A Canadian study published today in the Annals of Internal Medicine suggests that about one third of new prescriptions (written by primary care physicians) are never filled. Over 15,000 patients were followed from 2006 to 2009. Prescription and patient characteristics were analyzed, though patients were not directly interviewed about their rationale for not filling their prescriptions.
In short, patients were less likely to fill a prescription if the treatment was expensive, but certain types of drug indications had consistently higher non-fill rates:
- Headache (51% not filled)
- Ischemic heart disease (51.3% not filled)
- Thyroid agents (49.4% not filled)
- Depression (36.8% not filled)
Overall, hormonal (especially Synthroid), ENT (especially Flonase), skin, and cardiovascular drugs (especially statins) had the highest non-fill rates.
As far as those prescriptions more likely to be filled, antibiotics (especially for urinary tract infections) ranked number one.
Trends towards prescription compliance were seen among older, healthier patients, and those who were switching medications within a class rather than starting an entirely new drug. Patients who received prescriptions from a doctor that they visited regularly (rather than a new provider) were also more likely to fill their prescriptions.
This study was not designed to elucidate the exact rationale behind prescription non-adherence, but I am willing to speculate about it. In my experience, patients are less likely to fill a prescription if a reasonable over-the-counter alternative is available (think headache or allergy relief). I also suspect that they are less likely to fill a prescription if they believe it won’t help them (skin cream) or isn’t treating a palpable symptom (statin therapy for dyslipidemia). Finally, patients are probably nervous about starting a medicine that could effect their metabolism or cognition (thyroid medication or anti-depressant) without a full explanation of the possible benefits and side effects.
I was surprised to see how compliant patients seem to be with antibiotic agents (at least, filling the initial prescriptions). Given the increasing rates of antibiotic resistance, this reinforces the need to limit prescriptions to those agents truly indicated, and to analyze bacterial sensitivities during the treatment process to optimize medical management.
My take home message from this study is that providers need to do a better job of explaining the reasoning behind new prescriptions (their necessity, consequences of non-compliance, and risk/benefit profiles) and reviewing the overall cost to the patient. If a cheaper, effective alternative is available (whether OTC or generic), we should consider prescribing it. Providers can likely improve medication compliance rates with a little patient education and price consciousness. Extra time should be spent with patients at higher risk for non-compliance due to their personal situation (age, degree of illness, income level) or if a specific drug with lower compliance rates is being introduced (Synthroid, statins, etc.) Regular follow up (especially with the same prescriber) to ensure that prescriptions are filled and taken as directed is also important.
One of my biggest pet peeves is taking over the care of a floor-full of complicated patients without any explanation of their current conditions or plan of care from the physician who most recently treated them. Absent or inadequate verbal and written “handoffs” of patient care are alarmingly common in my experience. I work primarily as a locum tenens physician, traveling across the country to “cover” for my peers on vacation or when hospitals are having a hard time recruiting a full-time MD. This type of work is particularly vulnerable to gaps in continuity of care, and has heightened my awareness of the prevalence of poor sign-outs.
Recent research suggests that communications lapses are the number one cause of medical errors and adverse events in the healthcare system. An analysis published in the Archives of Internal Medicine suggests various kinds of consequences stemming from inadequate transfer of information, including missed diagnoses, incomplete work ups, ICU admissions, and near-miss errors. I have personally witnessed all manner of problems, including medication errors (the patient’s full list of medical conditions was not known by the new physician), lack of follow up for incidental (though life-threatening) findings discovered during a hospital stay, progression of infection due to treatment delay, inappropriate antibiotic therapy (follow up review of bacterial drug resistance results did not occur), accidental repeat fluid boluses in patients who no longer required rehydration (and had kidney or heart failure), etc.
It has long been suspected, though not unequivocally proven, that sleep deprivation (due to extended work hours and long shifts) is a common cause of medical errors. New regulations limiting resident physician work hours to 80 hours a week have substantially improved the quality of life for MDs in training, but have not made a remarkable difference in medical error rates. In my opinion, this is because sleep deprivation is a smaller contributor to the error problem than incomplete information transfer. If we want to keep our patients safe, we need to do a better job of transferring clinical information to peers assuming responsibility for patient care. This requires more than checklists (made popular by Atul Gawande et al.), it’s about creating a culture of carefulness.
Over the past few decades, continuity of care has been undermined by a new “shift worker” or “team” approach. Very few primary care physicians admit patients to local hospitals and continue to manage their care as inpatients. Instead, hospitalists are responsible for the medical management of the patient – often sharing responsibility as a group. This results in reduced personal knowledge of the patient, leading to accidental oversights and errors. The modern shift-worker model is unlikely to change, and with the rise of locum tenens physicians added to the mix – it’s as if hospitalized patients are chronically cared for by “float staff,” seeing the patient for the very first time each day.
