't remember decisions we'd already made. She changed her mind a million times. Finally, I flew away for the first week of my break leaving my husband in charge of dealing with her for the first week. He did well but there was no one to help during the next week when all four members of the family were in another country.

So two weeks later, I return to find this horribly diminished individual. She looked like she had lost weight and she repeated herself over and over and over until it was all one can do to keep from screaming "STOP". I seriously thought that we needed to change from a retirement home to an assisted living facility. Then the oddest thing happened. Thursday night the real estate agent called. She had a buyer for my mom's condo. I gave a verbal OK, then cringed at the reality of convincing my mother. The next morning my husband and daughter went to oversee my mother's signing of the papers. She did it, then my husband spent the day with her, feeding her twice. On Saturday I spent the evening with her and she accompanied me while I helped my daughter unload boxes into her apartment. While my mom couldn't do that, she sat next to the car while three of us shlepped the boxes which really helped get the unloading done faster. Then she came into the kitchen and unwrapped dishes. When she returned home my daughter called to thank her for helping. I fed her again. On Sunday I returned to help her with some financial questions regarding the move. This time she looked at me and said "You know I'm starting to think this move is a good idea. I'm even looking forward to it a little. By the way, I called people multiple times while you were gone, didn't I? I have no memory of that. It's like I've been in a fog. I think I went a little kooky. Could I have had a stroke? You've been working very hard for me, come on and I'll buy you dinner." 

I was amazed. Suddenly she was remembering stuff she did five and ten minutes before. She had insight. What happened?? How was it that I had my mother back? She still has trouble remembering but she's not the diminished lost woman I came home to. Was it just eating properly? I know she hasn't been eating during these stressful weeks and we had fed her well for an entire weekend. Was it the socialization? She'd been interacting with people all weekend. Was it honestly being helpful to someone? I have no idea. What I do know is that pseudodementia is complicating an underlying mild dementia that she refuses to take medication to treat.  

At any rate, my belief it that moving her to an environment with exercise and social stimulation will improve her mentation. Maybe she'll have quite a few years in her new home where socialization, activities and getting to know your neighbor is the norm. 

Saturday, June 8, 2013

Doctors 2.0 - Second Post

Sitting next to +Ronan Kavanagh in a nice French restaurant after the first day of the Doctors 2.0 conference, he commented, in his lovely Irish brogue, "You know, at our age we are not supposed to have the opportunity to make so many new friends. But look at this table, all brought together by a common bond." 

What great fortune, to be sharing dinner with six interesting people who I'd had the fortune to meet on Twitter during the last year. The cool thing was--they were every bit as awesome IRL (in real life) as they are on line. All of us share a passion for making the patient experience better using digital tools--gamification, the quantified self, video patient information, social media for physicians and patients, etc. And while I didn't meet John Brownlee on Twitter, he was the other common bond amongst us; the CEO and founder of ClearMD who organized the meal.

The Doctors 2.0 conference brought doctors, patients and entrepreneurs together in an incredible setting, la Cité Universitaire:

We heard from healthcare startups, e-patients, pharma, doctors and medical futurists among others while networking and eating French snacks. Maybe it was the wine, but when the two day conference was over, I was left with a hopeful feeling that patients, doctors and healthcare entities who put patients first can brainstorm and make a difference for the better in patient lives.

Monday, June 3, 2013

Doctors 2.0 - First Blog Post

It's a few days early but why not get a leap on my conference blogging? My daughter and I arrived in Paris in preparation for the Doctors 2.0 conference:


After not sleeping on the flight over (I never sleep on airplanes) we arrived at our very pleasant apartment in the Marais, set up through "A La Carte Paris". Kelly walked in the door, checked out the very high tech amenities as well as the bathroom hidden in the bank of cabinets on the wall: 

Oh MY -- there it is!

She then announced "We're staying in an Inspector Gadget's apartment!"

