Yes Cassie, there is a future in Primary Care

My daughter recently introduced me to a friend of hers via email. She is a newly minted fourth-year medical student who asked me the following question:

"I would love to hear your thoughts about the future of primary care and what it is like to work as a family medicine doctor in Louisville."

To start, I'd encourage you to read this recently published New York Times review of the state of primary care.  If you began in practice today you would quickly find yourself with more patients than you can adequately care for having just left residency and not expecting to see 25-30 patients daily. In Louisville, you will probably be employed by one of three healthcare systems. All of them have compensation based on patient volume and RVUs--I hope someone has showed you what RVUs are but I bet they haven't. Relative Value Units are supposed to measure the "time, skill, training and intensity"[1] of patient care and compensate accordingly. Unfortunately they are heavily skewed toward proceduralists. As Dr. John Mandrola,

Dr John Mandrola

a Louisville interventional cardiologist, observes in his excellent post Thirty Dollars...Really?, a doctor is paid a lot more to do a coronary catheterization than to talk about the causes behind coronary artery disease. To understand a little more why the RVU is skewed that way, here is an excellent post on the Kevin MD blog that summarizes it nicely: The Relative Value of How Physicians are Paid Needs to Change. So in today's environment you need to see more patients than you are comfortable with, spend less time than you deem adequate with them which will promote pill-pushing over explanations. This will mean your risk of burnout will be significant. It is estimated that 43% of Family Practice physicians are burnt out according to a Medscape survey done in 2013.[2]

There is some good news. Value-based care, which bases compensation on how well you take care of patients rather than the number of patients that you see, is coming. In our corporation, systems are being put in place that will help primary care doctors take quality care of their patients and compensate those that do it well better than the ones that don't. Of course how one is measured is controversial as evidenced by this NEJM article from November: Grading a Physician's Value. And data can't be gathered without an integrated EHR (Electronic Health Record) and those are far from prime time. Being a digital native,  you've likely already noticed that EHR software on your rotations is not up to the gaming software standards you are used to.

Social Media, regardless of what city you ultimately practice in, will be the best means of keeping up with the ever-changing landscape of medical advances, political hot potatoes and healthcare tech so if are not following healthcare thought leaders already on Twitter I'd advise you to start that today. Begin with Primary Care Progress (@PCProgress), Berci Mesko (@Berci),

Mike Sevilla (@DrMikeSevilla), John Mandrola (@drjohnmd), Kevin Pho (kevinmd), the Society for Participatory Medicine (@s4pm) and me (@docnieder), of course. If you haven't found ZDoggMD,

that's another must.

Primary Care is alive and, if not well, at least no sicker than the rest of healthcare in the world but I see better things on the horizon. If I were fresh out of residency today I would get my feet wet as an employed physician for a couple of years, making sure your non-compete clause does not include going into private practice but only prevents you from moving to a different healthcare system across the street. Then I'd look long and hard at the DPC movement (Direct Patient Care) and make that my goal. Taking care of patients in an atmosphere that values the doctor-patient relationship above all other business needs is what we go into medicine to do. Physicians in DPC are happier and so are their patients. While it remains a patient care area where it is difficult for lower income patients to access, this may change as this successful way of caring for patients brings down costs and increases quality. I believe that government entities will find ways of incorporating this model into their systems. The  DPC model can be affordable for people who can't afford health insurance but still make a modest living, giving them an option for excellent healthcare at low costs. For now, a physician can use the time generated by working in an upbeat and efficient model to volunteer at community health clinics like the Family Community Clinic

offered by St. Joe's on East Washington St. in Louisville.

So, yes Cassie, there is a future in Primary Care. It is an uphill battle that we need more young, dedicated and digitally savvy doctors to join. The future is exciting. The present is, well, we have a lot of work to do but our patients make it worthwhile. 


1. RVU BASED PHYSICIAN COMPENSATION AND PRODUCTIVITY. Merritt Hawkins. http://www.merritthawkins.com/pdf/mharvuword.pdf
2. Lifestyle and Burnout: A Bad Marriage. Peckham, Carol. Medscape.com. 3/27/2013. http://www.medscape.com/viewarticle/781161

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?

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 http://goo.gl/WAAWki 


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

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. http://www.kevinmd.com/blog/2013/08/reassess-patient-note.html
2. The doctor will see your medical record now. http://www.slate.com/blogs/future_tense/2013/08/05/study_reveals_doctors_are_spending_even_less_time_with_patients.html

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. 

