Monthly Archives: April 2013

Twitter Moves Markets: Can It Impact Disease?

For those who are engaged in social media, nothing is more powerful than an active Twitter account. Twitter demands engagement and fosters a sense of community. Medicine, although quick to adopt many new technologies has been slow to embrace social media outlets and, in particular, Twitter. The ability to share ideas and information in 140 characters provides a unique platform for physicians to communicate with one another, with patients and with the world. Twitter allows physicians to teach, to counsel, to support and to dispel rumors and myths. Twitter allows physicians from different parts of the world to consult with one another and share knowledge in order to determine the best treatment plan for a particular disease process or patient. Twitter affords patients with an opportunity to connect with other patients who may have similar medical problems and challenges.

Recently, as many who follow the financial markets are aware, the Dow Jones average took a 144 point plunge in 2 minutes.

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Fortunately, the market quickly rebounded and within a few minutes was back to its opening level. The SEC determined that a tweet suggesting violence or terrorism at the White House was responsible for the plummet. The tweet had been produced from a “hacked” Associated Press (AP) twitter account. As reported in the New York Times today, regulators have taken notice to the power of social media. The incident with the stock market serves to further demonstrate the influence that twitter and other social media outlets can have on human behavior as their repercussions on government and financial institutions. In the case of the Boston bombing tragedy on April 15th, social media and mobile technologies provided much needed evidence and assisted in police efforts to apprehend the men who carried out the senseless attack.

So, why are physicians and other healthcare providers so reluctant to embrace Twitter?

I think that there are several reasons and many valid concerns. Here are some of the most common: (The Top Three Questions I get when discussing social media with physicians)

1. “Silly Rabbit, Twitter is for kids”–Dispelling the Myth

Most often, when I ask colleagues, they respond by saying that twitter is something that their kids use on their iphones. They do not see it as a viable option for a serious medical professional. However, done correctly, Twitter has the potential to impact patients, physicians and healthcare as a whole.

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2.” I’m Late, I’m Late, I’m Late !” Twitter is time consuming–This is absolutely the truth

Providing engaging and meaningful twitter content takes time and research. Physicians must commit to the daily effort of developing new tweets that make people want to follow you and engage in conversation. Just as time management during residency and fellowship was critical to success, time must be set aside every single day and devoted to producing content and engaging with those in cyberspace.

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3. Twitter may not be something my Lawyer wants me to use–Legal implications of online engagement are real.

Before embarking on a social media campaign in medicine, it is essential that you meet with a legal professional and develop guidelines for your social media presence. Understanding exactly what constitutes a doctor-patient relationship and the nuances of HIPAA laws are important considerations. An excellent resource is www.lawandmedicine.com . Victor Cotton, a MD, JD provides wonderful insight into these issues and can be a great place to start. By having a good understanding of the legal issues surrounding online professional interactions and using a little common sense, many pitfalls can be avoided completely.

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So, What is the bottom line?

Twitter is a powerful tool. To date, only a very small percentage of healthcare professionals are engaged. Not surprisingly, the new generation of physicians that are training today are much more involved in twitter and other social media outlets. A recent survey found that 95% of all medical students use at least one form of social media as compared to 40% for practicing physicians. Twitter provides an enormous opportunity to impact disease, educate our patients and interact with and learn from colleagues. WE, as physicians, must act now–we must shape the way in which social media will be utilized in medicine in the future. The time is now–we can move markets AND impact disease

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Docs Sitting on the Dock of the Bay (Phone)…Wasting Time…

Most physicians (depending on specialty) spend between 3-8 years training after graduating from medical school.  During this time, we gain valuable experience in evaluating and treating patients with real problems during our internships, residencies and fellowships.  When learn judgement–when and where to test and when to perform invasive procedures.  On the job experience cannot be replaced.  As housestaff, physicians are witness to all phases of the disease process–the beginning, the middle and the end.

