July 1st, 2009 by SteveSimmonsMD in Better Health Network, Primary Care Wednesdays
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When my six-year-old daughter heard that I was going to write about President Obama’s speech to the American Medical Association in Chicago, she offered me this insight: “He’s not a doctor! He isn’t supposed to tell people what to do when they’re sick; he’s supposed to rule the world.” Yet, regrettably, doctors do need his help and it was with great interest that on June 15, the medical community listened.
I suspect that my colleagues in Chicago are the only crowd to boo the President during a speech since his election, and I think that much can be learned by examining why this occurred. Just moments before being booed, Obama received raucous applause when he acknowledged, “that some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue.” Physicians in the audience then booed the next line, “I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed.” The President went on to offer a plan to help physicians avoid practicing expensive defensive medicine. “We need to explore a range of ideas about how to put patient safety first, let doctor’s focus on practicing medicine, and encourage broader use of evidence based guidelines.”
I do not object to President Obama’s sincere and well delivered remarks to the AMA, but found some of them to contain trite platitudes. Encouraging physicians to “put patient safety first, focus on practicing medicine and follow evidence-based guidelines” is like asking airline pilots to pay attention to safety gauges, fly their planes, and respect passengers. I found the admonition to follow evidence-based guidelines as a means to avoid medical malpractice claims a particularly naïve statement. I’m not arguing against using guidelines, I just don’t see how guidelines will protect me from a lawsuit any more than the currently used standard-of-care.
I share the President’s opinion that any individual should have the option of remediation through the court system when wronged but large, punitive settlements change the way hospitals and physicians practice medicine and have resulted in an untold number of unnecessary surgeries as well as causing the actual death of many who never had their day in court. Unreasonably large medical malpractice settlements often have consequences that reach far beyond the parties involved in the original suit. Follow the relationship between cerebral palsy and C-sections and you will understand my assertion. In 1985, then trial lawyer John Edwards won a settlement of 6.5 million dollars against a hospital and 1.5 million dollars from an OB/GYN doctor arguing that if a C-section had only been done for an unfortunate child she would have been born without cerebral palsy. This case set off a chain reaction of suits throughout the country, leading obstetricians to practice defensive c-sections. The United States currently has the highest rate of C-sections in the world, the most expensive obstetrical costs per birth, and when measuring infant mortality ranks 42nd out of 43 industrialized nations.
In 1970, six percent of births in the U.S. were done by C-section; today that number has risen to over 30% while the WHO recommended, in 2006, that the actual rate should be no higher than 15%. Yet, the last four decades have seen the cerebral palsy birth rates remain close to 2 per 1000 live births in the U.S. without change. Considering that women are 4 times more likely to die during a C section than during a vaginal birth it becomes a simple and tragic mathematical exercise. Consider that in Scandinavia the maternal death rate is 3 per 100,000 births while 13 mothers die per 100,000 births in the United States; unless you’re African American–then you count an appalling 34 dead for every 100,000 births. Furthermore, once you have had a C-section there is a very good chance that all future births will be done the same way with an increased rate of hysterectomies, post-operative infections, blood clots, drug reactions, etc.
On the other hand, tort reform has resulted in major shifts in the physician workforce. In 2003 Texas put a cap of a quarter million dollars on malpractice settlements for pain and suffering but did not place a limit on the actual economic loss suffered by a plaintiff. The limit for a wrongful death case was set at 1.6 million dollars. Since 2003 Texas has seen 18% more doctors filing for new medical licenses per year (30% in 2007) and by the end of 2007 there was a 6 month backlog for the medical board to begin processing new license requests. The increased number of physicians has helped to improve access to care. Medical malpractice reform is necessary to avoid the kind of collective defensive behaviors that, ironically, may not be in the best interests of patients.
In my next few posts, I plan to discuss various aspects of our broken healthcare system. It is imperative that we understand all of these problems to avoid making things worse. This will require a probing and honest evaluation of what is wrong today. I also intend to discuss the President’s plans for reform and while I don’t agree with all of his plans, he has put forth many ideas that I do agree with. The time for reform is here, action appears inevitable, and the moment to speak out is now.
Until next week, I remain yours in primary care,
Steve Simmons, MD
June 24th, 2009 by AlanDappenMD in Primary Care Wednesdays
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For 18 years, primary care providers steadily have been eclipsed by “specialists.” It is no longer rare to hear calls for these competent generalists to drive straight to the scrap heap in order to be refitted as procedural, money-making Humvees. What may be implied by this scenario is that primary care providers are selling out so as to allow nurse practitioners to be a more economical, efficient and smarter primary care provider. In fact, such ideas are not impossible if primary care doesn’t take control of their own destiny and invest in their own future. Technology will prove such a pivotal investment.
