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An Appropriately-Inappropriate Cardiac “Shock”

He was 60-year-old man who underwent surgery for an implantable cardiac defibrillator (ICD) approximately 3 years prior who was returning to the clinic for routine followup. He felt well and had no other complaints.

He was connected to the EKG and the programmer’s wand was placed over the device. I interrogated his device and when the initial screen appeared, there it was — a single shock from his device, received two weeks ago.

“Mr. Smith, are you aware that you had an ICD shock about two weeks ago?”


“Why didn’t you call us?”

“I don’t know.”

“Did it bother you?”

“Not really.”

“Why not?”

There was a pause. I looked up from the programmer and took a quick look at him. He was looking away. Instantly, I realized the answer. Read more »

*This blog post was originally published at Dr. Wes*

The H1N1 Flu Vaccine: Who Should Get It?

mazeIn April I co-authored, Swine Flu Vs. Soap:  Our bet’s on the soap! with pediatrician, Dr. Gwenn O’Keefe, founder of Pediatricsnow.  We gave a brief overview about the swine flu H1N1 and discussed preventative measures.

While the information remains the same in our post, I’d like to now add a little info about the the H1N1 flu vaccine.

Health information about H1N1 is circulating the web faster than tweets zip through cyberspace and it can be very confusing.

It’s like you’re stuck in a maze and you don’t know which way to go to get out.  Information about the swine flu is circulating so quickly that it can even be frightening.  It’s really important that you don’t panic.

Gather your information and talk with you doctors and nurses.

Information about the H1N1 flu vaccine Read more »

*This blog post was originally published at Health in 30*

Making Health Care Affordable From The Bottom Up

Health care’s most important problem (and repeat ad nauseam) is the cost. How do we make health care affordable, cost less, and not inflate three times faster than the background economy?  While politicians and insurance companies rant and rave about saving health care from the top down, there is a nascent movement of doctors who are approaching the same puzzle from the bottom up.

What I mean by the bottom up is that doctors and patients are working together to build an independent system whereby they solve the typical day-to-day, or primary care, problems of health care without anyone else’s help or permission. From the bottom up also means that patients expect to be in control of their day-to-day care. This means paying for the service directly, which is the only real way to gain control. It means doctors are employed by the client, have transparent pricing, look the patient in the eye to explain the charge, and are better able to justify the cost. For the bottom-up means competition and a drive towards quality improvement and pricing that will cost a lot less than having ten people between you and getting what you need.

Here’s a simple example. You have a bladder infection. You had these exact symptoms a year ago so you know what’s wrong and what you need. Yet you’re held hostage by the health care “system” and are unable to get the medicine that has worked in the past.  You’re not alone: these type of infections account for 8.3 million doctors visits a year, primarily among women of reproductive age.

Here are three potential ways that this common problem could be handled:

1. The Existing Model: Your symptoms of burning and frequent urination coupled with barely being able to leave the bathroom are funneled though the appropriate gauntlet: receptionist, scheduler, in window, nurse, doctor, out window, billing specialist, insurance company, payment administrator, adjustor, and finally paperwork mailed to you acknowledging  payment.  Along the way you’re likely to get a urinalysis and several urine cultures.

Since you’re not paying for these tests, under insurance you don’t mind and consider this “good care.”  Your co-pay is $20. The insurance company pays $60 for the visit and the lab tests add another $30. You’re given three days of antibiotics and the problem’s resolved. The cost is $110.00 and 5 hours of your time assuming no major delays in getting into the office.

2. The Reformed Model: This would look very similar to the above system, but might include layers of oversight, fraud detection, pay-for-performance measurers, and “quality” assessment reviews, if one is to believe the rhetoric of people talking about “fixing” health care. Universal coverage likely will delay the wait time to be seen. The current delay for seeing a family practice physician in Massachusetts (the closest thing we have to Universal Coverage) is 63 days.

It’s difficult to believe that this added oversight can reduce costs but let’s pretend it pays for itself  by eliminating the unnecessary labs that evidence based standards repeatedly say provide no added benefit to outcome for simple bladder infections. Cost: at minimum $110.00 and your time: at least 5 hours for a three day treatment of antibiotics.

3. The Bottom-Up Model: Patient calls her doctor who answers the phone and listens to the story. This diagnosis repetitively has been shown to be most accurately diagnosed through history alone. Exam without other contributing factors is not helpful. Urine and cultures are not more sensitive or specific than the history.  The antibiotics are called to the pharmacy. Because you and your doctor know each other and work together to get you the best health care at the best price … and you care about the price …  your doctor might say “By the way I’ll call in a ten-day supply of antibiotics so you can keep a reserve treatment in the future whenever you get this again. This would give you two additional treatments in the future.