We spent the afternoon on a walk through Montmartre given by Chris through City Free Tours. After a beer in the Place de Tertre we made our way home and decided to eat in and then crash. 

Not too much Social Media in Medicine was accomplished today, but everyone deserves a day or two off. I'll be tweeting from the meeting and looking forward to learning more on that topic starting Wednesday night when I'll have the pleasure of dining with some of the best on #hcsm, @HealthHashtags, @clearmd, and #doctor20 IRL.*

In the meantime, Bon Appetit.

*In Real Life. 

Sunday, May 26, 2013

OUCH I must be a horrible doctor

Recently I began reading Dr. Kevin Pho's book, Establishing, Managing and Protecting Your OnLine Reputation. Last year I had encouraged patients to go to the Healthgrades to rate our office. It was helpful. My staff's friendliness needs some improving. My ratings were good but not fabulous. That got me to thinking about how to improve. Maybe it's because I am too straightforward? Am I not kind enough? Does my face show disappointment or frustration? 

The worst was looking at the site. There were only three ratings and the last one was abysmal, left in March of this year. I can't help but wonder what I did to anger  someone that badly. Was it the patient who left in a huff because a medical student came in first? (Yes, we warned him but apparently he expected me to accompany the student so we didn't properly explain it). Or the patient who was furious because I wouldn't give her a handicap sticker when her cardiologist refused to? Or the patient that I discharged from my practice when I found out he lied to me about his past drug history? The site itself is poorly monitored. It lists my internal medicine associate as a gerontologist with no address, my family practice associate as practicing at an address that she left five years ago, and my address is listed from four years ago. When I sent an email no one answered it. 

Most of the other sites listed were without reviews. It makes me wonder, with so many rating sites, how helpful can they be? Additionally our patients are asked to fill out a survey on Survey Monkey but the doctors aren't given the results. What good is that? 

Pondering my ratings I wonder, would using Motivational Interviewing improve how patients perceive my suggestions and bring something more tolerable and more workable for them? It's my hope to motivate, not lecture patients. If I see them as partners in their care, how best do I encourage their participation and help them?

Monday, May 13, 2013

Is Happiness a Value?

Glancing at my blogroll tonight I came across a recent post by Kent Bottles entitled, "How to Practice Medicine in a World We Can Never Truly Understand". While it is a little esoteric for this family doc's brain, reading it jogged my thought processes. He begins by discussing the pursuit of happiness, an ofttimes elusive goal in life. Is it unusual that happiness was never something for which I aimed? The closest value for me was satisfaction. As my children grew, I encouraged them to give the best they could in life--whether that was grades or friends or sports or art. Never once did I suggest they try to be happy. For me, happiness is something one may find, but when you make it a value, now there's a recipe for disaster.

My patients will tell me "I just want to be happy". They believe they will achieve that goal if they marry the right man, find the right job, get the right grades or buy the right ______ (insert necessary object here--car, house, dress, purse). Doing the best job in the job they are in, making the best grade in the most challenging class they feel competent to take, being the best friend to the friends they have...these are not enough. If they are not happy in their job or class or relationship, it is of little value, unless it can be justified as bringing happiness in the future. They search in chemicals to achieve happiness, be that legal (Prozac, Paxil, Adderal, etc) or illegal. If they are not happy, then something must be terribly wrong, even if they are unhappy for legitimate reasons; their mother just died, they lost their job, their boyfriend broke up with them. Their friends encourage them to take medications to be happy again.

This can be a type of cultural divide in an exam room. In the same way that language barriers can reduce good care, value differences make for dissatisfied patients who may intellectually understand that exercise will improve their health but if it doesn't make them happy to do it, it may not get done.

Happiness has followed me in my life many times. Most would consider me blessed. I wasn't looking for it. It's nice to have. But at the end of the day, I don't want to be happy, what I want is to believe that today's accomplishments were the best that could be done under whatever circumstances I found myself.

