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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.
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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.
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We’ve known for quite some time that weight loss can reduce the risk of developing insulin resistance and type 2 diabetes. However, a healthy diet alone (without weight loss) may also help to reduce risk. In a recent Spanish study (published in the Annals of Internal Medicine), 3,541 men and women ages 55-80 at risk for diabetes were followed for an average of 4.1 years. Those who ate a diet rich in fish, whole grains, fruits, vegetables, and olive oil were less likely to develop diabetes than those following other diets of similar caloric value.
This is interesting for a few reasons. First of all, it provides us with insight into the importance of what we eat (and not just how much we eat) for optimum health. When considering how to follow a Mediterranean diet, I think it might be easiest to focus on what is NOT on the menu, rather than what we need to add to our diet. Notice that the Mediterranean diet has very low sugar, refined carbohydrates, processed foods and animal fat (with the exception of fish oil). This is not a low carb or low fat diet. It is a low glycemic-index and unprocessed food diet.
Secondly, calorie-restriction alone may not be the optimal way to reduce the risk of developing type 2 diabetes. In the past we have focused primarily on fat loss for diabetes prevention – through calorie restriction and exercise. We’ve often heard that “a calorie is a calorie” and that folks can lose weight effectively on a low-carb, low-fat, or high protein diet. While it’s true that studies have been equivocal regarding the most effective type of diet for weight loss, and people have been able to lose weight on everything from a bacon and grapefruit to a cookie diet, a deeper look suggests that certain diets really are healthier for us in the long run.
Thirdly, what we eat can have a profound effect on our health, and food is an easily modifiable risk factor for illness. Unlike many diseases and conditions (such as type 1 diabetes and other autoimmune disorders) where we have little to no control over whether or not we contract them, it is exciting to know that a healthy diet is a powerful weapon against disease that does not rely on pharmaceutical products or medical interventions.
And finally, I found this study interesting because it confirms what I have noticed in my own life recently – that cutting out refined carbohydrates and sugars can have a very positive effect on body composition and overall health. I have always had a very difficult time with hunger during calorie restriction, and I finally realized that it had to do with being sensitive to blood sugar spikes and drops from too many refined carbs. Once I cut out all added sugars and white flours from my diet (replacing them with lean protein and whole grains) my chronic hunger resolved and I could settle in to a comfortable relationship with food without constantly battling the scale.
If you haven’t tried the Mediterranean diet, there’s no time like the present. While evidence suggests you’ll be healthier for it, my experience tells me you’ll feel a whole lot better too. Say goodbye to the food craving and hunger cycle, and hello to a new way of healthy eating that can be comfortably maintained for a lifetime.
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I am consistently bemused by those who recommend more rigorous or more pervasive standardized testing as the primary means for insuring physician quality. The vast majority of physicians have already passed through a complex gauntlet of multiple choice exams, extended credentialing and certification processes, and lengthy tests of knowledge and skill. And yet, some physicians (to put it bluntly, sorry friends) are very bad at what they do.
Intellectual intelligence is necessary, but not sufficient, for doctoring. It is emotional intelligence (EI) that is sorely lacking – because it has neither been cultivated, nor selected for, by many training programs. Some educators openly acknowledge the problem, pointing to “extra-curricular activities” as their primary means of distinguishing equally qualified applicants. The disappointing reality is that non-academic performance may be a tie-breaker for students with similar standardized test scores, but raw scores almost always trump any other factor. In the end, we have a physician work force that is highly adept at assimilating and regurgitating facts, but is only accidentally good at human interactions.
Is there hope for change in this arena? I believe that the prognosis is guarded. As our culture becomes more and more digital data-driven, a tsunami of “meaningless use” threatens to drown us all in false quality measures, electronic medical record documentation “quality assurance” requirements, and analysis of trends without comprehension of context or influencing variables outside the scope of the measuring instruments. Lies, damn lies, and statistics. We can’t get enough! And guess who are the biggest proponents of these methods? Why, people who only excel at standardized testing – mostly because their true flaws also lie outside the measuring instruments. Bad doctors (sometimes turned-administrators) themselves are often fueling the onslaught of fruitless quality improvement initiatives.