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:

“THE” INTERNATIONAL EVENT OF 2013 IN HEALTHCARE SOCIAL MEDIA & WEB 2.0

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. 

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 Drscore.com 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?

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.

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. 

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. 

Gluten

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.

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.

Cynical Thoughts about Medical Insurance

Is anyone else irritated by medical insurance companies' efforts to improve the health of their members by encouraging them to do recommended tests based on claims-made data? Recently, a patient asked me if he should get the pulmonary function tests his insurance company recommended based on his asthma diagnosis. He does have mild intermittent asthma. He uses a steroid inhaler once a year during the spring for about a month and might use his rescue inhaler with exercise four or five other times during the year. If you check the guidelines put out by the National Asthma Education and Prevention Program it is recommended that a spirometry test or PFTs be performed annually to assess any changes in lung function. The fact is, this patient has been treating his asthma the same way for about fifteen years. He feels fine. So will doing PFTs make a difference? We discussed it (over Christmas and through the patient portal, which I love) and decided that doing testing was unlikely to cause a change in therapy. Since he had better things to do than PFTs he would prefer to skip the tests. Hopefully he won't see an increase in his premium for refusing to follow his insurance company's medical advice. Does this make me worry about becoming nothing more than a flunky ordering tests for patients based on Humana or Aetna or Anthem's "best practices"? In a word, yes.

What irritates me more, is being faxed long lists of patient names with recommendations for mammograms, colonoscopies or diabetic eye exams. Our office is supposed to pull those charts and encourage patients to have their preventive exams. Of course if we do pull them, it turns out the "claims-made" data from the insurance company isn't all that accurate and many patients have already had their tests done. Thus another waste of the office employees' time pulling charts. Hopefully it will be easier with electronic records.

I suppose the cynic in me wonders "What's the angle here?". Does the the upper management of these companies really care about the members they insure that much? Is that what it takes to continue to make the obscene salaries their positions pay (see chart below)? When Humana sends me yet another envelope full of "healthy" coupons in their quarterly newsletter that shows me how much money they saved me with my last doctor visit, complete with lots of "healthy advice" enclosed, why does it make me roll my eyes?

When I want medical advice I will talk to my doctor or find an expert on-line, I will not talk to my insurance company. I do not want or need coupons from Humana. Nor do I want my insurance company to remind me of preventive care visits via my telephone. My patients are thrilled by it, however. "Humana pays for me to go to Silver Sneakers! Isn't that great?" or "A free 30-day Jenny Craig membership is available, what do you think doc?" 

Just call me Thomas, because I am a doubter. Nothing is truly free in the insurance business, so somewhere along the line the consumer is paying for the SilverSneaker membership and the salary of the individual who is soliciting companies to provide coupons from the insurance company. Please, just pay my claims and not give me such a headache trying to obtain my prescription from your 90 day pharmacy service. That's what I would call good service! 

http://www.ama-assn.org/amednews/2012/images/gbisf0531a.pdf

Physician Patient Communication

All professions need good communication skills. Obviously in healthcare the ability to communicate with patients should rank high in a physician's list of talents. These days that interaction occurs in a number of ways: face-to-face, direct telephone contact or though a staff member, via emails, patient portals, or even texting. Because the communication is in the arena of medicine, the protection of an individual's health information is paramount. Enter HIPAA, which is a federally mandated program to ensure patient confidentiality.

The face-to-face form of interaction is the most rewarding because multiple senses are used in the process. First, I listen to the words while hearing the tenor of a patient's voice; a few octaves higher with anger or fear, deep and gnarly from years of smoking, "push" of speech in an anxious or grandiose individual, or an accent that might be heavy enough for me to wonder if there is a cultural or comprehension problem. Sight gives me other cues; body language--crossed arms, angry face, tearful, an open posture, a resigned facial expression, stiff limbs or back. Sometimes my sight reveals more concrete things--bizarre tattoos, picked at sores, expensive accessories, worn and torn clothing. My nose may be assailed by the scent of the smoker, too much perfume, not enough soap, musty clothing or pleasant shampoo--all of that speaks to me. Finally touch--dry and peeling skin, a mass somewhere it shouldn't be whose texture may speak to me of reassurance or of terror. 

The opposite must be true as well. We speak volumes to our patients without opening our mouths, or despite opening them. The tenor of our voices may be patronizing, authoritative or uncertain. Our faces and body language reveal our thoughts with a roll of the eye, crossed arms, or open facies. We can look professional or casual. Smell can be important--what asthmatic wants to see a physician whose aftershave or perfume is overwhelming? Perhaps touch is the most expressive. Early on I learned that even when I don't need to, patients expect to have a "laying on of hands" in some fashion. They may trust you less if you haven't at least looked in an ear or listened to a heart. 