In other words, satisfaction without regrets. Happiness may follow.

Sunday, April 28, 2013

Medication Sticker Shock

Last week my office received a call from a distressed patient who went to the pharmacy to fill prescriptions following a hospitalization. The cost for a month's worth of three medications she was expected to stay on indefinitely was over $800. With mortgage rates being what they are, most people don't have mortgage payments that big. She called our office in a panic. As she related her story, I wondered how this fiasco could have been avoided. When I prescribe medications, either my EHR or my Epocrates program gives me an idea of what the patient's price will be based on her insurance. Is that too difficult for hospitalists to do? That sounds sarcastic, but I'm serious. Are the logistics for a hospitalist such that running medication through software to determine the likelihood a patient can afford them not realistic? What about the pharmacists in the hospital? Could this become part of the discharge process?  Patients should not have to deal with "sticker shock" after a difficult hospitalization.

I changed two of her meds to inexpensive generics and called a cardiologist to ask what to do with the anti-arrhythmic. He told me that the new medication was only slightly better than placebo in studies. And for that she was paying over $300/month!

One of the Affordable Care Act provisions is that hospitals will be penalized for readmissions within a month of discharge.  It will become incumbent on the hospital team to have a better understanding of medication costs, one of many reasons why patients are non-adherent[1] with their therapy. As the family physician getting panicked phone calls I view this as a good thing. My patients will be discharged on medications they can afford and will take. Then we can spend our time in the office taking care of health problems instead of fixing something that shouldn't have been broken to begin with. 

1. Medication Adherence: WHO Cares? Brown MD, Marie T. et al. Mayo Clin Proc. 2011 April; 86(4): 304–314.

Tuesday, April 16, 2013

Dying With Dignity

She is always put together perfectly and today is no exception.

She's tells me how she's giving away her things and I decide against complimenting the beautiful opal she wears, fearful she might hand it over. We've been together for six years yet I know so little about her. Her husband is also my patient and has been very ill for several years. Despite his many medical issues he seemed to take care of her so it concerned me that he would die first. 

Death decided he wants her instead. He stalks her but she stays gracious, not giving in to despair. She asks me about my daughters, she is honestly curious. She talks about how much her energy has ebbed but she is no longer frustrated by it. She teases her husband a little. 

As she leaves she thanks me for taking such good care of her. How can she say that? I've failed. Neither I nor the oncologist can stop this inexorable process that is whittling her down to nothing. She hugs me as she leaves and I feel healed. What a startling reversal of roles. 

Thursday, April 11, 2013

Can Social Media reduce Physician Burnout?

In late fall of 2011 I was tired of medicine. While seeing patients was still enjoyable, I felt under-appreciated in my employment and frustrated by the endless BS that I dealt with--new laws undermining the trust my patients place in me, increasing requirements from insurance companies for ordering tests or medications, more forms to sign, less time with patients, a cumbersome EHR to learn, more non-CME education requirements from the system I belonged to...the list grew endless. Most of it boiled down to less control over my professional life and less time to spend with the people I enjoyed-family, friends and patients.

The following February I began writing a blog on my professional frustrations as well as the occasional reward. Shortly after that I discovered Twitter--first as a "lurker" listening in the background, then as an active participant. I met so many interesting people--physicians, e-patients, Social Media gurus, pharmacists, nurses, other healthcare providers, patient family members, the list is endless. Through Twitter my office knew early on about the multi-state fungal meningitis caused by tainted steroid vials, the Newtown shootings (unfortunately) and the Open Notes study. If Mayo and Cleveland Clinics were using Social Media to reach and teach their patients, it was likely that Social Media was not just a passing fad. Meanwhile my fascination with the phenomenon grew.

