Monthly Archives: May 2013

The Doctor Patient Relationship On The Brink of Extinction: The Impact of Physician Post Graduate Training

It is unfortunate, but now medicine is “on the clock”.  We now must not only battle disease, but we must also battle time.  Physicians are asked to do more in less time.  Innovations such as EMR (which in theory are supposed to increase efficiency) sometimes actually slow clinical practice to a halt.  Additionally, ongoing debate exists as to how best train medical residents and prepare them for the practice of medicine.  Technology and mhealth applications are changing the way in which doctors and patients interact.  Training programs have been evaluated multiple times over the last 20 years and sweeping changes have occurred in the way in which the ACGME regulates the working hours of physicians in training.  These changes have a significant impact on the way in which physicians practice once they have completed their residency and fellowship commitments.

Medicine, more than any other profession, is best learned through experiential training.  “Hands On” contact with patients and families allows residents to immerse themselves in disease and the continuum of care.  Studies from the late 1980s (published in the New England Journal of Medicine) suggested that although resident hours were long and arduous, much of their time was spent doing paperwork and tasks such as drawing blood and transporting patients–even in the era of the 100+ hour week for interns only 20% of the work time was spent in direct patient care.  In the early 2000s with increasing pressure from politicians and other organizations, the ACGME issued a statement limiting the work hours of housestaff to 80 hours per week.  The arguments that led to the limitations in work hours revolved around mistakes and errors during times of sleep deprivation.  Citing patient safety and resident “burn-out” advocates for change stressed that care and learning would both improve if rules were put into place to limit consecutive as well as cumulative work hours.  However, a recent study in the Journal of General Internal Medicine explored the difference in mortality pre and post reform.  Interestingly, there was no overall change in mortality pre and post reform.  In fact, when interviewed, residents and attending physicians complained about the dangers of the “patient handoffs”.  In the old days, the “sign outs” would occur only once a day–in the evening to the on call team. Lists were prepared from every team and a verbal sign out would occur doctor to doctor and team to team.  In the morning, the on call doctors would discuss the overnight patient events with each team and ensure a proper continuum of care.   In the new system with trainees coming and going at different times, there are many opportunities for miscommunication and sometimes important patient care issues get lost in translation.  Many times the night call team is not even associated with the particular service they may be covering and may only cover a night or two here and there–resulting in zero continuity of care and no investment in the overall outcome of the patient.  More importantly, trainees never truly understand the entire course of a disease process as they frequently only see a portion of the span of therapy due to work hour limitations.

Clearly, the current system for training physicians is lacking.  Neither pre reform guidelines nor post reform guidelines are adequate.  This week in the New York Times, author Pauline Chen provides a nice review of the course of reform in medical education.  However, near the end of her essay, Dr Chen makes her most important points–ultimately, by limiting time spent with patients, we are working to eliminate the formation of the doctor patient relationship.  In fact, some data suggests that in addition to a training curriculum for residents most institutions also have a “hidden curriculum” that affects the attitudes of physicians toward their patients once in practice.  If the institution is heavy on paperwork and intern “scut work” there is little time for direct patient interaction.  These training experiences can shape the way in the doctor relates to patients throughout his or her career.  It is essential that we continue to teach doctors how to be healers.  No matter what the working hour limitations may be in the future, we must continue to foster skills for building healthy doctor patient relationships in our physicians in training.   In addition, we must help residents with time management and discover ways to improve the time that they spend in direct patient care while in training.  If we do not, we will find that the art of medicine may in fact be lost forever.

images

 

 

 

Improving Health Status in the US Today: An Ounce of Prevention Is Worth a Pound of Cure…

As Americans we spend more money on healthcare per capita than any other nation in the world.  We have the latest medical innovations and for decades have been able to provide cutting edge therapy without regard to cost.  However, as a profession, doctors are not doing nearly enough when it comes to prevention of disease.  Certainly, costs will be reduced if we are able to prevent chronic illness and associated complications.  By focusing on better health on the front end, we may be able to significantly impact cost on the back end.

An article this week in the New York Times highlights the issue with the American lifestyle and the widespread lack of individual responsibility when it comes to health and wellness.  In the article, author Sabrina Tavernise explores the change that immigrants experience in their health status after living in the US for an extended period of time.  Research has shown that the longer immigrants live in the US, the higher their rates of high blood pressure, heart disease and diabetes becomes.  Scientists have looked at these data and have postulated that much of the change in health status for immigrants is related to the adoption of common American habits such as smoking, drinking, high calorie/low nutrient diets and sedentary lifestyles.  In addition, areas where large populations of immigrants reside often contain large numbers of fast food restaurants–providing easy access to poor food choices.