The hardest communication for me is remembering to finish with eye contact and a plan: "We'll contact you with the lab results", "I will have our referral clerk Megan call you" or just "Have a great holiday" instead of rushing out to see the next patient. But the best visits include a hand shake or on a good day, a hug. 

Be Careful What You Wish For

Physician-to-physician communication has become an increasingly difficult problem and its lack has worsened the fragmentation of healthcare today[1]. The challenge is complicated by many things:

• Physicians lack the time to call colleagues about patients when their income is patient volume-based 
• Fewer opportunities for direct physician contact, i.e. the doctor's lounge
• EHR systems cannot talk to each other
• Patients don't always tell their physicians about other doctors taking care of them
• Printed EHR records are so full of verbiage that important findings are missed by the doctors trying to scan pages of unimportant documentation
• Patients rarely carry their health histories with them in any format outside of memory

Another problem, at least in the healthcare system where I work, is the lack of a centralized area where physicians can come together to find community specific information. Blast emails are sent to doctors whose boxes are already full of "junk", making it difficult to separate the wheat from the chaff. Recognizing this problem I recently approached the IT department at my institution. 

It was gratifying to me that they not only understood the issue, but were excited about assisting in a solution. My vision is to create a Physician Community where providers can go to find answers and communicate in a secure environment about any number of issues--problems with EHR, announcements, medical directors' updates, calendars with CME and other dates of interest, blogs, CME, vlogs, links to outside trustworthy medical sites, and a place to crowdsource patient or system problems. IT gave me access to build such a community in a Sharepoint environment. 

Of course in addition to the problem of building the environment and populating it with what the doctors need, is getting them to use it. I feel certain that "If you build it they will come" does not apply in this situation. I envision needing to enlist lots of assistance from the President and CMO of the system down to the office managers and EHR superusers. 

I'm a firm believer that Social Media is the most important revolution in patient care today. Effective electronic communication between physician is part of that movement. But today, as I'm reading Sharepoint for Dummies, I can't help but wonder--what was I thinking and can this make a difference? 

References:

1. Shannon MD MPH, Shannon. peg.org. January/February 2012. http://www.perfectserve.com/resources/docs/ACPE-PhysicianCommunication.pdf

An EHR Fantasy

Now that I've been using my EHR for more than three months, the muscle memory has taken over but there are still only so many clicks I am capable of doing in any given moment. Locating the right forms to insert, deciding how many templates to download, determining if I should plug the microphone back in between patients or carry it from room to room, figuring out the most expeditious way to document in the problem list from a scanned referral note or lab results and finding new ways to record a note, these things are all going to take a lot of time. Yesterday I came across an interesting article by Marla Durben Hirsch from the FierceIT blog: EHR vendors propagating a myth about their products. Amusingly enough, the article made me daydream:

I am in a room with a patient, iPad in hand. With touchscreen input, I easily target any templated buttons with my finger (instead of missing it with the stylus because it's not quite in the 'sweet' spot). There is a graphical interface that's pleasant to the eye, usable and intuitive. Dictation feeds directly into the chart from an adequately programmed microphone IN the iPad, so I don't have to cart a separate piece of equipment with a ten-foot wire. There are separate modules for each specialist and a broader one for me, the family doc. If I misspell a word, there is a spell-checker (incredibly, something my present EHR is without). To show an illustration to a patient I simply double-click the home button and choose the browser for the internet or another app to illustrate a point. If there's a video I'd like a patient to see it's up in an instant. From the iPad I can quickly email links, videos or relevant information to the patient. It rarely crashes, the screen can be enlarged or reduced depending on my needs. It is smaller than a laptop and less obtrusive than paper charts. I add apps specific to my interests or my patients. And they don't cost an arm and a leg. 

Alas I come back to the real world where my stylus still has to be placed just slightly to the left of the circle I'm aiming at. When I suggest to my IT support that hiring gaming developers might be a great way to improve the interface of our present EHR I'm really not kidding. Seriously, making patient documentation something inherently usable would go far to improve the acceptance of them with physicians. Despite claims to the contrary, physicians LIKE tech. We just expect the tech to be user-friendly. More specifically, we expect EHRs to work like the apps on our phones and our tablets. What a joy to look at a screen like this:

From the app iBP by Leading Edge Apps LLC

But no, my screen is riddled with tiny mono-color dots and clickorrhea is the name of the game. 