Medicine has changed.  In the past, a physician’s life was dominated by the quest to provide excellent patient care.  Now, medicine is driven by insurance payers, hospital, and government regulations.  Physicians are now required to ask permission to schedule tests and procedures.  No longer is our “experience” and instinct enough.  No longer can we interact with our patient, perform a thorough history and physical exam and then order an indicated test or procedure.  Often we are required to have “peer to peer” case discussions with physicians who are employed by the insurance companies in order to obtain approval to proceed.  Most of the time, these physicians are not trained in any specific specialty and have never performed the procedure they are tasked with approving.  Surprisingly, many of these “approval” physicians have no current experience with clinical medicine.

Today an article in the Wall Street Journal reported on a new study from the Annals of Emergency Medicine published this week that examined the amount of time physicians spend on seeking approvals for psychiatric admissions.  In the study, researchers tabulated the amount of time that physicians spent on the phone obtaining approval for psychiatric admissions as well as the length of time patients spent awaiting approvals in the emergency department.  The study was conducted over a 3 month time period and found that, on average, physicians spent nearly 38 minutes on the phone seeking approvals.  In 10% of  cases the time on the phone exceeded one hour.  Most of the requests (all but one ) evaluated in the study were ultimately approved but resulted in lots of wasted hours for physicians.  In fact, the total time wasted in the study was tallied at more than 1 million hours.  While tied up on the phone seeking approvals, physicians were pulled away from other more important patient care tasks and productivity suffered.  Moreover, ED bed space was occupied for great lengths of time during the approval time–the mean stay was 8 hours and the longest was 20 hours.  ED bed space can be at a premium in a major metropolitan area and the approval process may have resulted in delay in care to other patients.

Certainly, approval delays and physician time waste is not limited to psychiatric admissions.  In order to keep up with the demands of pre approvals from insurers, we have had to create entire departments in our practice with employees devoted to interacting with approval agents from insurance companies.  In my specialty, I often have to seek approval for Implantable Cardioverter Defibrillator (ICD) implantations as well as stress testing.  Many times I have to explain to the “approving physician” exactly what an ICD is and what it is being used for. Often, the “approving physician” seems to be reading from a script provided to them by their employers–and this gives me the impression that they are charged with finding ways to say “no” in order to protect the bottom line of the company for which they work.

This particular study serves as an excellent example of the inefficiencies that occur in the system when insurance companies and regulators are allowed to drive care.  Ultimately care becomes even more fractured and patient care suffers.  If insurers must require approval, I suggest that they find well qualified specialists to review cases rather than physicians who are untrained in a particular specialty.  In addition, streamlining the approval process and requiring less physician time on the phone will be a major step in the right direction. As physicians, we have trained many years to provide care for our patients.  We must be allowed to deliver appropriate care in a timely fashion without hours on the telephone discussing cases with insurers.

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Embracing Technology and Providing Care: The Role of Email and Texting in the Patient Encounter

As we become more connected as a society, it is inevitable that healthcare moves toward more of a virtual online presence as well.  Telemedicine and remote follow up is becoming more common.  I have previously blogged on the importance of the “personal” face to face office visit but at the same time, I embrace the digital revolution in healthcare.  Finding the proper balance is the key to successful integration of technology into the delivery of effective healthcare in today’s changing world.

Recently, an article in the Wall Street Journal addressed the controversies surrounding the use of email communication between doctor and patient.  This practice is fraught with significant legal, personal and professional issues.  Patients certainly deserve prompt answers to their questions and reasonable access to their providers–but should we as physicians be accessible via email 24 hours a day?  The WSJ piece profiles a few physicians and highlights the way in which each uses email to communicate with patients.  Based on recent national surveys, it appears that currently nearly 30% of physicians communicate via email to their patients.  Nearly 18% actually used text messaging to interact with patients.  Estimates suggest that only 5% of American patients included in the survey use email or text to communicate with their physicians or other healthcare providers.

So what are the advantages of email communication?  Physician proponents of electronic communication cite the ease of interaction and the avoidance of “phone tag”.  In addition, physicians who email say that it actually saves them time in the office visit because rather than having to deal with misinformation that patients have obtained via google searches about a particular condition, they are able to provide accurate medical answers when the patient wants them via virtual communication.  Moreover, these advocates also say that the “good will” and positive ratings that are afforded them by patients who are particularly pleased with email access helps them compete in crowded medical markets such as seen in Manhattan in New York City.