In my June 10 post, I discussed the five cornerstones of 21st century medical care as presented by a book published by the Institutes of Medicine entitled Crossing the Quality Chasm: A New Health Systems for the 21st Century. The first cornerstone presented a communication-centered medical practice and abandoned the traditional brick-and-mortar idea that “the answers to all medical questions must be delayed until the patient is seen in the office.” Rather than the doctor being the last person to know what’s happening to a patient, a communication-centered model puts doctors at the front of the office, answering phones, emails and internet-generated questions through the day, allowing the practitioner to be the first ones to know what’s happening with our patients. This model could eliminate up to 66% of today’s office visits while simultaneously improving speed of delivery of care, convenience, access, quality and reduce costs.
The second cornerstone that primary care needs to invest in and build is an advanced information management system, which still does not exist. An electronic medical record (EMR) that replaces a paper chart does not adequately explain the real potential of a tool that could transform the generalist.
Information in the communication-centered practice is managed differently than in traditional models. The health care provider, surrounded by phones and computers, is linked to a powerful network with electronic medical records, health information databases, sensitivity-specificity measurements, medical literature, and information about local facilities such as laboratories, pharmacies x-rays, and consultants and their costs, just to name a few linkages.
Imagine information no longer limited by what is in the doctor’s head, but rather, doctors who can access and find the answer to any medical question within seconds by having bookmarks that extend through an entire medical library, and searching for answers would be as easy as: The evidence based guidelines treatment for this problem is “click”… The differential diagnosis for night sweats is “click”… The medicines known to cause “weird smells” as a side effect are “click”… The cost of that test is “click”… The three labs closest to your home where I could fax the order are “click”…The sensitivity and specificity for this test or that symptom or that physical finding to be associated with lupus is “click”…The recommended treatment for this fracture is “click”…The three best articles for helping patients manage and educate themselves about their cholesterol are “click”… The telephone number to arrange setting up the test is, “click”… The facts and comparison for this medicine is… “click” The video link demonstrating the Canalith repositioning maneuvers is in your email box… “click.” Primary care providers help patients work through this information, discerning what is of utmost importance to their medical situation and issue. As it is said, “The role of the expert is to know what to ignore.”
Excellent primary health care requires continuous communication between doctors and patients so as to respond through the evolving and unpredictable twists and turns of illness and treatment . Doctors likewise need connection to the highest quality information and recording systems so as to actualize the science of best “healers”. The idea that doctors should always know the answer to a problem by using memory alone is as misguided as insisting mathematicians return to pencil and paper calculations to prove that they are “real” mathematicians. Despite the potential, primary health care has remained timid to challenge the unexamined assumptions behind the limits of Hippocrates medical practice. Were Hippocrates to return today I imagine him asking, “What have you done?”
Our patients need doctors to step up to the plate and go to bat for them. We as doctors need it too.
Until next week, I remain yours in primary care,
Alan Dappen, MD
June 17th, 2009 by AlanDappenMD in Primary Care Wednesdays
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There was an old lady who swallowed a pill
I know why she swallowed a pill.
To keep her alive.
There was old lady who mailed in her Rx
with wiggles and scribbles written on it.
She mailed the Rx to fill the pills.
I know why she swallowed the pill.
To keep her alive.
I know an old lady who ran out of pills, had no pill to swallow
How absurd she was left to wallow.
She’d mailed the Rx with wiggles and scribbles written on it.
She mailed the Rx to fill the pills
I know why she swallowed the pills,
To keep her alive.
I know an old lady who swallowed her pride
Wouldn’t have cried, she had too much pride.
She called Express Scripts to explain she had nothing to swallow.
She’d mailed the Rx with wiggles and scribbles written on it.
She mailed the Rx to fill the pills.
I know why she swallowed the pills .
To keep her alive.
There was an old lady who swallowed a whopper
“Your Rx was rescinded by your doctor.”
Imagine that, he canceled the order
With wiggles and scribbles written on it!”
She’d mailed the Rx to fill the pills.
I know why she swallowed the pills.
To keep her alive.
I know an old lady who swallowed frustration calling her doctor
She must be off her rocker to call her doctor.
She asked him to swallow his pride she knew he had nothing to hide.
To call Express Scripts about the Rx with wiggles and scribbles written on it.
She’d mailed the Rx to fill the pills.
He fully understood why she needed to swallow the pills.
To keep her alive.
I know the doctor who spent half a day
I dunno why there was such a delay
But a recorded voice during the stall
Said “Faxing an order might get you home before nightfall.”
He wrote another Rx with wiggles and scribbles written on it.
He again faxed the Rx to fill the pills
Saying she had to swallow the pills.
To keep her alive.
I know the old doctor who got back a fax
Saying, “Sorry Charlie. We’re sending this back.”
This medicine doesn’t need “Authorization. “
Just resubmit the Rx with wiggles and scribbles written on it.
What a nightmare to be trapped in midair
And so the doc did, with exclamation points!!!! written on it.
But the old lady never did get those pills,
Finally had to buy them herself.
To keep her alive.
Afterwards, from the above true story:
Generic cost to buy a 90 day supply of the medicine: $ 30
Insurance CEO payment: $30
Local pharmacy payment: $30
Cost of hospitalization without meds: $40,000
Cost to doctor for another “check-up” with his mental health “Provider”: $200
Number of hours of lost human productivity for this case alone: 10
Estimated average annual cost of lost productivity per/ primary care physician managing nonsense: $64,859
Physicians who smile and put up with it: 98%
The gaggle administrators, interfering in the doctor patient relationship: Priceless!