I began a master's level course on Social Media that is mind-blowing (and free) developed by +Bertalan Meskó, an MD-Phd from Hungary who is a Medical Futurist.
The Social MEDia Course
I read "The Creative Destruction of Medicine" by +Eric Topol who recently spoke  on the Colbert Report about the future of medicine. I submitted blogs and was  published by Dr. Kevin Pho, "social media's leading physician voice". 
In October of 2012 I attended Mayo Clinic's Social Media in Medicine Summit and met a few hundred people interested in how Social Media is changing medicine.  

In the process I found new ways to engage myself and my patients--using QR codes, putting up a white board in the exam rooms, recommending apps. 
Patients now get a business card with the access site to a patient portal, my twitter handle and my blog site. They can contact me 24/7, understanding that I'll answer with the same availability as my email. 

Last year's experience served to recharge my professional gusto. Patients are more interesting, I deal with the non-stop frustrations with more aplomb and less emotional exhaustion. I look forward to seeing my new friends on the #hcsm tweetchat on Sunday night. Suddenly the future of medicine looks a lot less lonely and a lot more interesting. 

Sunday, March 24, 2013

Another Surreal Moment in Modern Medicine

A few months ago my office manager, Debbie, informed me that it was time for my annual "coding audit". This is where my employer sends in a hired gun to determine if my choices of office codes for billing purposes are correctly done. Did I document enough to support a 99214? Did I code too many 99212s when my documentation should have been higher, and thus my reimbursement better? The audit is based on Medicare-guidelines, although the ten charts pulled were of patients of all ages and insurance types. Doctors generally approach these sessions with the same dread we felt getting our report cards in grade school.

The tiny blond that came in to discuss my results refused to sit down next to me. It was distracting and intimidating. Since I'm 5'10" it was also infuriating to have this schoolmarm personality towering over me while she explained why she'd flunked me. Seven out of ten charts did not pass her muster. Two of the explanations made sense - one was "overcoded" - not enough documentation to support the 99213 I'd coded and the other the opposite. Six charts were "complete physical exams" (CPE) done on healthy non-Medicare patients. Since Medicare does not pay for preventive exams why were they pulled for a Medicare audit? It got stranger. She told me that I'd flunked because there was no "chief complaint" on the physical form. What? There shouldn't BE a chief complaint for someone who is having a physical. In fact, by definition, there shouldn't be one because it is a preventive service. No amount of discussion would dissuade the woman that she was wrong. I didn't have immediate access to my own specialty society's information on the subject:
The comprehensive history and examination performed during a preventive medicine encounter are not the same as the comprehensive history and exam that are required for certain problem-oriented E/M codes (99201-99350) and defined in Medicare’s Documentation Guidelines for Evaluation & Management Services. In fact, the documentation guidelines don’t apply to preventive medicine services. The history associated with preventive medicine services is not problem-oriented and does not involve a chief complaint or history of present illness.
I gave up arguing, signed the form under written protest and she left. 

Here is the kicker--a week ago one of the people whose chart was audited called to tell us she received all her money back on her physical! She thought it was a mistake and  was upset. She argued with Debbie and insisted that my office take back the money saying "But Dr. Nieder did all that work and spent the time with me." 

I am furious. This suggests to those six patients that I did something wrong. Ironically, this means my employer is out hundreds of dollars for work they paid me for and that should rightfully have been reimbursed. Jawdropping in it's lunacy. Can anyone wonder why the concierge movement is such an attractive, viable alternative to this?


Wednesday, March 13, 2013

Care-less Care and Telemedicine

One of my irritations with fast track care, especially Kroger's Little Clinics, is the overuse of antibiotics. Living in Louisville, where allergies are king, a simple cold often turns into two weeks of miserably clogged sinuses from increased swelling in already perennially irritated mucous membranes.  A few days ago a new version of "careless care" appeared on my radar. Teladoc advertises itself as the first and largest telehealth provider in the US. Some insurance companies and employers pay for their members to utilize the service. This particular patient used it three times in six months, each time receiving and antibiotic for a "sinus" infection, despite the fact that each time she'd only had symptoms for four or five days. She finally came to see me because the medication the teledocs gave never seemed to help. Go figure.

We spent some time talking about the difference between viral infections and bacterial ones, and discussing the problem with bacterial resistance due to the overuse of antibiotics. She promised to see me with her next episode and appeared rueful that she'd not come in sooner with the previous episodes.

The fact that telemedicine can lead to the overuse of antibiotics has been studied[1]. I was unable to find any studies evaluating overprescribing in Urgent Care Centers so I can only relate my own experience. The ERs and the NP staffed Walgreen clinics in my area do a much better job than the Kroger "Little Clinics" where antibiotic prescribing seems to be more ubiquitous than high fructose corn syrup. 

As telemedicine and other forms of convenient care increase, the fragmentation of healthcare does the same. Did I get any patient information from the Teladoc physician? No, of course not. Almost never do I get documents from the Walgreens/Kroger/Walmart nurse practitioner. I can't fight the convenience and know that as more and more patients have difficulties conveniently getting in to see their primary care doctors, this will only get worse. It is imperative that these groups communicate with patients' physicians. The question is, do I have an imperative to educate the Board Certified Physician who works for Teladoc? And why do I suspect he/she might not appreciate that? The answer is, I need my healthcare system to allow me to use telemedicine to treat my own patients at their convenience.

1. Ateev Mehrotra, MD; Suzanne Paone, DHA; G. Daniel Martich, MD; Steven M. Albert, PhD; Grant J. Shevchik, MD JAMA Intern Med. 2013;173(1): 72-74.doi:10.1001/2013.jamainternmed.305

Sunday, March 3, 2013

Are Doctors the Ultimate Engaged Patients?

My nose and sinuses feel like they are about to explode. I am moving into the third week of this and it's getting old. At first I thought that my cold had morphed into allergies but now it is apparent that two viral loads in a row have slammed me, both affecting my upper respiratory tract. If a patient walked into my office as miserable as I am right now my advice would include a steroid dose pack to shrink the swelling, some decongestants, lots of fluid and rest. Since it has been going on for so long if the patient insisted I would probably toss an antibiotic in there as well though it is clear (to me) this is not a bacterial infection. I am using a multi-symptom nighttime OTC cocktail along with a topical antihistamine at night and a decongestant with a expectorant during the day. I have no fever and there is nothing to suggest a bacterial component.

Reflecting on my illness, it occurs to me that one of the reasons doctors are uncomfortable taking care of doctors is that we are the ultimate e-patient. We are participatory, we understand the underlying disease processes and we often waver between allowing the treating doctor to be in charge and taking charge. We want to be partners in our healthcare because we have the training for it and yet hesitate because that's not the way it's done. It brings to mind a moment in my first pregnancy (in eastern KY) when my nurse midwife told me to skip the hospital prenatal courses because I needed to be a patient, not a doctor, and the classes would thrust me into a difficult role in such a small community. I remember feeling relief and feeling good about "only" being a patient. 

Those times when I have needed to be a patient my choices in physicians have assured me that I would be a partner in my healthcare decisions. Most doctors find taking care of other doctors, or their family members, challenging. This can be both self-inflicted and patient-generated. As patients become more engaged in their healthcare perhaps taking care of our own kind will become less anxiety-producing. We will feel confident that no one is "only a patient" because all patients will be partners if they so choose. 

Wednesday, February 13, 2013


My daughter is a barista. She came home from work recently and said, "One of the customers came in today and wanted to know if our hot tea was 'gluten-free'. Seriously? It was all I could do to keep from asking her if she knew what tea was made of!"