I believe much can be learned about preventative health from lifestyle research.  Most importantly, studies such as the ones discussed in the New York Times emphasize the significant impact lifestyle choices can have on the overall health of a populations.  As a nation, we must work diligently to reinvent our healthcare system and contain costs.  It is readily apparent that physicians must spend more time providing preventative counselling and promoting better health choices.  Here are my Top Five Points of emphasis for prevention:

1. Education:  It is imperative that we educate patients on risk factors for illness and how they may go about modifying risk.  Patients need to understand the consequences of poor health choices and how these choices may negatively impact them and their families

2. Assessment:  Physicians must spend time in the office with each patient and carefully assess their individual risk.  Diagnostic testing and screening for disease in high risk individuals is warranted. Once testing and assessment is completed, a frank discussion with patient and family is required in order to promote positive lifestyle changes.

3. Empowerment:  Healthcare providers must empower patients to take control of their own healthcare.  Patients must become active engaged participants in the journey to better health in order to impact outcome.  Patients must understand that they MUST take individual responsibility for poor lifestyle choices and work to effect individual change.

4. Encouragement:  Changing lifelong habits can be incredibly difficult.  Patients may resist change and deny risk.  However, physicians must help patients to set reasonable goals, cheer them along their journey and celebrate victories–no matter how big or small.  We must work hard to promote a positive attitude along the way.

5. Reassessment:  Certainly, once lifestyle changes have been made and goals met, it is important to reassess risk.  This may require follow up testing and may result in new goals and other potential therapeutic changes.  However, it is essential to communicate with the patient and continue to motivate them to make positive lifestyle choices.

It is clear that as a nation, we make poor lifestyle choices that may significantly contribute to the development of chronic diseases and increase healthcare costs.  Studies such as the one discussed in the New York Times demonstrate the powerful effects of culture and lifestyle on one’s health and susceptibility to disease.  When citizens from other countries or cultures move to the US, it appears that our lifestyle has a negative impact on their health.  Individual responsibility and patient engagement are critical to prevention of disease.  It is essential that we begin to focus more on prevention in order to gain control of healthcare costs and ensure that all Americans have access to care.

Unknown

The Blogging Patient and Cyberspace: Unlimited Possibilities for Improving Health and Battling Disease

Social media has opened a whole new world for patients.  Now, information about disease is readily accessible and available to everyone.  Certainly, there are issues with reliability and accuracy of internet sources and this can create uneasiness and misunderstanding for both physician and patient.  However, the internet can also provide many new therapeutic possibilities.  In particular, online support groups, twitter chats and blogging can provide a positive outlet for patients suffering with disease.  Today, I want to focus on one of these internet opportunities–the patient blog.  Recently, a online article on iHealth Beat explored this concept  of patient blogging and its benefits.

Just as commonly experienced in the climax and resolution phase of Greek tragedy, writing a blog about one’s experience as a patient can be cathartic.  Patients with chronic illnesses or with a new diagnosis are often confused, frightened and angry.  Numerous studies in the psychiatry literature have demonstrated that journaling or writing about one’s feelings and experiences can have a very positive effect on emotional health.  Journaling has been shown to have several other unexpected benefits as well.  In the age of the internet and social media, journaling is now called blogging.  Blogging can be a private posting (where only you  or those you approve can see) or can be made public for anyone to see.

Blogging can have many benefits that are very similar to journaling.   From a pure neuro-biological standpoint, while you are occupied with writing, the analytical left brain is engaged in the writing process.  This allows the right brain to be free to feel, emote and create.  In this setting, you are able to better understand yourself and the world around you.  Specifically, there are four distinct benefits that patients can receive from blogging that I believe are worth mentioning:

1. Blogging helps to clarify thoughts and feelings:  Often writing down our feelings provides a way for us to better organize our thoughts.  Blogging can help patients with terminal illnesses better understand their disease and how they are reacting or adjusting to the challenges of the diagnosis and/or therapy.

2. Blogging helps you to get to know yourself better:  Writing routinely will help you better understand what makes you happy and content.  Conversely, writing will also help you better understand what people and situations upset you.  This can be incredibly important when battling chronic disease.  It is important that you are able to spend more time doing the things that make you happy and are able to identify and avoid things that are upsetting.