As a physician frustrated with the dangers of chronically poor sign-outs, these are the steps that I take to reduce the risk of harm to my patients:
1. Attend nursing change of shift as much as possible. Some of the most accurate and best clinical information about patients may be obtained from those closest to them. Nurses spend more face-to-face time with patients than any other staff members and their reports to one another can help to nip problems in the bud. I often hear things like, “I noticed that Mr. Smith’s urine was cloudy and smelled bad this morning.” Or “Mrs. Jones complained of some chest pain overnight but it seems to be better now after the Percocet.” These bits of information might not be relayed to the physician until they escalate into fevers, myocardial infarctions, or worse. In an effort to not “bother the physician with too much detail” nurses often unwittingly neglect to share subtle findings that can prevent disease progression. If you are new to a unit or don’t already know the nursing staff well, join their morning or evening sign out meeting(s). They (and you) will be glad you did.
2. Pretend that every new patient needs an H&P (complete history and physical exam). When I pick up a new patient, I comb through their medical chart very thoroughly and carefully. I only need to do this once, and although it takes time, it saves a lot of hassle in the long run. I make note of every problem they’ve had (over the years and currently) and list them in a systems-based review that I refer to in every note I write thereafter.
3. Apply the “trust but verify” principle. I read other physicians’ notes with a careful eye. Electronic medical records systems are notorious for “copy and paste” errors and accidentally carrying over “old news” as if it were an active problem. If a physician notes that the patient has a test or study pending, I’ll search for its result. If they are being treated empirically for some kind of infection, I will look for microbiologic evidence that the bug is sensitive to the antibiotics they are receiving. I’ll ask the patient if they’ve had their radiology study yet, and then search for the result. I’ll review the active medication list and see if one of my peers discontinued or started a new medicine without letting me know. I never assume that anything in the medical record is correct. I try my best to double check the notes and data.
4. Create a systems-based plan of care, reconcile it each day with the active medication list. I like to organize patient diseases and conditions by body systems (e.g. cardiovascular, endocrine, gastrointestinal, neurologic, dermatologic, etc.) and list all the diseases/conditions and medications currently being offered to treat them. This only has to be done thoroughly one time, and then updated and edited with additional progress notes. This helps all consultants and specialists focus in on their particular area of interest and know immediately what is currently being done for the patient (both in their system of interest and as a whole) with a glance at your note. Since medications often have multiple purposes, it is also very helpful to see the condition being treated by each medication. For example, if the patient is on coumadin, is it because they have a history of atrial fibrillation, a prosthetic heart valve, a recent orthopedic procedure, or something else? That can easily be gleaned from a note with a systems-based plan of care.
5. Confirm your assessment and plan with your patient. I often review my patients’ medication and problem list with them (at least once) to ensure that they are aware of all of their diagnoses, and to make sure I haven’t missed anything. Sometimes a patient will have a condition (otherwise unmentioned in their record) that they treat with certain medications at home that they are not getting in the hospital. Errors of omission are not uncommon.
6. Sign out face-to-face or via phone whenever possible. These days people seem to be less and less eager to engage with each other face-to-face. Texting, emailing, and written sign-outs often substitute for face-to-face encounters. I try to remain “old school” about sign-outs because inevitably, something important comes up during the conversation that isn’t noted in the paper record. Things like, “Oh, and Mr. Smith tried to hit the nursing staff last night but he seems calmer now.” That’s something I want to know about so I can preempt new episodes, right nursing staff?
7. Create a culture of carefulness. As uncomfortable as it is to confront peers who may not be as enthusiastic about detailed sign-outs as I am, I still take the initiative to get information from them when I come on service and make sure that I call them to provide them with a verbal sign-out when I’m leaving my patients in their hands. By modeling good sign offs, and demonstrating their utility by heading off problems at the pass, I find that other doctors generally appreciate the head’s up, and slowly adopt some of my strategies (at least when working with me). I have found that nurses are particularly good at learning to tell me everything (no matter how small it may seem at the time) and have heard time and again that things “just run so much more smoothly” when we communicate and even “over-communicate” when in doubt.
“The Devil is in the details.” This is more true at your local hospital than almost anywhere else. Reducing hospital error rates is possible with some good, old-fashioned verbal handoffs and a small dose of charting OCD. Let’s create a culture of carefulness, physicians, so we don’t get crushed with more top-down bureaucratic rules to solve this problem. We can fix this ourselves, I promise.
I’m excited to announce that US News and World Report has invited me and some other social-media savvy physicians to participate in a live Twitter chat about how to find a good doctor. The chat will be held on Thursday, March 20th at 2pm EST. You can join the conversation by following the #DoctorFinder hashtag or take the pre-chat poll here.