Others see electronic communication with patients as problematic.  Obviously there are significant issues with privacy, security and miscommunication of important medical instructions or advice.  In addition, there may be major legal implications when providing access via email or text.  For example, if you provide email and text access to your patients, are you responsible for responding immediately on a weekend or holiday?  If the patient suffers a major negative health event, are you responsible if you did not respond.  I am certain throngs of litigators are licking their chops at this new frontier of frivolous malpractice claims.  Certainly, allowing access during time at home with family and during weekends and holidays may even further reduce a physician’s “down time” and reduce the quality of time spent with family and friends.  With workloads increasing and time away becoming scarce, burnout rates are as high as ever and this type of 24-7 connectivity may lead to even quicker flame outs.  Other physicians cite concerns over reimbursement–time spent emailing and texting patients is unpaid.  With reimbursements falling yet again, providing free services just doesn’t make sense to many providers’ bottom line.

Technology such as email and text can be an incredibly powerful tool in medicine.  I communicate with colleagues and with consultants routinely in this manner.  Departmental business can be easily handled via email communications.  Although many patients certainly enjoy the convenience and speed of email and text access to their physicians, I am not sure the medical system is ready for this interaction at this time.  We must define parameters for these interaction and come up with professional guidelines.  We must ensure that patients remain safe and do not replace important office follow up visits with virtual communications.  In addition, a method for compensating physicians for the time spent in electronic communication must be defined and incorporated into current reimbursement policies.  The trial lawyers must be prevented from taking advantage of the numerous pitfalls associated with email and text communications.  For privacy reasons, we must ensure that messages are encrypted and for medical-legal reasons we must create a way for email and text communications to be downloaded into the electronic medical record in order to fully document all doctor patient interactions that occur.  The digital revolution in medicine has begun–it is going to change the way we do business–it is essential that we guide its development in ways that positively impact outcomes and improve quality of care.

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The High Healthcare Costs of Emergency Department Visits: Stop Pointing Fingers and Begin Offering Solutions

Nothing exemplifies more the complete lack of understanding of the issues surrounding our healthcare system than an article that appeared in the New York Times this weekend.  Author Jane Brody’s piece attempts to address issues with the astronomical costs and misuses of Emergency Department (ED) visits in the US today.  While I agree with Ms Brody that ED visits for routine issues are a waste of resources and money, her suggestion that physicians should be available 24-7 and see office patients on holidays and during weekends shows a complete lack of understanding of the practice of medicine.  In fact, I found her comments to be down right insulting to all hard working physicians.  Many physicians have spent well over half of their adult lives working endless hours in training.  Many relationships, marriages and opportunities to bond with children have been sacrificed all in the name of our very noble profession.  The article seems to suggest that if ONLY physicians were willing to work during “off hours”  and provide cell phone access for patients that the healthcare savings would be enormous.  Reality is that if physicians are pushed to do even more and are provided with even less downtime burnout rates will be even higher than they are now.  In fact, I would predict that this type of access requirement would result in a mass exodus of many talented physicians from the profession entirely.

In a complete bit of journalistic ignorance, Ms Brody actually states in her piece  “many doctors now work 9 to 5 jobs”–I am certainly not aware of any of my peers who are full time physicians that are working these “bankers’ hours”.  In fact, most doctors in my practice work well beyond the traditional 40 hour work week.  As a group practice we ALWAYS have a physician on call for emergencies.  However, we do not have office hours in the evenings or on weekends.  The cost of overhead for staffing and support makes this type of after hours practice completely unrealistic in the current market.  Maybe the solution is for a government funded healthcare system to train more primary care physicians and have government run and owned clinics that are staffed in 24-7 shifts.  The answer is NOT to burden already overworked healthcare providers with more hours, less privacy and more demands.

However, in spite of the abundance of erroneous statements, there are some true statements in the Times article that are worth emphasizing. First, Ms Brody points out that ED care is costly and inefficient.  Some of the blame may be placed on lack of healthcare insurance or lack of personal responsibility for one’s own health.  Countless patients continue self destructive behaviors such as smoking, drug use, alcohol use and other high risk activities.   Some of the blame lies on the “system” with limited access and opportunities for care for some patients (but I do not see the new Obamacare improving this particular issue).  Secondly, Ms Brody correctly points out that engaged patients who actively participate with their physicians have better outcomes and fewer ED visits.  Engagement with a physician does not require having the physician’s cell phone on speed dial–it does require personal contact and routine office visits for preventive care and the ongoing treatment of chronic disease.