Gluten sensitivity is a hot topic these days as illustrated by a recent article in the New York Times "Gluten Free-whether you need it or not". I have many patients who are curious about gluten-free diets.  Patients are trying them and losing weight, having fewer migraines, reducing PMS symptoms, getting more energy, and/or making allergies going away. After having been in medicine for a sufficient number of years the exuberance of interest in gluten reminds me of any number of healthcare fads. Because we are human we hope to find an easy answer to our lifestyle problems. 

When patients ask me what I think, my answer is usual a very definitive "I have no idea." Then I elaborate since that tends to be disconcerting to them. First I need to know exactly why they are asking. Do they have symptoms of celiac disease: constipation, diarrhea, nausea, weight loss and abdominal pain (which can be caused by any number of entities besides celiac sprue)? Have they read something on the Internet or heard from a friend about gluten sensitivity and believe they have a problem? Are they presently following a gluten-free diet and if so, for how long and how do they feel? Only after I know where my patient is coming from can I decide where I need to go with her in the context of the visit.

For most individuals I want to be reassured that they are eating a nutritionally balanced diet and beyond that, I don't have easy answers. Usually I find questions like this involve a bit of fact, some fad and most definitely the hope that this "latest thing" will solve their problem, whatever that problem may be. In terms of my response, most things in medicine, like life, are best answered sensibly: All things in moderation.

Sunday, January 27, 2013

What would you do?

A text lights up my phone late in the evening. It's from someone who is a patient but we've been together for so many years I consider her a friend. She has my phone number from other times she's needed medical advice. She knows me well enough that she can assume I am adept at texting though we've never communicated that way before. The patient is immune deficient and somehow managed to scratch her leg. It didn't originally look all that bad but in the last hour or two it has become red and swollen around the scratch and she is concerned about cellulitis

There are no Immediate Care Centers open this late on a Sunday night. It is not clear to me from the description, even after speaking with her on the phone, if it is bad enough to need hospitalization. If not, the best care would be to start an antibiotic tonight and check it in the morning. My choices: send her to the ER at the height of flu season (a terrible idea for anyone but especially an immunocompromised individual), have her wait eight hours until morning and I can see the wound, treat it empirically, or have her send me a picture. The picture can't be in a text because that's not HIPAA compliant. It also can't be email because that's not HIPAA compliant. SKYPE? Maybe but I'm not sure how good the encryption is. 

So I sit on my couch and weigh options--all the while thinking, "How did we get in such a quandary, where taking the best care of the patient is not first on my list of considerations? Where common sense is delegated to the back of the bus behind government regulations and insurance rules? And where the technology to make all this simple can't be utilized to help my patient or me?" Patient portals are great but can she figure out how to load the picture on it? And our portal only accepts up to a 50 MB file. What if it's larger? Will she know how to reduce the size? Yes, I could do what my 1950's MD ancestor would do, which is hop in the car and make a house call, but he only saw 12 patients in the office the next day and made relatively leisurely rounds at the hospital. Not the frantic 20+ I'll see tomorrow, needing all the rest I can get. 

What would you do?

Saturday, January 19, 2013

The Expensive Process of Med School Application

Discouraged by her parents, my oldest didn't consider a career in medicine until after  graduating from college with a BFA in Art History. After taking an Americorps position and feeling lost at sea, she took a battery of aptitude tests. Interestingly enough the tests pointed her to a career in medicine, specifically as a physician or other treating provider. Growing up and watching her parents struggle through the difficulties of primary care, she certainly knew what she was getting into but somehow she must have seen the rewards we shared under the frustration.

So back she went to college, obtaining a 3.8 Science GPA. She took the MCAT, the dreaded test all pre-med students must do well on in order to be considered for medical school in the US, and made a decent if not stellar score. Then she began the application process.

Applying to medical school was an expensive and somewhat demoralizing undertaking. First she paid to send all the necessary materials-scores, transcripts, letters of reference, etc.-to each school through an organization called AMCAS. Then medical schools invited her to submit a secondary application.  At first she thought she'd made it through some sort of vetting process. Each school had a different set of requirements usually involving essay questions. Quickly she learned that they were all "interested" in her, well in her money. Amazingly paying $50-$150 per secondary application doesn't guarantee even a polite rejection email. Most students apply to about 20 schools. That's a lot of cash, considering that only about nine percent of all applicants are actually admitted[1].