Most people, including physicians, rely on personal references to find a good doctor. But what do you do when you’re far from home, or you don’t know anyone with firsthand knowledge of local doctors? My parents recently asked me to recommend a physician for them in a state where I knew none of my colleagues personally. This is the 10-step process that I used to help them navigate their way to an excellent specialist – I hope it helps others you find the right doctor as well!
1. Determine what kind of doctor you need. You’d be surprised how many different specialists treat the same symptom – depending on its underlying cause. Take “back pain” for example – should you see a primary care physician, an orthopedist, a neurosurgeon, an anesthesiologist, a rheumatologist, or a rehab specialist to evaluate your symptoms? That depends on the cause of the pain, which might not yet be evident to you. The first step to finding a good physician is to figure out which type is best suited to your potential diagnosis. Bouncing from specialist to specialist can be costly, so if you’re not sure which kind of physician specializes in treating your disease or condition (or if you haven’t been diagnosed yet), start with a primary care physician first.
If you’d like to ask an online physician about your symptoms (or find out which specialist would be the most appropriate for you or your loved one), eDocAmerica.com is my favorite online physician consultant service (note that I answer questions for them.)
2. Compile a list of all the doctors (of the specialty you need) in your area. This list can be generated by your insurance carrier or by an online search of doctor-finder databases such as Healthgrades.com, Vitals.com, or US News & World Report’s Doctor Finder directory.
3. Narrow online choices by your preferences (available via Healthgrades.com or Vitals.com databases.) Check out the doctors’:
Years in practice
Types of insurance accepted
Review CV if available (often on affiliated hospital website)
Check out patient reviews (take them with a grain of salt in case they are skewed by an unfairly disgruntled patient)
Make sure they’re accepting new patients
4. Do an online “background check” of your top choices.
5. Make an appointment – consider the following qualities in a good physician experience:
- The team: courteousness of scheduling staff, professionalism of nurses, PA’s, techs, etc.
- Facilities – cleanliness, comfort
- Medical records/communication – how will they provide you your data? EMR? Email?
6. Come prepared
- Bring your list of medications
- Bring a list of your medical and surgical history/conditions
- Bring a list of your allergies
- Bring contact information for your other physicians/providers
- Bring your insurance information
7. Ask the right questions
- How many procedures (like the one I’ll need) have you performed previously?
- What are the risks/benefits of the procedure? Alternatives?
- What should I read to learn more about this?
- If unsure of diagnosis: What else could this be?
- Are there other medicines that are less expensive that we could substitute?
8. Go with your gut
- Did the doctor explain everything clearly?
- Did the doctor seem to care about you?
- Do you trust your doctor to be thorough with follow up?
- Do you like your doctor?
9. Get a second opinion
- If the doctor did not meet your expectations in any significant way, find another one
- If you want to be sure that you’re on the best path, get a second opinion from one of his/her peers or do it online: eDocAmerica (for generalist questions), Best Doctors (to be matched with top national specialists)
10. Reward good doctors with good online recommendations so others can benefit. Physician ratings are only as reliable as the reviewers. Help other patients locate good doctors by promoting those who deserve it.
Thanks to support from OTCSafety.org, I’ve created a series of health tips for common medical concerns. This week’s article is about how to diagnose and treat sleep difficulties in children and adolescents. There are many possible causes of insomnia, which include everything from emotional distress to bad dreams, breathing problems, stomach pains, medical conditions or behavioral problems.
In my article I discuss how you can work with a healthcare professional to determine the cause of your child’s sleep difficulties (this includes details on how to keep a sleep diary). I offer instructive do’s and don’ts to promote healthy sleep, and offer examples of symptoms that may require medical intervention.
For the full article, please click here. I promise it won’t put you to sleep!
I am a huge fan of the winter Olympics, partly because I grew up in Canada (where most kids can ski and skate before they can run) and partly because I used to participate in Downhill ski racing. Now that I’m a rehab physician (with a reconstructed knee) I’m thrilled to have the opportunity to interview Team USA’s Chief Medical Officer, Dr. Gloria Beim. As we enjoy the Sochi Olympic games via our TV sets, keep an eye out for Dr. Beim! Please read on to get her behind-the-scenes account of what it takes to care for and keep Team USA Olympians in tip top shape.
Dr. Val: How did you become the Chief Medical Officer (CMO) for the U.S. winter Olympic team?
Dr. Beim: My practice, Alpine Orthopaedics, is located in an area of Colorado that attracts all levels of athletes, especially elite athletes. I initially entered the elite sports arena in a volunteer capacity at major ski and cycling competitions. Fortunately, my skills and knowledge were noticed at these competitions, which resulted in my servicing a number of medical teams that parlayed me into the world games and Olympic arena. I believe my collaborative, tireless work ethic led to being part of the 2004 and 2012 Olympic Games and as CMO of the 2011 Pan-American Games. Most recently, I was a physician at the World Cup Ski Championships in Beaver Creek, Colo. Between my private practice and my volunteering, I am honored to have been appointed CMO for the Sochi Olympic Winter Games.
Dr. Val: What does being CMO mean?
Dr. Beim: It means overseeing 77 other health care professionals and taking care of 228 U.S. Olympians. As CMO, I work in tandem with a team to deliver the highest level of care to our athletes. We are using the latest technology, evaluating a mix of treatments to ensure peak performance, and are ready to respond to whatever might come our way. It means working long and busy hours during the Games, where the team is faced with everything from common colds and illness to traumatic injury. It also means having compassion and understanding while applying your medical expertise in a fast-moving environment. The days can be long, but it is always rewarding to see our athletes rebound and put their best performance forward. It’s an honor to be a part of that process.
Dr. Val: Give me a “behind-the-scenes” description of what the medical support of the athletes looks like.
Dr. Beim: Well, it looks pretty much like any medical clinic you might be familiar with. There have been dozens of boxes shipped to Sochi in preparation for caring for our athletes. Our doctors can see everything from coughs and flu to sprains and breaks. As a result, we have a very comprehensive team assembled to address whatever health-related need might come through the door. We look at the mix of care providers, such as athletic trainers and physical therapists or chiropractors and massage therapists, to assess and provide the best solution to the problem. Our goal is to have our athletes back on the slope, track or rink as fast as possible, performing at their peak.
I have been learning to speak Russian to interact with local hospitals and facilities. We need to be able to communicate our needs quickly and accurately. At other Games, I have found learning the local language to be valuable in the overall care we can access for our athletes. In addition, it is a lot of fun! I really enjoy communicating with the locals and I know they enjoy it, too.
Dr. Val: Does each country bring their own EMS/MDs/coaches?
Dr. Beim: Many countries bring their own medical team, but not all. The athletes do have access to a polyclinic located at the villages, which can address most of the medical issues that can arise during the Games. These polyclinics are generally staffed with excellent physicians and specialists in many areas, as well as a lot of diagnostic equipment and a full pharmacy. Team USA also will have access to these great polyclinics; however, it is quite efficient and simple for our athletes to receive care and recovery modalities in our own sports medicine clinics.
Dr. Val: Who cares for the athletes if there is a life-threatening injury?
Dr. Beim: There would be a team effort between doctors/specialists/emergency providers from the Olympic Organizing Committee and our Team USA doctors. We feel confident that through our collaborative efforts, we will be able to care for our athletes in just about any situation.
Dr. Val: What kinds of on-site medical facilities are there (one at each event or just a centrally located area)?
Dr. Beim: We are fortunate to have a very comprehensive medical area to treat our athletes. There is a polyclinic at both the coastal village and the mountain village, which will have some imaging capabilities and several specialists as well as a pharmacy. We always will have one of our physicians with the team during training and competitions at the various sites. This gives us the flexibility to provide immediate care should the situation arise.
Dr. Val: How are injuries being prevented?
Dr. Beim: Preventing injury is part of the support we provide. Aiding athletes and coaches to condition appropriately and prime their bodies with good nutrition and recovery efforts while in Sochi is all part of the “whole” care we provide to Team USA. We can use technology to assess and evaluate to ensure our athletes are at their peak to perform. The travel and extreme competition can take a toll on a body. We do our best to keep the athletes healthy in every respect.
Dr. Val: Are there any new technologies being used by the US medical team in Sochi?
Dr. Beim: One of the tools we use is GE Healthcare’s Centricity software. This tool is really amazing and provides our physicians and athletes the ability to communicate health information instantaneously and securely. The software maintains diagnostics, treatment evaluations and test results, and it can all be accessed virtually. This is especially critical when you’re traveling from venue to venue in another country. I have implemented this same software in my private practice through Quatris Health. Now, no matter who is involved in the patient’s care, the health care professional has easy access to all the critical information and can respond accordingly. We also have several GE ultrasound machines that we travel with, which is an incredible diagnostic tool for many musculoskeletal injuries.
Dr. Val: How might other young physicians follow in your footsteps?
Dr. Beim: I would encourage any physician that aspires to this kind of appointment to begin connecting with officials in their area of interest. My work with the U.S. Cycling Team helped build my reputation among other elite sports organizations, where I was able to establish relationships and convey my interest in working with them. It can take a lot of time volunteering, but the work is invigorating and stimulating because you learn so much in the process. I really believe I am a better physician and surgeon because I have had the chance to work in these situations. I can bring that experience back to my private practice, which elevates care for everyone.