My first instinct was to yell into the phone as loudly as possible.
Run away, run away while you still have time.
But I suspected that the medical student on the the other side of the mobile would have been traumatized. She was just trying to find an attending to shadow. How was she supposed to know that at that exact moment the nursing home administrator had pulled out thousands of computer generated order sheets. Each bearing my hand written signature but apparently now needed to be dated. For ten years I had signed these documents without dating them. But all the sudden some distant regulation had changed, and I was on the hook.
Certainly annoying, but no big deal. At least, no big deal unless taken in context of the rest of my day. It started at 6AM with a phone call from the nursing home announcing a skin tear.
Sorry to wake you doc, we are following the wound care protocol, but its regulations, you know!
Then there was the discharge from the hospital. After seeing the patient and documenting appropriately, a new litany of computer/paperwork: med-reconciliation, continuity of care form, discharge instructions, and a face to face eval.
The office was no better. The papers on my desk had stacked up over the last twenty four hours. I plowed through the hand written narcotic scripts, assisted living history and physical forms, duplicate death certificates, FMLA, and disability questionaires. Of course, the power wheel chair application for my paraplegic patient was denied because I forgot to strike a pertinent negative from the review of systems.
All of this before seeing my first patient and contending with the futility of meaningful use and all those pointless clicks.
The primary care physician is being slowly picked to the bone.
Better to not say a word to the medical student.
Let her shadow me. The facts will speak for themselves.
Another budding radiologist/dermatologist/allergist in the making.
Monday, June 3, 2013
Thursday, May 30, 2013
The Fallacy Of Big Medicine
If you listen to the pundits, the future of medicine is big: big medicine, big data. And indeed the healthcare policy of our nation is couched in the promise of what is to come. Many dictates of the accountable care act focus on the ability to aggregate and consume a variety of inputs. ICD-10, EMRs, and meaningful use all tie nicely into a beautiful computational orgy.
Big data, however, has it drawbacks. One wonders if in usual fashion, politicians and pundits will do more harm then good.
Correlation and Causation
There is a hierarchy in medical data. Every clinician knows that prospective, randomized, double blind studies are the gold standard. The reason why, is that lesser models (retrospective and case study), often are only able to show correlation. Time and time again, we find that clinical decisions based on correlation are faulty. High homocysteine levels are associated with coronary artery disease but bringing them down with folic acid can be harmful. Poor dental health may be related to cardiac disease, but good hygiene has little effect on the risk of heart attack. In a world where the LDL and HDL hypotheses are quickly being disproven, one loses a taste for relying on such logic.
Yet, big data is clearly a correlational model. One can only compare it to the weakest forms of evidence (case control, open label). There is no ability to use it in a prospective randomized manner.
Poor studies lead to poor medicine.
Period.
Garbage In, Garbage Out
I am not a big fan of meta-analysis. The reason why, is often the bias of the investigator clouds the results. If you want certain answers, you ask certain questions. Inclusion criteria can be tricky and bend to the will of those crunching the numbers.
Big data suffers from the same fundamental issues. Who knows the political pressures that will be placed on scientists. If you don't get the answer you want, maybe you have to ask the question differently, query the database more delicately.
Anyone can produce results, but will they be meaningful.
Faulty Inputs
For years scientists have relied on death certificates to understand causes of death in America. But as almost any signer of such documents knows, they are often completed in a hurried, haphazard way. As a physician, I have no reason to care if the cause of death is correct. Often, in fact, I don't even know the answer. It's just another paper to fill out: cardiovascular collapse (whatever that means). A grand majority of times when I review these documents as a medical expert, the cause of death on the certificate is inaccurate.
Big data relies heavily on ICD-9 and CPT codes. Providers often manipulate these codes, however, for a variety of reasons. Want the venous doppler to be covered, say the patient has a DVT (of course you don't know yet because you haven't done the test). Want the blood tests to be paid for by insurance, say the patient has fatigue. The EMR doesn't have a code the suitably fits the situation, just use another, who cares if it's not accurate?
Most of the time these data inputs have no real meaning to the clinician and thus only receive a passing thought. They are another hurdle to providing care, they are to be dispensed with as quickly as possible.
Keeping Our Eye On The Ball
The great task of big data is falling squarely on the shoulders of overburdened clinicians.
ICD-10, CPT, EMR, Meaningful Use, PQRI
Inputting all this data takes huge amounts of time, time that is being taken away from patient care. Years of practice and training has formed clinicians who strive towards perfection. These distractions destroy our attempts at mastery.