Dr. Howard Luks, orthopedic surgeon and social media activist, wrote a provocative blog post on the subject of why physicians don’t engage more in social media. He suggests that many avoid it because they lack people-skills in the first place and don’t genuinely enjoy engaging with patients. If you’re a “jerk” in real life, he argues, then what advantage is there to making that more obvious on blogs, Facebook, Twitter, etc.? Better to stay socially quiet.
The interesting thing is that social media might be the most reliable way to discover whether or not your doctor is kind, thoughtful, observant, and detail-oriented. Reading a physician’s thoughts online can help you get to know their true personality and work ethic. In the future it would be nice if medical schools and residency training programs took the time to read applicants’ blogs (for example) instead of crunching their test scores for admission via the path of least resistance. An extra hour of reading up front could save our medical system from a new wave of low EI providers.
As Seth Godin put it, “Uncaring hands are worth avoiding.”
We all recognize the importance of this statement intuitively, but have a hard time quantifying “caring” with standardized tests. That’s why admissions officers and patients alike must use their judgment when selecting doctors. We pay verbal homage to the importance of “clinical judgment” in medicine but in reality are culturally afraid of straying from numbers to support our decision-making.
How will you know a good doctor? You’ll know him [or her obviously] when you see him. And sometimes you can see him best on social media platforms.
A few caveats of course:
1. Social Media is a sensitive but not specific test. Meaning, you can probably accurately identify caring doctors from their blogs, etc. but if they don’t have one, it doesn’t mean they aren’t good/caring.
2. It may not matter if you find a great doctor online if they’re not in your limited ACA network.
3. Direct primary care is a potentially excellent way to get connected to exceptional doctors. I am a fan of this movement and have been actively involved in a practice in VA. The practices can reduce costs and enhance quality care, though recent caps on Health Savings Accounts (initiated by the Obama administration) have reduced consumer freedom to spend pre-tax income on direct primary care.
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Over the years that I’ve worked in acute inpatient rehab centers, I have been truly vexed by a particular type of patient. Namely, the stubborn patient (usually an elderly gentleman with a military or armed forces background). I know that it’s not completely fair to generalize about personality types, but it seems that the very nature of their work has either developed in them a steely resolve, or they were attracted to their profession because they possessed the right temperament for it. Either way, when they arrive in the rehab unit after some type of acute illness or traumatic event, it is very challenging to cajole them into health. I suspect that I am failing quite miserably at it, frankly.
Nothing is more depressing for a rehab physician than to see a patient decline because they refuse to participate in activities that are bound to improve their condition. Prolonged immobility is a recipe for disaster, especially in the frail elderly. Refusal to eat and get out of bed regularly can make the difference between life and death within a matter of days as leg clots begin to form, and infectious diseases take hold of a body in a weakened state. The downward spiral of illness and debility is familiar to all physicians, but is particularly disappointing when the underlying cause appears to be patient stubbornness.
Of course, the patient may not be well enough to grasp the “big picture” consequences of their decisions. And I certainly do not pretend to understand what it feels like to be elderly and at the end of my rope in regards to prolonged hospital stays. Maybe I’d want to give up and be left alone too. But it’s my job to get them through the tough recovery period so they can go home and enjoy the highest quality of life possible. When faced with a patient in the “wet cat” phase of recovery (I say “wet cat” because they appear to be as pleased to be on the rehab unit as a cat is to being doused against their will), these are the usual stages that I go through:
1. I explain the factual reasons for their admission to rehab and what our goals are. I further describe the risks of not participating in therapies, eating/drinking, or learning the skills they need to care for themselves with their new impairments.
2. I let them know that I’m on their side. I understand that they don’t want to be here, and that I will work with them to get them home as soon as possible, but that I can’t in good conscience send them home until it’s safe to do so.
