Archive for August, 2014
Doctors are unhappy because the medical world is not what they expected (or dreamed about).
An essay in the Wall Street Journal today “Why Doctors Are Sick of Their Profession?” describes the feelings of many doctors. What are those feelings? What do they mean?
Most physicians cope very well and are quite successful in society. Clearly, they do not have a psychiatric disorder as a group. Yet, the WSJ article lists certain symptoms. These are feelings of:
frustration, failed aspirations, malaise, worthless sacrifice, loss of control, conspiracy of lawmakers and insurance companies, devalued work, and recurrent intrusions of unpleasant thoughts. Lawyers (the scum of the earth) make more money than they do. And, oppression is keeping them from doing things the “right way”.
If a patient complains of those symptoms the diagnosis would be: depression with underlying obsessive-compulsive and narcissistic traits. For doctors it may just be the world is not what they expected when they started 15 years of training. The job is basically good and it’s too late to start over.
Is money an issue? If a distraught patient says their anxiety has nothing to do with a “recent divorce” … it really has everything to do with the divorce. If a doctor say it “has nothing to do with money” … it’s the money.
As a group doctors have a huge capacity for delayed gratification. They go through difficult years of training by thinking it will get better later — the salary will go up, all the testing will stop, professors will go away, long hours will improve, and no one will question their decisions. Welcome to the real world: stagnant salaries, maintenance of certification tests, professors who set evidence based guidelines, long hours and insurance companies that question decisions.
Medical training is mostly to blame. It’s too long, often unfocused, minimizes teamwork and shuns consistency. The fight for doctors to follow evidence based guidelines is undermined by the constant drum beat of “cook book medicine”. In fact, most medical treatment is by the book — a stunning revelation to most. If physician expectations were better managed during training the dissatisfaction after training would not be an issue.
Many employees find their job the least stressful part of the day. Stressed physicians need to focus on their job of diagnosis and treatment — it is very rewarding. Extraneous worries can drive you crazy.
Accountable care organizations reduce physician stress by focusing physicians on the job of taking care of patients while business professionals manage the business. Perhaps increasing the structure of medical care is the solution for physicians, not the enemy.
It’s likely the actual shelf life of your medications is much longer than the date printed on the box. Medications required “as needed” often sit in the bottle for a long time — patients wonder when they should be discarded but really don’t want to pay for another expensive prescription. Heidi Mitchell of the Wall Street Journal describes this problem in her story 8/25/14 “Are Expired Medications OK to Take?”
The military has the shelf-life problem on a large scale — numerous doses of medications are stockpiled in case of an emergency. Fortunately, in 2006 the military commissioned the FDA to study the problem — just as we all suspected, most medications last much longer than the expiration date — on average 5.5 years longer.
Medications fail the shelf-life tests if there is a significant loss of potency, leakage, crumbling of pills, loss of pressure within an inhaler, mold growth or bacterial contamination. The latter two problems are mostly with liquid medications and are manifest by a cloudy or discolored appearance.
Although most medications last much longer than expected there are some cautionary notes: Don’t keep medications for emergency life-saving situations beyond the expiration date. This would include insulin, nitroglycerin and injectable epinephrine. Also, medications requiring refrigeration should not be kept beyond the expiration date. Many medications exposed to high temperatures (such as in an automobile glove compartment for several summer days) may deteriorate rapidly and are probably best discarded.
All medications, stockpiled or not, need to be kept out of the reach of children.
Medications don’t become poisonous with storage but they can become less potent. A pain pill that is 10% less potent is actually not much of a problem — most people can’t notice a 10% change.
So, if the military stockpiles medications 5 1/2 years beyond the expiration date so can you — save some money!
A good patient portal is wonderful; a bad patient portal is a waste of time. A recent post by Dr. Yul Ejnes suggested portals may not be patient centered and don’t get much use.
An alternative view is that all patient portals NOT are the same. Some have great features and are supported by the providers offering them. Other portals are not much more than advertising — generally something a patient does not revisit. Sadly, many businesses have the latter type of portal — no wonder people don’t flock to medical portals.
Check out your health care provider’s portal. If it does not really provide a benefit then TELL THE PROVIDER, complain, and say other providers do a better job.
Admittedly, a poorly functioning provider office will likely have a poorly functioning portal. Just because the portal lets you send a message to the nurse or provider is no guarantee the response will be helpful.
Large vertically integrated health systems or ACOs have the best chance of a good patient portal. The portal needs monitoring and rules for providers — rules that require questions to be answered the same day. And, that the portal will display lab results within 48 hours, regardless of whether the provider has or has not seen the results. Responses from nurses need to be monitored for accuracy and timeliness — the lazy but profitable response to just make an appointment is not adequate. Integration of pharmacy functions is essential.
Here is a checklist of possible portal features — how does your provider’s portal stack up?
- Responses to online requests take less than 24 hours
- Ask a medical question
- Ask medication related question
- Make a follow up appointment
- Make a same day urgent care appointment
- Get refills on a chronic medication
- Get a message from your provider about test results
- Report drug side effects or drug allergies
- Send a picture of a skin rash.
- Diabetics can send blood sugar results
- Asthmatics can send peak-flow measurements
- Look at your list of medical diagnoses both active and inactive
- See a list of current medications and the diagnosis for which they are prescribed
- Links to drug information about the drugs on the medication list
- Review the providers notes
- Review any test, x-ray or consultation report
- Your provider can send questions to specialists and forward the response to you
- You can print your lab, pathology and x-ray reports
- See your most recent medical summary including past medical history, social history, family history, medications list allergies — and be able to print the report if needed for consultations or to take on trips.
- Request a summary of billing and payment information — including when bills are sent to insurance and when payment is received.
- Pay your bills on-line
- Links to reliable on-line information sources about tests, treatments, drugs, immunizations and diseases. Include a symptom checker — a computerized diagnosis based on symptoms — something to discuss with your doctor.
- Provider office provides training to use the portal.
A provider might say: “I’m not paid for running a portal or answering questions”. That is very true for many providers in the US health care system. But, in systems without fee-for-service billing then portals are a huge driver of efficiency. If a patient’s questions or problems can be resolved via the portal so much the better for both the provider and the patient. The handwriting is on the wall — fee for service is going to go away — the efficiency of portals will be a strong driving force.
Highly educated and experienced cardiologists just can’t get it right: the correct dose of aspirin after a heart attack is 81 mg (called low-dose), NOT 325 mg (called high-dose). The current prescribing error rate is 60.9% as published by the American Heart Association in 2014.
Personal communication with several cardiologists elicits the comment: the higher dose is needed because of the risk of another heart attack — and “in my experience” it just works better. It’s hard to believe this clinical error in this age of quality assurance. The problem is BLEEDING not heart attacks! The stomach BLEEDS due to aspirin and the higher the dose the higher the risk of BLEEDING.
Just imagine the risk and strain for a recent heart attack victim who vomits blood, needs a transfusion and must undergo a stomach scope — some patients die. From a cardiology standpoint: “they died from something unrelated to the heart attack” — great thinking.
Cardiologists completely and totally get it wrong when they simultaneously prescribe high dose aspirin and the anticoagulant warfarin — the ghastly mistake happens 40% of the time.
The chemical reaction of “acetylation” is caused by aspirin within small blood cells called platelets. Acetylation of platelets is responsible for the favorable heart effects of aspirin. It has been known for at least 30 years that 81 mg of aspirin completely acetylates every platelet a person has — more aspirin does no more. According to the 2012 TRITON-TIMI trial:
“We observed no difference between patients taking a high dose versus a low of aspirin as it relates to cardiovascular death, heart attack, stroke or stent thrombosis,” according to Payal Kohli, MD involved in the study and quoted in Science Daily.