No one would think of asking the conductor of a symphony to also collect tickets at the front door in the middle of a performance.
What is gained in knowledge with big data, is lost many times over in faulty, distracted, and poor face to face care.
In Conclusion
We are left with one basic question.
Do we want big medicine, or good medicine?
I'm not sure we can have both.
Big data, however, has it drawbacks. One wonders if in usual fashion, politicians and pundits will do more harm then good.
Correlation and Causation
There is a hierarchy in medical data. Every clinician knows that prospective, randomized, double blind studies are the gold standard. The reason why, is that lesser models (retrospective and case study), often are only able to show correlation. Time and time again, we find that clinical decisions based on correlation are faulty. High homocysteine levels are associated with coronary artery disease but bringing them down with folic acid can be harmful. Poor dental health may be related to cardiac disease, but good hygiene has little effect on the risk of heart attack. In a world where the LDL and HDL hypotheses are quickly being disproven, one loses a taste for relying on such logic.
Yet, big data is clearly a correlational model. One can only compare it to the weakest forms of evidence (case control, open label). There is no ability to use it in a prospective randomized manner.
Poor studies lead to poor medicine.
Period.
Garbage In, Garbage Out
I am not a big fan of meta-analysis. The reason why, is often the bias of the investigator clouds the results. If you want certain answers, you ask certain questions. Inclusion criteria can be tricky and bend to the will of those crunching the numbers.
Big data suffers from the same fundamental issues. Who knows the political pressures that will be placed on scientists. If you don't get the answer you want, maybe you have to ask the question differently, query the database more delicately.
Anyone can produce results, but will they be meaningful.
Faulty Inputs
For years scientists have relied on death certificates to understand causes of death in America. But as almost any signer of such documents knows, they are often completed in a hurried, haphazard way. As a physician, I have no reason to care if the cause of death is correct. Often, in fact, I don't even know the answer. It's just another paper to fill out: cardiovascular collapse (whatever that means). A grand majority of times when I review these documents as a medical expert, the cause of death on the certificate is inaccurate.
Big data relies heavily on ICD-9 and CPT codes. Providers often manipulate these codes, however, for a variety of reasons. Want the venous doppler to be covered, say the patient has a DVT (of course you don't know yet because you haven't done the test). Want the blood tests to be paid for by insurance, say the patient has fatigue. The EMR doesn't have a code the suitably fits the situation, just use another, who cares if it's not accurate?
Most of the time these data inputs have no real meaning to the clinician and thus only receive a passing thought. They are another hurdle to providing care, they are to be dispensed with as quickly as possible.
Keeping Our Eye On The Ball
The great task of big data is falling squarely on the shoulders of overburdened clinicians.
ICD-10, CPT, EMR, Meaningful Use, PQRI
Inputting all this data takes huge amounts of time, time that is being taken away from patient care. Years of practice and training has formed clinicians who strive towards perfection. These distractions destroy our attempts at mastery.
No one would think of asking the conductor of a symphony to also collect tickets at the front door in the middle of a performance.
What is gained in knowledge with big data, is lost many times over in faulty, distracted, and poor face to face care.
In Conclusion
We are left with one basic question.
Do we want big medicine, or good medicine?
I'm not sure we can have both.
Tuesday, May 28, 2013
Do Not Pass Go
I'll give you three nights in the hospital for a a hundred days in skilled nursing.
How bout a lung mass and a go directly to hospice minus room and board?
Oh... your stay was deemed an observation, do not pass go, do not collect a hundred dollars!
I sometimes don't know whether I'm doctoring or playing some insane nonsensical board game. The complexities of sickness and healing have been eclipsed by the administrative nightmare of our payment system. Providers no longer stress over diagnosis and treatment, we huddle with social workers and agonize over disposition. Families no longer sit at their loved one's bedside and hunker down stubbornly in the face of the ravages of disease, instead they pace lonely hallways hoping to bypass the phone tree and speak to an actual person at the insurance company.
Try as we may to manage our patients pathophysiology and psychology, we now attempt to manage their checkbooks. Not only the finances of our patients, but the economic well being of a nation is being placed at our doorstep.
We are not accountants. We are not economists.
We neither created nor profited from the distorted system that we loosely call healthcare (to the extent that others have). Most of the time, we slunk around the edges trying to squeeze the fat to create a few drops of precious water for the parched.
Let the doctors doctor.
For God's Sake, that's what we were trained for.
How bout a lung mass and a go directly to hospice minus room and board?