While patient care is serious there is no reason why electronic documenting could not be a joy to use. As more digital natives enter medicine they will be more insistent that the software they use to take care of patients be as easy to use as the apps they use to monitor their heart rates with exercise, check in with Foursquare, or text their friends. From my perspective, they can't get here fast enough!

The Thanksgiving Z-pack

Emma & Great Uncle Tim

Thanksgiving this year is likely to become one of my favorite holiday memories. My husband's niece, her husband, sister and fifteen-month-old daughter visited from Mississippi. We had a nice time showing them our pretty Louisville Zoo where Emma got a new hat to protect her ears. We ate a delicious turkey dinner, checked out some restaurants and explored Christmas lights in the "MegaCavern" which was an old crushed-stone mine now used for rentable storage and zip-lining.

Belle of Louisville in lights.

My daughters stayed up late with their cousins while Tim took to his job as great uncle with enthusiasm.

This year I was on call for our office which is usually quiet but a long weekend can be busier especially since we elected to keep the office closed on Friday. Typically the calls concern respiratory infections and urinary tract issues.

As I explained the normal symptomatology of an upper viral infection (or cold) to the patient on the phone Thanksgiving day, I noticed my husband's niece listening. When I got off the phone I said, "Everyone thinks a Z-pack is going to make them better. Typically the request for an antibiotic is about halfway through the process and in a few days, they feel better. They assume it's from the antibiotic but in reality, they were going to get better anyway." I could see the wheels turning in her head. "My doctor always gives me an antibiotic." So we talked about the negative aspects of getting an antibiotic every time she has a respiratory infection. The virus won't respond to it but the bacteria that live in and on her can become resistant to antibiotics. She will be at increased risk of developing MRSA--methicillin resistant staph infection, a skin infection that is difficult to treat. If she does develop a bacterial-caused illness such as a true bacterial sinus infection (usually one-sided sinus pain, purulent nasal drainage AND a fever), a skin infection, urinary tract infection or pneumonia, it may take stronger and more toxic antibiotics to kill the organisms. It is even possible that the infection could be fatal. A good over-view of this topic is here.

She was pleased that the pediatrician had not given her daughter antibiotics, even though Emma has been seen several times for various upper respiratory infections and stomach bugs. She commented that most of her friends' children were frequently treated with them. Obviously she can't control what the doctor prescribes for her but maybe next time she will ask, "Is the antibiotic really necessary?" Sometimes that is just the opportunity a provider needs to say "No, it probably isn't. Let's just try a little symptomatic relief and lots of fluid and rest!" Maybe another participatory patient was born this holiday.

A Humbling Experience

As Physicians are becoming aware, consumers of health care products (better known as patients in my world) are increasingly likely to leave reviews of their physicians on sites such as Healthgrades, RateMDs and Vitals. Of course the angry patient is more likely to vent criticism than the satisfied one unless the physician's practice is actively encouraging patients to go to the sites.

I use a service that emails me once a week with my data listings on several rating sites, including the ones included above. Rarely is there anything new but yesterday my email indicated a new evaluation. I clicked on the link and found the following comment, "Rolled her eyes at me with her head bent down when I told her I thought I had something going on--I presume she thought I couldn't see that gesture." Ouch! It is certainly not inconceivable that I did that. It is, however, very unprofessional. Was I burnt out that day? Was I actually rolling my eyes at the computer that tries my patience on an on-going basis? Had it been a horribly unproductive day and I wasn't listening the way I should have been? Whatever the reason the behavior was completely inappropriate. I believe in patient-centered care. No matter what was going on with me that day, my patient should not have felt undervalued and patronized. In checking the patient schedule from the day the review was written and the day before I could find nothing outstanding. Fortunately the review site allows physicians to comment (many don't) so I took the opportunity to apologize. More importantly, this gave me an opportunity to think about my reactions to patients and remember to pay more attention to my interactions, especially on days when I am frustrated or tired.

Physicians have long been protected from such reviews but as more and more "quality" data is released to the general public by the Centers for Medicare and Medicaid (CMS), not only will specific comments from patients be available but sites like Angie's List and Consumer Reports will use that data to rate physician practices.

It's a scary world to physicians, but frankly some days I need a little constructive criticism. The good news is when I get this critique: "Excellent physician. Will not tell you what you what to hear but tells you what you need to know. Does not claim to know it all and will refer to specialists (the best available) without a second thought. I trust her with my life and have for 19 years." 