3. Blogging helps you to reduce stress:  Patients who receive a diagnosis of a major illness or who suffer daily with the challenges of chronic disease often have a great deal of anger and resentment.  It is human nature to ask questions such as “why me?”.  Blogging about angry feelings can be a positive and therapeutic release of emotion.  It allows for the writer to return from the blog more centered and better equipped to deal with negative emotion

4. Blogging helps unlock your creativity:  Often we approach problem solving from a purely left brain analytical perspective.  This is how we are taught throughout our education to attack problems in math and science in school.  However, some problems are only solved through creativity and through the use of a more right brain approach.  Writing allows the right brain to creatively attack problems while the analytical side of the brain is occupied with the mechanics of the writing process.

I believe that blogging can be just as important as medication compliance in patients with chronic disease.  The diagnosis of a chronic disease can produce a great deal of stress and emotional angst.  Patients who are able to deal with negative feelings and emotions in a more positive way are better suited to tackling their health problems.  As mentioned above, blogging has many benefits on our emotional health.  By dealing with negative emotions and unlocking creativity, we are better able to deal with the realities of chronic disease and more effectively interact with friends and loved ones.  I encourage everyone–patient, physician, family member or friend–to begin to blog.  I expect that the health benefits of writing will be well worth the time in front of the computer screen and the insights that you may discover about yourself may be be life changing.


shakespeareblog

 

Slinging Mud Over Recalls and Advisories: What About the Patient?

Salesmen in medicine are charged with moving product.  Competition in certain areas such as the Pacemaker and Defibrillator space can be fierce, particularly in a flat or declining market.  Unfortunately, companies often rely on “mud-slinging” and “competitor bashing” rather than on hard data in order to gain market share.  A particularly poignant example is that of the recent battles between Medtronic and St Jude Medical over lead recalls.  Both companies have been dealing with significant recall issues that have negatively impacted thousands of defibrillator patients in the last several years.  In the interest of full disclosure, let me begin by saying that I have no financial stake in either company.  I have been a consultant for both of these organizations over the last 10 years but own no stock.

As I mentioned, both companies have had their share of recalls and advisories.  Some are very significant and can pose a serious danger to patients.  Medtronic has the Fidelis lead and St Jude Medical is dealing with the Riata lead both of which have failed at alarmingly high rates.  Although both companies have a significant lead recall issue, Medtronic’s problems occurred first.  Because of the timing nature of the recall events, more recent press has been devoted to the St Jude Medical lead issues.  In order to gain a competitive advantage, many Medtronic sales representatives in my area have approached doctors with information on the “terrors” of the competitor’s lead rather than focusing on their own product in an attempt to gain market share.  Relying primarily on anecdotal and non documented evidence, the Medtronic push has been to connect known and documented failures in the Riata lead with those of a next generation lead known as Durata.

Recently data was presented at the Heart Rhythm Society scientific sessions in Denver Colorado concerning the failure rate of the controversial Durata leads manufactured by St Jude Medical.  The registry review was scientifically rigorous and was conducted independent of industry sponsorship.  The authors/presenters of the analysis compared their work to clinical trial work as opposed to the current “anecdotal evidence” that has been the basis for numerous articles in the New York Times and Wall Street Journal.  No one argues that the Riata lead from St Jude Medical is a real problem with negative impacts on patients.  However, the assumption that the same issues would occur with newer generation leads appears to be unfounded.  The independent research presented this week indicates that the failure rate of the Durata appears to be less than 1% at 5 years (consistent with some of the best leads in the market today)

Chart below from a Post published by Heart.Org this morning summarizing registry findings on Durata presented at HRS this week 

End point

Failure rate (%)

Freedom from failure at 5 y (%)

All-cause mechanical failure

0.35

99.4

Conductor fracture

0.22

99.6

Insulation abrasion

0.07

99.9

Externalized conductor

0

100

These data were derived from more than 10,000 leads from 3 separate registries.  Althougth we cannot be sure that issues will not arise further into the life of the lead, it does appear that there is a significant misconception about failure rates of the Durata lead in the market today.  The true impact of the Durata lead will not be known for several more years.  Objective study and vigilance is the best course of action moving forward.

To be fair, it is not just an issue with Medtronic and St Jude Medical.  On the last day of the Heart Rhythm Meetings, I received an email sponsored by Boston Scientific displaying a graph that showed the failure rates of Medtronic leads.  It is my assumption that the advertisement email was intended to boost sales of Boston Scientific leads–but instead of touting the performance of their own leads, they focused the reader on the high failure rates of the Medtronic Fidelis lead.  It is important to note, however, that Boston Scientific had a record number of device recalls several years ago–some of which resulted in patient deaths.  For many company executives and PR personnel it must be “out of sight, out of mind”.  I find this type of behavior appalling.