Oh... your stay was deemed an observation, do not pass go, do not collect a hundred dollars!
I sometimes don't know whether I'm doctoring or playing some insane nonsensical board game. The complexities of sickness and healing have been eclipsed by the administrative nightmare of our payment system. Providers no longer stress over diagnosis and treatment, we huddle with social workers and agonize over disposition. Families no longer sit at their loved one's bedside and hunker down stubbornly in the face of the ravages of disease, instead they pace lonely hallways hoping to bypass the phone tree and speak to an actual person at the insurance company.
Try as we may to manage our patients pathophysiology and psychology, we now attempt to manage their checkbooks. Not only the finances of our patients, but the economic well being of a nation is being placed at our doorstep.
We are not accountants. We are not economists.
We neither created nor profited from the distorted system that we loosely call healthcare (to the extent that others have). Most of the time, we slunk around the edges trying to squeeze the fat to create a few drops of precious water for the parched.
Let the doctors doctor.
For God's Sake, that's what we were trained for.
Saturday, May 25, 2013
I Should Have
There's something strangely heart breaking in the You Should'ves:
You should've treated the infection sooner!
You should've made the diagnosis faster!
You should've done more!
These words uttered accusingly from a patient's mouth can cut to the core of a physician. We've all been there. No matter how rigorous your skills and training, there will be many bad outcomes. Unfortunately, from time to time, a patient or family will point the finger directly at you.
I don't blame them. How else to deal with death, destruction, and illness. Some turn inward. Some point to the heavens and ask why. And some look you in the eye and spit venom in your direction.
I always try to step back and appraise the situation as objectively as possible. I am not infallible. Humans make human mistakes. But often, I find, that bad things happen without adequate explanation. We are both wondrous machines with infinite intricacy and ticking time bombs all at the same time. If I thought accepting the burden of blame would ease the suffering, I would throw myself under the bus without question.
We all know this won't undue that which has already been done.
Yet, there is a menace, even more devastating to the psyche of those who have taken such sacred oaths. I am referring to none other then the havoc wreaked by the I should'ves. Every physician I know is haunted by the times when their skill fell just a little short, their insight was lacking, or their timing was imperfect.
These are the cases that make you toss and turn through sleepless nights. These are the faces you carry year after year.
So you walk into the room of the grieving patient or family. You look these people who love and trust you in the eye, and you tell them of your shortcomings. Mostly they shake their heads and forgive you quickly. It's of little consequence that you shamefully accept the comfort they bestow on you. You will not escape unscathed.
Over the coming months and years,
the wounds you inflict on yourself will do nothing but fester.
You should've treated the infection sooner!
You should've made the diagnosis faster!
You should've done more!
These words uttered accusingly from a patient's mouth can cut to the core of a physician. We've all been there. No matter how rigorous your skills and training, there will be many bad outcomes. Unfortunately, from time to time, a patient or family will point the finger directly at you.
I don't blame them. How else to deal with death, destruction, and illness. Some turn inward. Some point to the heavens and ask why. And some look you in the eye and spit venom in your direction.
I always try to step back and appraise the situation as objectively as possible. I am not infallible. Humans make human mistakes. But often, I find, that bad things happen without adequate explanation. We are both wondrous machines with infinite intricacy and ticking time bombs all at the same time. If I thought accepting the burden of blame would ease the suffering, I would throw myself under the bus without question.
We all know this won't undue that which has already been done.
Yet, there is a menace, even more devastating to the psyche of those who have taken such sacred oaths. I am referring to none other then the havoc wreaked by the I should'ves. Every physician I know is haunted by the times when their skill fell just a little short, their insight was lacking, or their timing was imperfect.
These are the cases that make you toss and turn through sleepless nights. These are the faces you carry year after year.
So you walk into the room of the grieving patient or family. You look these people who love and trust you in the eye, and you tell them of your shortcomings. Mostly they shake their heads and forgive you quickly. It's of little consequence that you shamefully accept the comfort they bestow on you. You will not escape unscathed.
Over the coming months and years,
the wounds you inflict on yourself will do nothing but fester.
Tuesday, May 21, 2013
In Memoriam: Letting People In
They found you in death much as you had been in life.
Alone.
You once told my office manager that I saved you. I shrugged. I couldn't help but feel that I was watching you die day by day. It's not that I didn't try. I fought with you tooth and nail. Begged you to go to the hospital, for anything: a pneumonia, vomiting, I would have been willing to make up a diagnosis. But you told me that hospitals were places that people go to die.
I watched and waited. I scolded that one day I would get a call from the police telling me you were gone. You lived up to that prophecy. I wondered back then how I would feel. I suspected some version of relief. After struggling for months and years, I couldn't help but suffer a certain amount of battle fatigue. I now know more accurately what resides in my heart
Emptiness.
Something strange happens when people let you into their lives. You struggle through their peaks and valleys. You become soldiers in a common battle. In many ways they become a little part of you. The hazard in this profession is letting too many people in.
Because they all die eventually.
And tragically, predictably, a special piece of you goes with them.
Alone.
You once told my office manager that I saved you. I shrugged. I couldn't help but feel that I was watching you die day by day. It's not that I didn't try. I fought with you tooth and nail. Begged you to go to the hospital, for anything: a pneumonia, vomiting, I would have been willing to make up a diagnosis. But you told me that hospitals were places that people go to die.
I watched and waited. I scolded that one day I would get a call from the police telling me you were gone. You lived up to that prophecy. I wondered back then how I would feel. I suspected some version of relief. After struggling for months and years, I couldn't help but suffer a certain amount of battle fatigue. I now know more accurately what resides in my heart
Emptiness.
Something strange happens when people let you into their lives. You struggle through their peaks and valleys. You become soldiers in a common battle. In many ways they become a little part of you. The hazard in this profession is letting too many people in.
Because they all die eventually.
And tragically, predictably, a special piece of you goes with them.
Saturday, May 18, 2013
Embrace The Joy
It's not exactly Dr. Jekyll and Mr. Hyde, but everybody knows my level of patience varies from time to time. So I was surprised to find myself happily telling the emergency room that I would assess the patient shortly. The kids were horsing around on the playground, and I knew I would have to call my wife and ask her to come home. It would be my second forty five minute trip to the hospital on an otherwise busy Saturday afternoon.
For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, listened to the patient calmly, and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn't my life's work make me feel this way all the time?
I guess it starts with one simple fact. I blame myself: every heart attack, stroke, or new diagnosis of advanced cancer. As disturbing as it sounds, how could I not? It takes a certain type of personality to want to be a doctor. A kind of hyper conscientiousness pervades our wounded souls. What else would drive us to study while our cohorts play, or slave away in gross anatomy while our peers receive their first pay checks? And how does one wake up in residency after an hour of sleep with a foreboding sense of nausea and fatigue, and face an overwhelming twelve hour day of patient care?
You learn to believe that your actions matter, that your struggles draw the line between life and death. If you only work harder, stay up later, study more, bad things will cease to happen. This is the promise that drives us through these PTSD inducing situations. And, of course, the joy.
The joy in those fleeting moments where you hold a hand, sigh gently, and become one with the great swath of murky humanity. Those moments are what sustains us through the everyday torture that many of us signed up for eons in advance of the knowledge of what we would be doing.
Half of today's practicing physicians have been irreparably damaged by the experience, and huddle behind walls so impenetrable that patients can't break through their stone faced facade. The other half are trying so desperately to once again feel deeply, and yet not suffocate under the immense pressure of their daily lives.
If your are a patient, I suggest you avoid the former and seek out the latter.
If you are a medical student, you may want to learn how to embrace the joy now,
before it's too late.
For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, listened to the patient calmly, and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn't my life's work make me feel this way all the time?
I guess it starts with one simple fact. I blame myself: every heart attack, stroke, or new diagnosis of advanced cancer. As disturbing as it sounds, how could I not? It takes a certain type of personality to want to be a doctor. A kind of hyper conscientiousness pervades our wounded souls. What else would drive us to study while our cohorts play, or slave away in gross anatomy while our peers receive their first pay checks? And how does one wake up in residency after an hour of sleep with a foreboding sense of nausea and fatigue, and face an overwhelming twelve hour day of patient care?
You learn to believe that your actions matter, that your struggles draw the line between life and death. If you only work harder, stay up later, study more, bad things will cease to happen. This is the promise that drives us through these PTSD inducing situations. And, of course, the joy.
The joy in those fleeting moments where you hold a hand, sigh gently, and become one with the great swath of murky humanity. Those moments are what sustains us through the everyday torture that many of us signed up for eons in advance of the knowledge of what we would be doing.
Half of today's practicing physicians have been irreparably damaged by the experience, and huddle behind walls so impenetrable that patients can't break through their stone faced facade. The other half are trying so desperately to once again feel deeply, and yet not suffocate under the immense pressure of their daily lives.
If your are a patient, I suggest you avoid the former and seek out the latter.
If you are a medical student, you may want to learn how to embrace the joy now,
before it's too late.
Thursday, May 16, 2013
In Which I Respond To A Faithful Reader
Below find excerpts of an email sent by a faithful reader. I have included the whole text, but broken it down to respond to each point accordingly.
I have really enjoyed your blog postings and the sensitivity you showed toward patients. But, your new venture is a real turn off, and makes it hard for me to want to read your posts anymore.
I have been waiting for this. Expecting it. I knew that when I changed my practice model there would be anger and disappointment. For this reason, I have gone to the trouble of telling each patient face to face in the office when they come in for an appointment.
This has been my decision. I will own up to it. I won't hide behind a formal letter or slink out of the room. If patients are upset, I will soak in the anger and accept it. I owe that much.
So far I have received mostly understanding with a smattering of joy and disappointment. My patients know me very well, they don't believe I mean them harm.
My dear reader, sometimes you have to look eye to eye to see into some one's soul. A blog, unfortunately, does not allow for that.
As a patient (not yours), it seems like you are abandoning patients who do not have the money to pay your new fees for which you will take no insurance. Instead of staying in the trenches and finding the insurance battle with them, you seem to be washing your hands of it and leaving them on their own. Onward to people with disposable incomes to pay for handholding.
On the contrary, I'm still taking insurance. For fifty percent of my practice: nursing home, hospice, and palliative care there will be no extra charge. These are some of the most difficult and high risk patients. I will continue to stay in the trenches and battle for them.
I am changing, however, my outpatient primary care practice. I will charge a yearly fee along with billing insurance. The yearly fee pays for uncovered services like home care, cell phone access, and prolonged visits. I believe this is a fair trade off.
My perception may well be wrong. Perhaps I did not listen carefully enough to your explanations. I want to believe that you are who you appeared to be, a great, caring physician. But, I thought that you might like to know that at least one of your loyal blog followers doubts that now. Take care.
I would like to think that I am still perceived as a great, caring physician. I would also hope to be viewed as a strong patient advocate. But the problem is, I can't protect my patients from the ridiculous, pervasive stupidity of medicare and our modern day insurance Goliath.
I can keep bending, and giving, and finding ways to work around the vicious beast. Or, I can choose to step out of the lion's den. I will not be an enabler of this broken system.
Change will only come when doctors and patients alike are willing to stand up and say enough is enough.
I am in the unique position to do just that.
I have really enjoyed your blog postings and the sensitivity you showed toward patients. But, your new venture is a real turn off, and makes it hard for me to want to read your posts anymore.
I have been waiting for this. Expecting it. I knew that when I changed my practice model there would be anger and disappointment. For this reason, I have gone to the trouble of telling each patient face to face in the office when they come in for an appointment.
This has been my decision. I will own up to it. I won't hide behind a formal letter or slink out of the room. If patients are upset, I will soak in the anger and accept it. I owe that much.
So far I have received mostly understanding with a smattering of joy and disappointment. My patients know me very well, they don't believe I mean them harm.
My dear reader, sometimes you have to look eye to eye to see into some one's soul. A blog, unfortunately, does not allow for that.
As a patient (not yours), it seems like you are abandoning patients who do not have the money to pay your new fees for which you will take no insurance. Instead of staying in the trenches and finding the insurance battle with them, you seem to be washing your hands of it and leaving them on their own. Onward to people with disposable incomes to pay for handholding.
On the contrary, I'm still taking insurance. For fifty percent of my practice: nursing home, hospice, and palliative care there will be no extra charge. These are some of the most difficult and high risk patients. I will continue to stay in the trenches and battle for them.
I am changing, however, my outpatient primary care practice. I will charge a yearly fee along with billing insurance. The yearly fee pays for uncovered services like home care, cell phone access, and prolonged visits. I believe this is a fair trade off.
My perception may well be wrong. Perhaps I did not listen carefully enough to your explanations. I want to believe that you are who you appeared to be, a great, caring physician. But, I thought that you might like to know that at least one of your loyal blog followers doubts that now. Take care.
I would like to think that I am still perceived as a great, caring physician. I would also hope to be viewed as a strong patient advocate. But the problem is, I can't protect my patients from the ridiculous, pervasive stupidity of medicare and our modern day insurance Goliath.
I can keep bending, and giving, and finding ways to work around the vicious beast. Or, I can choose to step out of the lion's den. I will not be an enabler of this broken system.
Change will only come when doctors and patients alike are willing to stand up and say enough is enough.
I am in the unique position to do just that.
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