Before the conversation with your doctor, he sends you a follow-up email offering an overview of the diagnosis and complications when you should contact him. Cost: $45. Time from call until taking the first pill:  1 hour.

Do the math. Eight million cases times $110.00/ UTI infection case/year. Don’t forget the human toll of  40 million human hours/year wasted in the funnel (link).  The lawyers will want to add a value for pain and suffering too.

Compare this to a direct pay system — innovation wave one from the bottom-up, where you can reach your doctor day or night or even a weekend, take your dose of a prescription within an hour of calling, and have a reserve treatment for the future when inevitably you get the infection again. Imagine being treated like an adult. Frankly, $45 for the convenience is a steal compared to what’s being subsidized now.

Not all cases of bladder infection are cured through this simple formula, but seeing them in the office doesn’t reduce this chance either.  Conservatively, more than half of the cases could be done this way, meaning hundreds of millions of dollars saved  each year on this diagnosis alone. Don’t forget the guesstimated 20 million hours of lost productivity, plus the lost opportunities of railing about how someone else should “fix my health care.”

Going forward, we’ll see what the bottom up has to say about upper respiratory illness, poison ivy, low back pain or tick bites.

Until next week, I remain yours in bottoms-up primary care,

Alan Dappen MD

The Five Cornerstones Of 21st Century Medical Care

Eight years ago, the Institutes of Medicine published a paper entitled Crossing the Quality Chasm: A New Health System for the 21st Century, which envisioned the future medical practices. Many of the concepts discussed were adopted and endorsed in years to come by the American Academy of Family Practice, The American College of Physicians,  the American Medical Association, among others.

The five major innovations of care outlined by this study include:
1.    A communication-centered practice model,
2.    Information management,
3.    Technology replacing office staff,
4.    Reduced pricing and transparency in billing, and
5.    Removing external conflicts of interest between doctors/providers and patients.

Complete adoption of these innovative concepts can cut at least 30% of primary care costs while significantly improving patients’ quality of care, and further reduce overall health care costs by offering immediate and highly accessible care that avoids emergency room visits, enhances wellness, manages chronic illness and diagnoses disease early. These cost savings and quality improvements are enabled by utilization of advanced communications and information technology that replace much of office overhead and staff, and encourage patients to seek the most cost-effective and convenient care possible.  Many medical practices have adopted some of the recommendations, yet less than 1% have transitioned to complete and consistent adoption because they frankly have few financial incentives to do so.

These innovations are the cornerstones of retooling our broken healthcare system, and in turn can pave the way to “fixing” many of the issues plaguing this system. The five cornerstones provide for what so many Americans are clamoring for yet are unable to find: continuous access to a medical provider team thus enhancing patient access, control, and convenience of care; increasing the quality and speed of treatment; reducing the cost of care; creating transparency in pricing; and removing external parties that create conflicts of interest between doctor and patient and often interfere with providing quality and speed of care to patients.

I’ve built my own primary care practice on these five concepts, and while all can significantly lower costs while vastly improving the patient experience,  I’d like to take a look at the concept I find to play a pivotal role: a communication-centered practice model.

A Communication-Centered Practice Model
Twenty-first century, day-to-day-primary care starts with the primary care provider being the first in line to answer a patient’s phone call or email. During this call or email, the provider reviews a patient’s history, and bearing in mind that the provider already knows has a professional relationship with the patient, then can make appropriate decisions.  At least 55% of the time, the patient’s situation does not require an office visit, however instead involves going straight to the pharmacy for medications, going to labs for tests, getting an x-ray, or recommending a referral.   In this model of practice, the doctor spends at least half the time of the time answering phones and emails, thereby providing immediate access and convenience to the patient.

If either the clinician or the patient believes there is a need for an office visit, the visit is arranged immediately.  Patients can talk to their medical expert or an on-call member of the medical team 24/7. This instantaneous access can result in patients having most of their day-to-day  issues addressed within 10 minutes of reaching the practitioner, and can expect care from their personal provider from home, work or anywhere in the U.S.

As mentioned above, over 50% of medical issues can be addressed by telemedicine, specifically by phone or email, as long as a patient-doctor relationship exists. This results in people being healthier and on the road to recovery much faster, thus not taking time off from work.   Office hours are flexible and can be arranged day or night and any day of the week including weekends.

