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. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068890/


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.
twitter

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 Mesk√≥, 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. 
RelayHealth
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.