3. I give them a projected discharge date to strive towards, with specific tasks that need to be mastered. I try my best to give the patient as much control in his care as possible.
4. I ally with the family (especially their wives) to determine what motivates them, and request their presence at therapy sessions if that seems fruitful rather than distracting. (Helpful spouse input: “Mike only wants to walk with me by his side, not the therapist.”)
5. I ask loved ones how they think the patient is doing/feeling and if there is anything else I can do to make his stay more pleasant. (Helpful input: “John loves ice cream. He hates eggs” or “John usually goes to bed at 9pm and gets up at 4am every day.”)
6. I meet with nursing and therapy staff to discuss behavioral challenges and discuss approaches that are more effective in obtaining desired results. (For example, some patients will always opt out of a task if you give them a choice. However, they perform the task if you state with certainty that you are going to do it – such as getting out of bed. “Would you like to get out of bed now, Mr. Smith?” will almost certainly result in a resounding “No.” Followed perhaps by a dismissive hand wave. However, approaching with a “It’s time to get out of bed now, I’m helping you scoot to the edge of the bed and we’re going to stand up on 3. One, two, three!” Is much more effective.)
7. If all else fails and the patient is not responding to staff, loved ones, or doctors, I may ask for a psychiatric consult to determine whether or not the patient is clinically depressed or could benefit from a medication adjustment. Typically, these patients are vehemently opposed to psychiatric evaluation so this is almost the “nuclear” option. Psychiatrists can be very insightful regarding a patient’s mindset or barriers to participation, and can also help to tease out whether delirium versus dementia may be involved, and whether the patient lacks capacity to make decisions for himself.
8. If the patient still does not respond to further tweaks to our approach to therapy or medication regimen, then I begin looking for alternate discharge plans. Would he be happier in a skilled nursing home environment where he can recover at a slower rate? Would he be amenable to an assisted living or long term care facility? (The answer is almost always a resounding “no!”) Is the patient well enough to go home with home care services and round-the-clock supervision? Does the family have enough support and can they afford this option?
9. At this point, after exhausting all other avenues, if the patient is still declining to move or eat or be transferred elsewhere, some sort of infection might set in. A urinary tract infection, a pneumonia, or bowel infection perhaps. Then the patient becomes febrile, is started on antibiotics, becomes weaker and less responsive, and is transferred to the medicine floor or higher level of care. Alternatively at this phase (if he is lucky enough not to become infected) the patient might have a cardiac event, stroke, blood clot with pulmonary embolus (especially if he is a large man), kidney failure, or develop infected pressure ulcers. Any of which can be cause for transfer to medicine. In short, if you stay in the hospital long enough, you can find a way to die there.
10. After much hand-wringing, angst, and generalized feelings of helplessness the wives and I review the course of events and ask ourselves if we could have done anything differently. “If I had acted like a drill sergeant, do you think he would have responded better?” I might ask. “No dear, that would only have made things worse.” She’ll reply. I’ll see how disappointed she is in his deterioration, staring off towards pending widowhood, engaging in self-blame and what-ifs (E.g. “If we had only had more money perhaps we could have taken him home with 24 hour nursing care until he was better…” “If I had cooked all his meals, maybe he would have gained enough strength to avoid the infection…” etc.) I try to be reassuring that none of this would have made a difference, myself reeling from the failure to get the patient home.
This 10 step process happens far more often than I’d like, and I certainly wish there were a way to head off the downward spiral with some kind of effective intervention. Would it help to have a volunteer unit of ex-military peer counselors in the hospital who could visit with my patients and help to motivate them to get better? (Operation “wet cat” perhaps?) Should I change my approach and put on my drill sergeant hat at the earliest stages of recovery to force these guys out of bed? Can educating younger law enforcement and military workers about illness help to prepare them to be more compliant patients one day?
I don’t know the cure for stubbornness, but it sure leaves a lot of widows in its wake.