Until next week, I remain yours in primary care,
Alan Dappen MD
June 10th, 2009 by AlanDappenMD in Primary Care Wednesdays
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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
June 3rd, 2009 by AlanDappenMD in Primary Care Wednesdays
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Between what is said and what is not, the truth lies in waiting. Palpate the silence. Hear the double meaning. Smell the hesitation. See the nostrils flare. Watch the direction of the gaze. Feel the tension.
The truth vibrates in myriad ways. It is deep, below the surface. Frank Herbert’s novel Dune illustrates the concept with fascinating fiction. Imagine a people –the Bene Gesserit — genetically bred and trained as seers into the unconsciousness, sensors of the truth, like breathing lie detectors. Little did I know that such truth seers are not just a part of fiction, and although a rarity, live and walk amongst us.
I have met such a seer. Towards the end of my residency training, a gifted psychologist was assigned to follow me as a routine part of our training. I’d become competent and efficient in administering my craft. “My doctoring will impress her,” I thought with some pomp.
Right before the first person we saw, she told me, “Pretend I’m not in the room.” Then, for the duration of the morning, she silently observed the patients I saw and my interaction all while in the back of the room.
After seeing a few patients, we’d break and talk. The patients I saw, I felt, were representative of standard primary care issues: Joe forgets to take his medication. Susan can’t quit smoking. Elaine has unexplained abdominal pain. My medical paradigm explained that Joe, like most people, can’t comply taking continuous medications. Susan is addicted, not interested in quitting smoking until she’s good and ready. Elaine’s pelvic pain is mysterious but not worrisome.
I’m stunned when, after my medical analysis, the psychologist paused, emitting a rueful smile. She sighed knowingly and responded, “Actually, Joe is angry at his wife and defies her by refusing to comply. Susan has unresolved issues with her father who’s probably an alcoholic. Elaine’s pain suggests sexual molestation.”
“Give me a break!” cried a voice from inside of me. And as the days rolled along there were other voices too. “I am a family doctor. This is not medicine! I don’t have time for this! Just what you’d expect from a psychologist; too much Freud!”
As the weeks turned, I reluctantly see her hit nail after nail on the head. She saw complex patterns in people’s behaviors and complaints that I’m too blind, and too unwilling, to see.
With this new, almost astonishing, dimension to medicine, I see, for the first time, art, compassion, insight, and intuition as equal partners to the formulas of science. I slowly wonder what it truly means to be called “a doctor,” when so much is missed in the science of “performance.” I am captivated, begging to know: How does she see? Can I learn? Is she gifted or crazy?
We are in the final days of my tutelage when we meet an enraged Sharon, in follow-up from the emergency room after a miscarriage. She didn’t know she was pregnant, began to bleed, and ended-up in the ER. She was pushed into a back room, left alone for a long time, bleeding heavily. She felt abandoned, angry, and humiliated. The ER attending staff, she insists to me, made her feel like a “slut.” I listen and then promise to investigate and call her back.
In the post-patient meeting I explained to the Bene Gesserit (as I now secretly called my psychologist mentor), “Delays occurred in the ER’s treatment of Sharon and she was over reacting but never in danger.”
“Right about the danger,” the Bene Gesserit concedes, “Wrong about what happened. Sharon had an affair her husband found out about it through the miscarriage.”
Having been humbled too many times, my resistance drops. “What did I miss can you show me?” I beg.
“You sense her over-reaction, her anger, yet dismissed it. Something else fuels her rage. Close your eyes. Pretend to be having a miscarriage right now. I’ll coach you through it.”
“This will be tough.” I think, “I am a man and can’t really miscarry and am sitting in the doctor’s lounge with plenty of colleagues enjoying this play acting.” I close my eyes and settle into a foreign reality. It doesn’t take long to be guided to bells ringing in my head. “I don’t feel like a slut.”
The Bene ignores me and continues, “The vibrations are always there if you tune your antenna to the right frequency. People are pools of water with surface and depth. Illness arises within a context. Ripples on the surface are the symptoms caused from objects thrown-in or vibrations from the past arising to the surface. To reveal this union between the physical and emotional bodies is a unique potential of a healer. “
Sharon’s husband visited my office three days later, chief complaint chest pain. The betrayal was written all through him and verified as forecasted by my mentor. Unnerved I began in earnest to train my own antenna as to reach my fullest possible potential as a healer, a potential only realized by committing the time to listen comprehensively, intuitively, respectfully needed to do so.
Medical care today is all about the quantitative: 10-minute office visits, performance-based measurements, and only the facts. Medical problems are often not simple algebra formulas where the sum equals its parts. Many times healing requires the art of listening, intuition, trust, insight, empathy, grace and even spirituality. It’s not neat, nor quantifiable, but many have journeyed through life enough to know it’s true. Even after all the science has spoken, the art hides itself in myriad ways, patiently waiting.
Until next week, I remain yours in primary care,
Alan Dappen, MD