Price Transparency in Medical Care

As healthcare costs become a bigger and bigger chuck of our Gross Domestic Product (GDP), price transparency is a subject that insurance companies and patients are talking about. The idea of knowing how much something costs, be it canned black beans in the grocery store or replacing the leaking faucet in your kitchen, seems obvious but it will be an uphill battle to enact change within the healthcare system. The concept seems simple--make prices accessible to the people who are paying them just like in any other service industry. While healthcare is more complex than a plumbing job, there are still some things that should be easy to price--cataract extraction, blood pressure check, yearly physical, uncomplicated appendectomy. The hidden prices and unknowns in medicine can quickly add up. It is no wonder that  patients are angry, frustrated and incredulous.

Case in point, my mother called yesterday to ask why she was not told that going to a cardiologist in our system for a test was "outpatient treatment" in a hospital. She had no idea that was the case until the  EOB (Explanation of Benefits) came from her insurance company with a charge specifically associated with that. The answer is that the cardiologists are employees of the hospital so there is an additional fee tacked on to her bill. Even though her visit appeared to be in a doctor's office, it is now an extension of the hospital. As such they tack on a "facility fee" that, while technically allowable, I find distasteful and misleading, even as it is done by my own healthcare system. Talk about a lack of transparency! My mother had no clue and at 84, even if someone did explain it to her, I doubt she understood what they were talking about. Not until she got the EOB from her insurance company did she start to question.

A patient with congenital heart disease told me this week she was putting off getting an imaging study on her heart because she can't afford the $1000 hospital fee that her now-hospital-employed physician would be adding to her bill. One thousand EXTRA billed dollars solely for that reason??? How do hospitals justify this? They state that patients are paying for the "added services" that being a hospital-associated facility affords them, like infection control and patient safety. I doubt anyone thinks paying four times what the doctor charges for a facility fee is justified by patient safety. For another take on this please read: Medical Billing: a world of hurt.

It's encouraging to see patients becoming more involved in this process--pushing for price transparency[1]. Doctors are also beginning to understand that we can no longer hold ourselves above the fray, believing that caring for the patient in the best manner possible without knowing the economic burden that care incurs to the patient or family is not our concern. Best care does include knowing costs. In the meantime, my patient who needs the echocardiogram waits, and hopes for the best.

1. Outofpocket.com. Lori, Mona. Frisbie, Patrick. 11/07/12. Flying Aces Incorporated Inc. 11/10/12 http://outofpocket.com/Blog/2012/11/07/TheBiggestQuestionNoOneIsAskingInHealthCare.aspx

Patient Access to Their Data

The Open Notes initiative has created a flurry of interest in the on-line medical community but not even a blip that I can tell in my personal world. Patients appear oblivious. The story was not covered by our local newspaper. No physicians are nervously or otherwise discussing it in our doctor's lounge.

Despite Meaningful Use criteria breathing down our organizations's neck, which includes patient portals with the capability to obtain their records electronically, no one is talking about this important study: three healthcare systems, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in  Pennsylvania, and Harborview Medical Center in Seattle participated. This included 105 doctors and more than 13,000 patients. When the study was finished 99% of patients surveyed wanted continued access to their notes and NO DOCTORS opted out. 

The last phrase is the most important one to me as a physician. In my world doctors are often very nervous at the thought of patients obtaining access to their own records even though technically the patient owns the record. Yet the more I see of charting, especially electronic charting, the more important it is that patients have the ability to access and help us improve their records. 

As an example, I recently had a new patient who related being involved in a motor vehicle accident many years ago. He'd had surgery shortly after but he wasn't sure whether or not he'd had his spleen removed, though he knew it had ruptured. This is important because individuals who have no spleen are at increased risk of certain kinds of infections and need routine and regular followup vaccinations to protect them. The first thing I did was access records from an abdominal hernia surgery he'd had just a few years ago, to repair a hernia he had as a result of the first surgery. The operating doctor dictated in his note that the patient had had a splenectomy. I wasn't convinced so I dug a little further and fortunately the hospital still had records of the first surgery (by law the hospital does not have to keep records from over twenty years ago). The patient did not have his spleen removed and thus needs neither recurrent vaccinations or  expensive imaging to figure out the answer. But what if I'd just taken the mistaken word of the second surgeon? How much better if the patient had been given easy access to his records years ago when he'd first wondered? 

Soon, patients will have access to their own charts and will be capable of giving much better histories or better yet, will have their medical stories in their own Personal Health Records. This can save a lot in time and unnecessary tests, not to mention improved accuracy in patient records. Because after all, who has more at stake in the accuracy of the record than the patient? Or as e-Patient Dave deBronkart says: