Monthly Archives: July 2013

Providing The Best Care For Our Patients: Sometimes An Old Dog Must Learn A Few New Tricks

When I was in training at Duke University Medical Center, we prided ourselves on practicing evidence-based medicine.  During my tenure there, Dr Robert Califf had constructed the clinical research mecca known as the DCRI (Duke Clinical Research Institute).  As cardiology fellows in training, we were all actively engaged in clinical trials and quickly understood the importance of choosing therapies that had been proven to be safe and effective through rigorous evaluations in randomized controlled clinical trials.  (RCT).  In fact, when making rounds in the coronary care unit (CCU) with my attending physician, I can remember being chastised because I had prescribed an ACE inhibitor without mortality data rather than one that had been proven to save lives.  In the eyes of my attending,  I had wrongly assumed “class effect” and had used an unproven therapy.

This week in the New York Times, author Nicholas Bakalar explores the same issue in today’s medical practice.  In a recent publication in the Mayo Clinic Proceedingsinvestigators evaluated 10 years of published studies in a single high impact journal.   Of the studies evaluated, 367 represented an examination of a well established medical practice or therapy.  Surprisingly, 147 of these studies of established practices found that the accepted therapy was no better or even worse than the alternative treatment practice.  Of these well established treatment practices that were examined, nearly 40% were found to be ineffective or actually harmful to the patient.  However, physicians continued to utilize these particular therapies.  Why?  What can we do to effect changes in practice?

Old habits die hard.  Often, in medicine, the momentum it requires to make a change in practice can be overwhelming.  We often do things because mechanistically, they just make good sense.  Many physicians that are procedure-oriented like myself fall into the trap of believing that if we are able to impact the cause of a problem or change the course of the disease, that the outcomes will be improved.  This is not always the case.  For example, in the case of coronary artery disease, it makes sense that if we “un-block” an occluded coronary artery, we should be able to make the patient live longer.  In fact, the data clearly shows that angioplasty and stenting are valuable in relief of symptoms but have no impact on mortality.  This does not necessarily mean that we should not revascularize patients percutaneously BUT it does mean we must understand the true impact our revascularization procedure will have on the patient and their quality of life.

In medical school, most physicians were trained to think as scientists.  The scientific method suggests that scientists should evaluate a problem in the following manner:  1. ask a question, 2. make a hypothesis, 3. develop a “test” for the hypothesis and then 4. Collect and interpret the results.  As practicing physicians, we must continue to think like  scientists and look for evidence to guide our clinical decision making.  We must ensure that even if we believe that a particular treatment makes good biologic and mechanistic sense, it must still be proven effective by rigorous clinical trial evaluation–if it is not or if it is shown ineffective, we must find alternative therapies without delay.

Medicine remains an art.  The way in which we are trained has a significant impact on how we practice later in our careers.  In residency and fellowship, we are taught the current, state of the art therapies for that particular time.  Thankfully, medicine is not static–innovations and improvements in care occur almost every day.  We must learn to adapt to changes in the “state of the art” as medicine continues to advance.  A good scientist (and a good physician) continually evaluates the “state of the art” in order to see if there are better ways to treat and serve our patients.  It is essential that we continue to practice evidence based medicine and provide the best PROVEN therapies  (and reject those that are found to no longer be effective)–even if it means and “old dog” must learn a “new trick”

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The Future of Medicine: Coding For An Orca Bite

When I was in medical school in the mid-1990s at Wake Forest University, the only thing I knew about “codes” was how to use an ATM machine (which was often linked to a very empty bank account).  As my training progressed through internship, residency and fellowship, the idea of coding provider services never even crossed my mind.  No one taught me anything about the “levels of service” or what an ICD-9 (The International Classification of Diseases) code actually was even though the coding system has existed for more than 30 years.  I remember my teachers and mentors scribbling on a card in the front of the chart whenever they interacted with a patient, but I had no idea what the exercise was about.  Years later, I am all too familiar with coding of patient services.

Billing codes serve as a way for the Center for Medicare and Medicaid Services (CMS) to create a payment schedule for services rendered based on diagnoses.  Each diagnosis is given a particular code and then there are “modifiers” that attempt to make the billing code more specific.  Government bureaucrats created a massive list of poorly contrived codes that have been utilized for the last decade known as ICD-9.  Over the years, those responsible for these codes have realized that in order to accurately document medical conditions and improve billing accuracy (and reduce fraud) that these codes are in need of updates.  Thankfully, our government has been working on this new system tirelessly over the last several years.  In fact, the Wall Street Journal reported on the development of this new brilliant system as early as 2008.  Next year, the new set of billing codes will go into effect–they have been created with the goal of improving the specificity of the diagnosis and improving care (through quality measures).  This brilliant work and expansive list of new codes (approximately 150,000 codes as compared to the current 18,00) includes such ingenious diagnoses as code W5621XA “bitten by an orca, initial encounter”.  Another important code that has been created is the commonly used W6112XA-”struck by a macaw”.  As a practicing physician, I am relieved that when the next patient who visits my office after suffering “a burn due to water skis on fire”–I can quickly and easily document the encounter using the ICD-10 code V9109XA.

As government seeks to continue to regulate healthcare and contain costs, it seems to me that our efforts in reducing costs and improving quality of care are a bit off track.  Instead of working to improve efficiency and reduce redundancy in healthcare, we are now focusing on creating codes for injuries that may only occur to Wile E. Coyote during an epic battle with the RoadRunner.  As a physician, I have been required to complete nearly 20 hours of online training to help me understand the new ICD-10 coding system.  After an endless marathon of computer modules, I still have no idea how or why the ICD-10 system will improve my ability to care for patients or improve either the efficiency or quality of care in my practice.   In fact, I am certain that the new coding system will actually add more hours of documentation to my already burgeoning pile of electronic paperwork.  Eventually something has to give….there are only so many hours in the day.  Personally, I would rather see patients and care for those that need my help rather than coding for an attack by a talking bird or a personal watercraft injury due to burning water skis.

Our healthcare system has lost its way.  The new coding system is just one example of misplaced priorities within regulatory agencies.  Instead of creating codes for ridiculous scenarios, we should be training docs to provide thoughtful efficient care. We should be teaching doctors to communicate with each other about patient care and to avoid unnecessary testing.  Time, money and energy could be much more effective if spent on engaging patients in preventative care strategies and modification of risk factors.  Until then, I can at least sleep well tonight knowing that there is in fact an ICD-10 code for the next patient who walks in my office after being “hurt at the opera” …I will be able to quickly use code Y92253.

Please note:  All of the codes mentioned in this blog are REAL.  They are all part of the 150,000 codes that doctors and billing specialists are supposed to know and implement in the next year.  You can verify all codes by using this ICD-10 code look-up website

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Guest Post: Musings on General Medicine at a Teaching Hospital

The Following Post is Written by Dr Deborah Fisher, Associate Professor of Medicine, Division of Gastroenterology at Duke University Medical Center.  Dr Fisher is both a brilliant clinician, writer, and researcher…and also happens to be my wife. http://www.durham.hsrd.research.va.gov/cv/Deborah_A_Fisher_MD_MHS.asp

Usually I spend about 65% of my time in clinical Gastroenterology and 35% in research, but 4 weeks a year I put on my General Medicine hat and supervise the housestaff.  General medicine is more challenging than ever because of resident time restrictions, multiple patient care hand-offs, and the increased administrative burden for all physicians (in-training and supervising). For readers not familiar with the academic calendar, it runs roughly July to June rather than January to December. This past General Medicine rotation I drew the lucky card of July.  Or so several administrators would have me think.  “Residents are enthusiastic in July, no burn-out” “They don’t argue with you” “They treasure every clinical pearl you offer” and the like.  Perhaps.  I must admit that residents rarely argue with me during any month and often General Medicine induces burn-out in even the newest residents.

Nonetheless, I thought it might be less pressure to teach in July.  The classic Chalk Talk is all but gone.  Allegedly, residents are all self-teaching basic pathophysiology and differential diagnosis during the time carved out by duty hour regulations, but the empiric and published evidence is not obvious to me.  My teaching goal is to bring relevant data to the clinical setting in the context of individual patients. Of course, I provide feedback regarding data collection, patient presentations, and plans for management, but I also emphasize the importance of communication: within the team, with covering physicians, with consultants, and with patients and their families.  I teach critical appraisal of guidelines. Guidelines can be useful summaries of the available data, but they can also be biased opinions and above all they cannot be applied to any patient without considering how that patient may have complicating comorbidities or other circumstances not addressed in a given guideline. Finally, in all clinical settings, I emphasize that in this age of technology we must connect with our patients and engage them in their own healthcare. I worry when in clinic residents only make eye contact with the computer screen or on the wards when, after morning rounds, they deliver all news to patients via bedside telephone (even when on the same hospital floor and wing). The Mantra from Administration is “Discharge planning begins on admission.” My interpretation is that we are not attempting to discharge as quickly as possible for its own sake, but that we must understand something of a patient’s social situation and other potential barriers to managing their health to start mobilizing resources to address these barriers. The sooner this is done the better.  We must tailor the evidence for an intervention with the individual needs of the patient.

To avoid taking myself too seriously in my role as a clinician-educator I will end by sharing my 2 super powers.  This is timely as July is also filled with superhero summer blockbuster movies.  My best super power is the ability to arrange endoscopic procedures with a single phone call.  My second super power is the ability to approve Miralax (polyethylene glycol) for constipation.  Oh the might! The glamor!  Of a Gastroenterologist on General Medicine.

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The Future of Medicine: Big Brother is Watching

Big brother is watching.  Just as in George Orwell’s futuristic novel 1984, the advent of big data has brought with it the ability for organizations to track our every move.  Smartphone applications track your children’s habits when they are playing games on their devices.  Government crooks such as those managing the Internal Revenue Service are able to tap into your private conversations and business dealings and create a special tax code for “non conformists” and those who disagree with the current administration.  Your GPS navigation system can track your location and analyse your travel habits.  Internet search engines compile profiles of your search history and display advertisements based on your determined interests.  Now, physicians are being tracked and rewarded (or penalized) based on their net cost to hospital systems.  Ultimately, patients, and our helathcare system in general, will suffer.  Linking economics too closely with the physicians providing patient care may be similar to allowing “church and state” to dance to closely on Capitol Hill.   As physicians, we are trained to work hard and to make decisions that are in the best interest of our patients.  Hospital administrators, CEOs and “bean counters” are trained to do what is in the best interest of the hospital system and ultimately their own pocketbooks.

This weekend in the Wall Street Journal, author Anna Mathews discusses the issues surrounding “Big Data” and healthcare systems.  In a California healthcare system, physicians are tracked through the use of massive data collection systems.  Their cost to the system is analysed as well as their patient outcomes.  The Electronic Medical Record (EMR) mandate has now begun to allow hospital systems to better track physician behavior and clinical habits.  EMR databases can be easily queried and the data “mined” for easy analysis.  In this particular California based system, Big Brother is now watching every time you order a CBC, a chest X-ray or a CAT scan.  If those who administrate the system and evaluate cost do not agree with your clinical decision, you may be penalized.  The most frightening thing about the entire story is that it is unclear WHO sets the standards and exactly WHAT data these standards are derived from.

This article has left me with more questions than answers.  Just as referenced in the WSJ piece, many physicians are angry and feel as though they cannot practice medicine any longer but must learn to follow a checklist and move carefully through disease specific and symptom specific algorithms.

What’s the fallout of big data and how will it impact patients? Are physicians no longer treating patients and practicing medicine?  Or are administrators and data analysts now going to mandate how medicine is practiced?  What happens to the ART of medicine and gut instinct?

As I contemplate these questions, I am feeling a bit depressed.  The future of medicine is not as I imagined it when I was in training.  Here are my thoughts on some of these questions:

These types of practices may very well end the need for lengthy residency and fellowship training–rather than learn how to make decisions and respond to clinical scenarios at 3am, physicians in training may be better served learning how to read flowcharts and algorithms and negotiate with hospital executives.  I worry that many physicians will not want to treat the elderly, sicker patients with multiple medical problems as these patients often have poorer outcomes and  may bring down an individual physician’s performance rating.  Unfortunately, these patients are the ones who often need the most help–these patients benefit from a doctor who understands complex illnesses and treats them with instinct and compassion.  I am frightened by the prospect of having my clinical decision making and practice habits evaluated by an MBA executive for a healthcare system with absolutely NO clinical training and NO medical degree.  I am afraid that with government mandates, greedy healthcare systems and administrators with egos as large as oceans, we are in for a dark period in medicine.  In medical school and residency we are taught to think critically about patients and their problems….in the future we will be taught to think carefully about our clinical decisions because…Big Brother is watching….

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Throwing the Doc Under the Bus: Undermining Trust and the Doctor-Patient Relationship

We ALL try to do our very best for our patients.  Often the decisions we make have profound impacts on outcomes.  Medicine is NOT always “cut and dry” and many times gut instinct and judgement calls must play a role in choosing therapies for patients (especially when made in the setting of best available data).  As it is in most professions, “monday morning quarterbacking” frequently occurs in medicine as well.  It is much easier to make decisions and treatment choices when looking back on a case from the other side–it is much dustier in the trenches of an ongoing illness.

Today, in the New York Times, author Pauline Chen discusses the consequences that occur when doctors publicly (in front of other patients or colleagues) criticize another medical professional.  It is only human nature to want to present ourselves to our patients as the expert in a given area–the doctor with the best chance of making them better.  Unfortunately, some providers routinely make negative public comments about other physicians’ abilities or treatment decisions.  Even though these comments may be accurate and well substantiated, these types of comments ultimately harm the patient and the healthcare system.  Certainly, many physicians see “protecting” patients from harm or substandard care as part of their job–rightly so–however, there are much better ways to accomplish this goal.

During training, even though much time is devoted to cultivating a culture of respect for and collaboration with colleagues from different specialties, incidences of “throwing {other doctors or teams} under the bus” can occur on a regular basis.  Fatigue and the pressures of training often play a role in the poor judgement associated with making derogatory comments.  In my experience in training these comments were often made between physicians of different specialties–such as internists vs. surgeons.  In training turf battles between specialties often deteriorated into negative commentary about the physicians or specialties in general.  These bad habits often translate into future lapses of judgement when in practice.  Instead of the sleep deprivation and military style training experienced by residents, pressures for increased productivity, increased documentation and higher volumes create the “mental fatigue” and frustration for the practicing physicians.  No physician is immune as we are all human–I myself have been guilty in the past of making negative comments about another physician who had a very high major complication rate in the Electrophysiology Lab.  Although my motivation for my comment was protecting patients from an incompetent surgeon, my course of action was flawed.  In the end, the physician was fired BUT, by making public comments concerning his abilities, I undermined the trust that patients have in their doctors.

It is essential that patients are able to trust their doctors to provide competent, compassionate care.  It is also essential that physicians stand up for their patients and speak up when they see care that it not up to standard.  However, physicians must utilize proper channels for addressing peer to peer related performance issues (such as Medical staff QI committees, etc).  Badmouthing colleagues reflects poorly on everyone involved and jeopardizes the doctor-patient relationship.  A recent study published in the Journal of General Internal Medicine explored the impact of doctors criticizing other doctors.  In the study the researchers found that critical comments were most often made about physicians in different specialties and resulted in higher levels of patient distrust in physicians in general.  It is very clear that we must do a better job of training physicians to work in a more collaborative way–constructive criticism (in the proper setting) can be beneficial to everyone.  However, publically throwing a colleague “under the bus” is never the right answer.

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Considering A Divorce From Your Doctor? Here’s What You Need to Know

Just As in marriage, the ability to communicate is essential to any successful doctor-patient relationship.  In fact, the most successful doctor-patient relationships are a lot like a marriage.  Both parties must be willing to listen, to negotiate and to support each other’s decisions.  As I have stated in many previous blogs, outcomes improve significantly when patients are engaged in their own healthcare.  Engagement only occurs when doctors and patients are able to effectively work together to solve health problems.  The days of the paternalistic physician dictating lifestyle changes and treatment plans are long over.  Today, patients are better informed and armed with information as they enter the office for consultation.

Unfortunately, just as in marriage, not all doctor-patient relationships work out.  Sometimes changes have to be made in the spirit of moving forward with effective healthcare. This week in the Wall Street Journal, author Kristen Gerencher addressed the issue of “When to fire your Doctor”.  In this piece Ms Gerencher provides sound advice on how to determine when it is time for a change.  She mentions 5 warning signs that may indicate that a divorce and remarriage to another provider is important.  In particular, if you feel worse when you leave your physician’s office than when you arrived, it may be time to consider a change.

Here’s my take on the warning signs that the WSJ mentions:  (the warning signs listed are directly from the WSJ article, the commentary below each one is mine)

1. You leave with more questions than answers.  

It is critical that physicians take the time to communicate clearly to patients.  Essential to this communication is allowing time for questions AND clarifying any misunderstandings or addressing concerns about a treatment plan.  This can be challenging for doctors in the current healthcare environment where federally mandated documentation requirements and pressures to see more patients in less time are limiting the time once dedicated to patient discussion.  However, it is essential to the health of the doctor patient relationship that physicians do not allow these conversations to be pushed aside.  Remember, patient engagement is key.  An informed patient is much more likely to be engaged.

2. Your doctor dismisses your input.

In the age of the internet, patients often come armed with lots of information (lots of which is unreliable and shady at best) that is obtained from online searches.  Rather than simply dismiss the information as junk, it is important to guide our patients to more reliable and more accurate sources of internet information such as MedPage Today and other good patient friendly information sites.

3. Your doctor has misdiagnosed you.

Medicine is not a perfect science.  It is important that you work with your doctor every step of the way along your path to diagnosis.  Mistakes in diagnosis happen–however, these mistakes are not always negligence.  Consider if your physician has carefully considered your problem and has provided a well thought out differential diagnosis before leaving due to a misdiagnosis.  It is important that communication continues during the process of misdiagnosis.  If there is no good communication at this stage, it may be time to choose another provider.

4. Your doctor balks at a second opinion

A good physician is never afraid of a second opinion.  In fact, I often welcome a second opinion in cases where there are multiple choices of a plan of action.  It is essential that patients feel comfortable with their treatment plan–a feeling of comfort breeds engagement and engagement is key for success.  As physicians, we must be willing to put our egos aside in order to provide the best possible care for our patients.

5. Your doctor isn’t board certified.

When choosing a physician, it is vital that you examine his or her background and training.  Typically, doctors must complete a course of training in residency and fellowship in order to be boarded in a particular specialty.  Board exams (some written and some oral) must be passed and competency must be proven.  Once certified, physicians must maintain competency through continuing medical education and re-certification every 10 years.  If your doctor is not board certified, it is not necessarily the end–ask why.  There are several reasons that they may not be including overseas training that is not recognized in the US by the US societies responsible for board certification.

Choosing a doctor is a lot like choosing a spouse.  Decisions should be made in cooperation with one another and both sides must contribute to planning and execution of the chosen course of action.  Patients must weigh options, consider pros and cons and discuss issues with their provider and the provider’s staff when unhappy with a particular physician or physician group.  IF communication is not productive and there is no engagement, patients must make a change.  Good healthcare is a two way street.  Doctor and patient must work in concert in order to achieve optimal outcomes.

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