Putting all of this aside, however, the biggest issue with the lead recalls and advisory is the way in which industry handles the fallout.  Some leaders take an offensive approach and rigorously defend the product.  Others push the microscope away from their recalled product and focus on the shortcomings of the competition.  Both approaches, in my opinion, are flawed.  The real issue with lead recalls is the PATIENT.  Both industry and physicians should focus more on the best way to protect patients from adverse events.  Sales and market share must become secondary when it comes to saving lives and reducing morbidity.  (I realize this is not realistic in the business world, but it feels good to say it anyway).  Capitalizing on the failures of competitors and marketing product with a negative sales pitch is dishonorable.  Even though the medical industry is all about making a profit and keeping shareholders happy, I believe that those in the medical space must rise to a higher calling–keeping the safety and well being of the patient at the top of the spreadsheet.  By turning attention to the mission of preserving life and treating those will devastating illness, all of us will ultimately succeed–no matter whose company ID you wear on your jacket.

F2.large

1-s2.0-S1547527112004213-gr3

EQ (Emotional Intelligence Quotient) or IQ (Intelligence Quotient): Which Best Identifies Success in Medicine (and in Business) Today?

Medical education today requires students to assimilate lots of facts and amass an incredible fund of knowledge quickly.  As medical science advances, more material must be mastered.  Medical students must be able to organize facts and apply them to patient care.  Medical care today is becoming more of a team effort.  Successful physicians must be adept at both leadership roles and in the role of a team member (worker bee).  Much of these character traits are also important for success in the world of business and many MBA schools are working to identify students with these particular skills.

Today while reading the Wall Street Journal, I came across an article highlighting a new approach to business school admissions.  As I have blogged in the past, I believe that much of what makes a good business school student, also makes for a good medical student.  In this era of reform and declining reimbursements, a mastery of spreadsheets will be required for all physicians in order to be successful and to remain financially sound.  In the WSJ piece, author Melissa Korn reports on a new parameter for business school admission at the University of Notre Dame–the Emotional Intelligence Quotient (or EQ).  Just as in medicine, business school success requires high energy, high aptitude students.  However, once graduated, these high powered MBAs will need to be able to motivate, inspire and interact with the work force that they lead.  The EQ is calculated from a battery of questions.  Students complete a 206 item online questionnaire that is called a Personal Charateristics Inventory which identifies prospective students with traits such as leadership and teamwork abilities that have been shown to be present in the most successful MBA graduates and world business leaders.  Similarly, the Yale University School of Management uses another Emotional Intelligence Inventory to evaluate their prospective students.  Almost all admissions administrators admit that the EQ is just one piece of a complex puzzle–the challenge is to identify students who will be successful both in the school and beyond in the real world.

In medicine, it is now incredibly important to train physicians who are able to work well in teams–in both leadership positions and as team members.  Moreover, the pressures associated with the practice of medicine in today’s environment result in the highest rates of physician burnout that have been seen in modern times.  In order to get a better understanding of the things that lead to burnout, the University of Ottawa has begun to administer EQ tests to incoming students.  Through the EQ testing they are able to identify certain characteristics such as altruism and resiliency that may be important in developing young physicians.  More importantly, by tracking students use of mental health support services and other indicators they are able to identify students that may be headed for early “burnout” as physicians.  By identifying EQ profiles that are associated with burnout, study leaders hope to be able to intervene early and help students change behaviors that may be self destructive.

Physicians face medical, professional, financial and emotional challenges every single day.  Today’s healthcare environment demands more of providers than ever before.  Successful physicians must not only have high IQs and be able to quickly assimilate knowledge and understanding in a way that can be applied to the care of the sick patient BUT must also be able to relate positively to others and work successfully as both a leader and a member of a team.  Increasing pressures for productivity, electronic documentation and the financial strain of declining reimbursements have contributed to high rates of physician burnout in the last 3-5 years.  The EQ that business schools are beginning to use may be a useful tool for identifying students who are likely to best succeed in medicine.  In addition, the EQ test score may also serve as a good way to identify interns, residents and even practicing physicians who are at risk for early burnout–early identification may lead to early intervention and reduce burnout rates altogether.  However, we must keep in mind that no single parameter is able to identify those who will be successful and those who are prone to burnout.  The EQ is another piece of a complex puzzle that we can use to identify and train the leaders of tomorrow in medicine and beyond.

Unknown