One obvious aspect that must be added to any discussion of after hours care must be that of liability issues.  Without tort reform, medical malpractice litigation continues unchecked in this country.  Many competent physicians have been forced out of practice due to escalating malpractice insurance costs.  As Ms Brody references, many “after hours” messages from physician offices do state to “Call 911 or to Go to the ED”–this is a direct response to the irresponsible litigation that has plagued medical practice in the US today.  Physicians are advised by legal counsel to have this type of messaging available in order to protect themselves from lawsuits involving after hours care.  Any real healthcare reform in this country must also include a limit to malpractice awards and the elimination of frivolous lawsuits.  These activities also serve to increase the cost of ED care–ED physicians are often forced to practice “defensive medicine”–and order more tests than a physician in another setting might perform for the same clinical scenario in order to avoid litigation.

Certainly, healthcare costs in this country have become nearly unmanageable.  I do not claim to have the perfect answer or even a complete solution.  The cost of an ED visit is much higher than an office visit with a primary care provider for a routine problem–no one would argue this point.  However, the solution is much more complex than Ms Brody will lead us to believe.  The answer is NOT to have physicians provide cell phone access 24-7 to patients.  The most ideal solution must involve physicians, elected officials, attorneys and patients all working together to reduce costs and provide better care.

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Salesmen in the Operating Room: Whose Best Interest is at Stake?

Industry and medicine are permanently linked together–like it or not.  Attempts to separate them are fraught with difficulties.  Certainly, physicians should have no financial incentives to use any particular product or drug.  Choices of therapy should be based on available data and on what the best treatment for a particular patient may be.  Medical device companies and pharmaceutical corporations have long spent millions of dollars trying to pursuade physicians to use a particular product.  In the past, lavish dinners and trips to faraway destinations were the norm.  In the last 10 years, reforms and government regulations have nearly eliminated these types of activities.   However, in spite of their past “less than upstanding” behavior with physicians, industry is an important source of research and research funding for medical science.  Industry sponsored studies (although often self serving) can provide important data that guide our treatment decisions in complex situations.  In fact, many research studies have changed the way we approach certain diseases and have resulted in better outcomes and quality of life for our patients.

Recently, an article appeared in the New York Times addressing the role of industry in medicine.  The piece has troubled me ever since I read it and I have spent the last week carefully planning my words for this blog.  In the Times, author Roni Rabin, relates a story of a patient who died after a surgeon used a particular new technology in the operating room during a routine procedure.  The surgeon had been trained on the new tool by an industry sponsored “crash course”–common in the the medical device industry.  The sales representatives for the company’s technarology (as evidenced by emails made public in court proceedings) applied pressure on the surgeon to use their device and even attempted to manipulate surgical schedules in order to meet predefined sales quotas by the end of the quarter.  Ultimately the patient had complications during the case and died.  Here, sales and the bottom line of the business became the focus instead of the patient.  The surgeon was “trained” by the company’s standards–not those of the medical community or any academic or FDA regulation or standard.  In fact, company emails even commented “don’t let credentialing of [the doctor] get in the way”.

These business “sales first” attitudes have given all of industry a bad name.  (Like Bon Jovi and Love) Ultimately, these types of behaviors have hurt patients, tarnished reputations and put physicians in compromising positions (many without even realizing it).  We must find better ways to police the actions of industry sales personnel while at the same time working with them to improve care.  Many hospitals have a strict “credentialing” program for sales representatives and require them to produce training certification and check in with a secure badge upon entering the facility.  Many hospitals require reps to wear red colored surgical caps so that they are clearly identified.  As I mentioned earlier, company support is often essential when using implantable technology and improving the science of medicine through research.  However, physicians must also be mindful of the fact that ultimately these folks are there to produce sales.  As physicians we are held accountable for quality and standard of care.  Salespeople are held accountable for the bottom line.  As physicians, we have trained for many years to be considered competent in our specialties–therefore we should certainly feel a little strange when a company says that they can train you to implant a new medical device or use a new technology during a weekend “crash course” in Mexico.  We must carefully evaluate new technology and ensure that we all have a good understanding of it before venturing out into the world to use it on patients without supervision.  I believe that comprehensive proctored training by competent experts is the best way to train physicians in new technology.  It should be the opinion of the proctor–not the company–as to when the physician is properly trained and ready to proceed.  Hospital credentialing committees should require careful documentation of legitimate proctored training prior to allowing a physician use a new device or technique independently.