As a bystander I have to wonder - is there anyone in the medical education community at least a little ashamed that so many of the hopeful individuals that apply to your "august" bodies are not granted even that tiny courtesy?

As a side note, she did get accepted. And despite all the frustrations I've been through and the issues that face her once she gets into practice, I'm proud of and happy for her. 


Monday, January 14, 2013

Saying Goodbye

It's Friday afternoon and I check the day's schedule. A name jumps out at me and I groan a little and worry--what am I going to say to someone I've treated for twenty years, who's my age and just been admitted to hospice care? If this is goodbye, how do I as a physician, who is more than an acquaintance but not quite a friend, handle this appointment?

All kinds of things go through my head. Do I really want to charge for this? How bad will he look? Can I keep from crying? Is there anything I can do for him anyway? Will I ask the right questions? Will I say the right things?

He comes with a relative. He is living alone but they have found a nursing home that he liked today and he hopes to transition there quickly. He has one sorrow and one fear. He needs to find a home for his dog of 14 years. He shows me a picture of a cute lap dog of some sort. Amazingly, during his last hospital stay he met someone who is willing to take care of the dog. His fear is how breathless he will be near the end. I reassure him that every effort will be made to make him comfortable and he should not suffer.

We talk a little about his parents, with whom he has been estranged for some time. He assures me that he has spoken with them. They are older and have had their own medical challenges. I cannot imagine how they feel. He jokes a little about his relationship with them.

Finally it is time for him to go. He looks tired, but not that ill. He asks me if he should try to eat, he doesn't have much appetite, and I encourage him to eat whatever he wants. He stands up and gives me a hug, whispering "I love you" in my ear as he does. After reminding me that the phone is a good method of communication, he leaves.

I am lost in thought and emotion but still have two more patients to see. I take a breath, walk into the next room and apologize for my tardiness. It's probably obvious that I'm upset but the rhythm of seeing patients takes over and somehow, reassures me.

Thursday, January 3, 2013

A Very Personal Understanding of Aging

My todo list is overflowing, my emails are piling up, I have 17 pages to read in my book and all of these are things I enjoy doing. But my mother has just called me for the fifth time in less than 60 minutes about the new safety monitor we got her for Christmas, the 5Star Urgent Response. New things challenge her and the idea of having both a cell phone and this device is beyond her ability to assimilate. As I sit at the kitchen bar trying to concentrate on any number of items the phone rings two more times. It's not that I don't want to work more but my spirit is broken by the phone calls. I give up and walk toward the stairs to the bedroom. My mother must have picked up on my frustration because when the phone rings again, it is not mine. My husband picks up his phone which is playing "Mother-in-Law" (see below).  

Over the years, as my patients have aged along with me, they have told me their woeful stories regarding their parents. I knew my time would come and over the last year my 84 year old mother has diminished with each month. She refuses to take any "more" medication and, like many of the dementia patients I've treated, doesn't see the problem. Since the evidence on the "Alzheimer's medications" is not all that convincing anyway[1], I am not willing to fight over it. She limits her driving mainly to daytime and to places she knows. But if you throw anything out of the ordinary, like the new device that she needs to clip on her person and charge every night, it becomes a nightmare. Not only for her but for me and my husband as well. 

My daughter has already approached her about moving into a personal care home but she will have none of it. She has good days and bad days. My job keeps me busy and disinclined to force the conversation. It is coming. My patients have prepared me for it and I thank them for this. But just like them, there is a black hole of dread that I see approaching. One thing for sure, while I will avoid discussing what is a personal matter, my empathy will go out to the next adult child dealing with their unwilling parent.