The importance, barriers to adoption, and the unexamined assumptions as to why 97% of all  medical care currently occurs in a medical office and nowhere else has been reviewed in several of our prior postings:

Are Face-to-Face Office Visits Really Required to Provide the Highest Quality Care?
In Defense of Remote Access Medical Visits
The Commonplace Tool That Can Revolutionize Health Care
Telemedicine Care: A Malpractice Risk? Au Contraire …
Telemedicine Checks In On Chronic Health Care Problems

In the future, I plan on taking a look at the additional four cornerstones that need to have traction if the Obama administration hopes to restore vitality to the primary care system.

Until next time, I remain yours in primary care,

Alan Dappen, MD

In Defense of Remote Access Medical Visits

Back in 1983, as a third year medical student, I read a study stating that 80% of medical visits were not needed.  After finishing the text, I remember thinking, “Hmm, there aren’t that many hypochondriacs in our office!”

It wasn’t until I had practiced medicine for 20 years that I finally understood this statement for what it really meant: doctors were not helping patients through remote means, instead insisting on seeing patients in the office for all medical issues, even the most routine of issues out of habit, out of fear, out of how to get paid.

In 1996, I set out to prove that allowing established patients to remotely access doctors for care would improve their medical outcomes. I convinced my medical partners to let me conduct an experiment: I would work a few half days on the phones, fielding medical-related calls from our HMO patients. Since HMO plans paid us a flat rate to take care of them, bringing these patients to the office cost us money and offering these patients medical consults by phone instead, for routine issues, would be more cost-effective for us and a lot more convenient for them.

At that time, the front desk fielded over 500 patient calls a day.  I sat next to the four receptionists, and the HMO screened patients with straightforward medical problems would be triaged to me. I then would speak to the patient, review their medical history and address their medical issue and get them what they needed.  I was able treat 90% of the screened patients I spoke over the phone, while determining that the other 10% needed face-to-face appointments. During a typical 3.5 hour shift, I routinely spoke to 25 patients, and immediately helped 23 of those patients with their medical issues thereby avoiding an office visit.

Unfortunately, the experiment didn’t last long.  To the business managers of the practice, we lost $500 in co-pays while I logged half days on the phone, not billing a single dollar for the practice.  Where I saw opportunity and a new paradigm, they saw lost income.

Thus, I returned to my routine day, seeing 25 patients a day in person, day after day. But drudgery of this led to deepening despair. So many unnecessary office visits, patients upset with their delays, apologies for running late, and meetings about how to see more patients, see them faster, charge the insurance companies more. In some cases all the delays had led to a complication that could have been avoided with more timely care.

Not undeterred, I discretely planned a study in 1999. For two weeks I collected data on each patient I saw. Recording data on a laptop during each visit, I analyzed three questions: How long did we talk, how long did the exam take, how often did I already know what to do through history alone and not due to findings from the face-to-face exam.

Here are the results: I saw an average of 23 patients a day. The longest office visit was 45 minutes, and the longest physical examination of a complicated patient took 10 minutes. Sixty-six percent of my patient visits had no reason to be in the office, with my diagnosis relying on patient history and not being influenced by my physical exam.

On reflection of the data, the implication of the data awoke me to a new realization. I must step outside the “Matrix” that I had been a part of: a healthcare system that often delayed and even held hostage 2 of 3 patients I saw each day.

But making the decision to step outside this system was not easy: why should I risk my medical career as I knew it, and my financial security to do what is best for my patients and deliver them the quality they care they needed?

It was my wife, who, in 2001, finally convinced me to move on. She wrote a resignation letter to my medical practice, a practice filled with respected friends and colleagues. As I sat pondering the risk I’d confront by handing in the letter, my wife reminded me of a familiar refrain, “Ships are safe at harbor, but that’s not what ships are for.”

And so, in 2002, I founded doctokr Family Medicine, a practice that does step outside the typical paradigm of healthcare. My patients control how and when they are seen by our medical team. At doctokr, all of the patients establish their care through a face-to- face visit at the office. We gather their history, review their records and do an exam. After that, all established patients are free to email or call the doctor directly, 24/7.  Over half of patients’ issues are resolved remotely, via phone or email.  Our medical team also sees patients if they want to be seen, or if we feel we need to see them 7 days a week.

As a medical practice with 3000 pioneering patients, we sail on empty oceans but with full faith that we will not have done so in vain. Our experience has shown happier and healthier patients, providers with a mission and passion again and pricing that is 50% less than the current system price of healthcare.

For doctors and patients, staying “safe” behind the many unexamined assumptions in health care makes such harbor risky indeed.

Until next week, I remain yours in primary care,

Alan Dappen, MD

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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