As I mentioned at the outset, this blog topic has troubled me for  weeks.  I firmly believe that industry must play a role in the care of patient thru  research  and development of  new technologies.  However, it may be best if the personnel in the OR representing the company have no vested interest in sales.  These individuals should be trained as engineers and should be compensated in a different manner than the commission driven sales representative.  Physicians and credentialing committees must look carefully at how new procedures and technologies are brought into the hospital and how operators are trained.  It may be that industry can pay for the training but not be directly involved in the proctoring or certification process.  Food for thought….


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Improving Patient Outcomes Through Prevention: Fitness and the Physician

As physicians, we are all held to a high standard.  It is our responsibility to care for patients and their families.  We must assimilate knowledge and apply it to individual patients and their diseases.  As healthcare costs continue to rise to even higher levels, prevention of disease becomes incredibly important.  As healthcare reform is phased in, more documentation of preventive care counseling is going to be required.  Physicians must ask about smoking, exercise, alcohol use and diet.  Weight control and striving for optimal body weight is critical in prevention of many chronic diseases such as diabetes, heart disease, hypertension, arthritis and sleep apnea.  However, often counseling is not enough–as physicians, we must lead by example.

Physicians who practice fitness in their own lives are much more credible when given advice to patients who may be overweight or deconditioned.  Recently, an article in the Cardiovascular Business addressed the issue of inspiring and motivating patients to make lifestyle changes.  Researchers examined studies on physical fitness, exercise and attitude and created a meta analysis that was presented at an AHA scientific session in New Orleans last month.  The findings were quite profound.  If physicians counseled patients and THEN provided referrals to community support groups or organizations, patients were more likely to effect change and make important lifestyle moves that improved their overall health.  Even more impressive was the fact that the analysis showed that if the physicians who were doing the counseling were more physically fit and DEMONSTRATED a lifestyle with healthy habits, patients were much more likely to “buy in” and change their own lifestyles.  Moreover, 23 observational studies which were included in the analysis, showed that physicians who participated in physical activity and had healthy lifestyles were much more likely to counsel patients in the first place.

As I reported in my blog from February 2012, a study in the journal Obesity, studied over 140,000 physicians and found that overweight physicians were unlikely to bring up weight loss and diet and other important preventative medicine topics during routine office visits.  However, those who regularly exercised and had more optimal body weights were much more likely to discuss these issues.  This particular study received a great deal of press in the New York Times and I believe that there are many lessons from these studies that will benefit both doctor and patient.  First of all, in order to be most effective in treating and counseling our patients, we must strive for better health ourselves.  Although the demands of our jobs often make good nutrition and exercise difficult, MAKE time for fitness.  Share your own personal journey to better health with your patients.  As a healthcare provider, we can inspire our patients and show them the way to better health.  In the US today, we spend more money per person on healthcare and disease than any other industrialized country in the world–as a corollary, the US is the most OBESE country in the world as well.  We can and must make an impact in nutrition and fitness in order to help control costs and prevent disease.  Counseling in the office may not be enough–use community resources to help patients along the path to better fitness.  Referrals to nutritionists, personal trainers, weight loss groups and supportive gyms can make the difference between success and failure.  In particular, learning better nutrition habits may be the critical part of the entire process.  Locate a registered dietician in your area of practice and partner with them.  Consider bringing a nutritionist into the office to see patients a few days a week.

As physicians, we must set the example.  We must strive for better fitness and nutrition and avoid habits such as smoking that can have a profound negative impact on health outcomes.  The key to the future of medicine in prevention.  The key to prevention is proper counseling, follow up and patient referral to appropriate community resources.  Most importantly, physicians must “practice what we preach” and demonstrate a healthy lifestyle to the patients we care for every single day.

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