Hospital quality improvement programs need the “guts” to just say NO. 325 mg is not correct. Cardiologists are the sweetheart doctors making millions of dollars for hospitals — it should not matter, JUST SAY NO.
It’s almost impossible for even the most proactive patient to question the great doctor that just saved their life. So, hospital quality assurance has an even greater responsibility than usual. The prescribing error needs to be corrected — hospital pharmacists and quality improvement departments need to be strongly involved — this error has gone on far too long.
Medication mistakes are common. A recent study by Amanda Mixon following discharge from the hospital pegs the error rate at an astounding 50%. The study focused on whether instructions given to patients at the time of discharge from the hospital matched what the patient later took at home.
The study is biased by assuming all the errors are caused by patients — not the providers. The authors point to patient problems of low health literacy and a poor facility with numbers. Illegible instructions, poor communication skills, excessive complexity of medical regimens, conflicting instructions, and giving verbal instructions to the wrong person are all provider or institutional issues.
Even a simple phone call after discharge might have cleared up patient confusion — perhaps the study would have been better with a phone call and no phone call comparison.
The article conclusion is to apply more effort to find those high risk patients. Another conclusion would be to find those high risk hospitals having difficulty telling patients what drugs to take. The study was done at a VA facility affiliated with Vanderbilt — a good place to start the search.
A practicing physician can look back to answer the question: what time was wasted during training? In other words, what was not applicable and forgotten. The answer is about 50% of college, 40% of medical school, 20% of residency and 20% of specialty training. Altogether the inefficiency of training (wasted years) adds to about 3 years for primary care and 4 years for a specialist. Wasting years of time is bad for students and bad for the US health care system.
Freedom to choose a type of practice seems to be the basis for US training. Consequently, the training is designed for maximum student choice. Required courses cover all the basics until far into training when finally a choice dawns.
The illusion of choice is the student never knows what practice is like, does not know what care givers are actually needed and assumes they can practice anywhere. Sometimes they choose just based on potential income — since they do have to pay off student loans.
Some would say: the student paid for training so they are entitled to choose. The fact is they pay a very tiny fraction of training cost, which society reimburses them many times over. Reimburses with a salary after medical school, reimburses by taxes going into Medicare and Medicaid, reimburses from insurance premiums paid by individuals and business. Society is paying for health care providers in aggregate. Health care has become a utility.
Given the utility nature of healthcare providers, why should health-care students have full choice of specialty, location or fees? A proper utility should provide uniform service and access where needed.
The problem: a disconnect between the demand for manpower and the product of training.
A solution: The pay-forward system. Openings for health care training should be presented before college. The student makes a decision very early. Education can be focused and much shorter. The options might be: nursing, primary care, laboratory medicine, surgical specialties, anesthesiology,dermatology, radiology, hospital care, or medical specialties (with a similar manpower guided choice a few years later). In exchange for participating in the new system, education is free to the student — paid for by reducing the salary over the career of the provider. But, there is an obligation to practice what and where manpower demands indicate.
The advantage of focused training is the ability to go into productive work in less time:
Dermatology: 6 years (vs. 12 years)
Primary care: 7 years (vs. 11 years)
Cardiologist: 8 years. (vs. 14 years)
Neurosurgery: 12 years (vs. 18 years)
Those students who perceive the need for a more broad education could spend several years in college pursuing whatever they want before committing to the health care track. One would expect some students would not make the grade needed in the health care track — they may want to fall back on another career possibility.
The University is helped by moving health care training away from other majors. The new track would allows majors in chemistry and biology to concentrate without the competition of pre-med students who do not intend to work in those fields.
The best part is the results of training program yield the providers needed. And, the providers practice where there they are needed — without crushing debt.
Delinquent, delayed and diverted the electronic health records in the US are missing. According to the Washington Post two Presidents set 2014 as the target for all medical records to be electronic — so has American medicine hit the target?
According to a study by the Robert Woods Johnson Foundation US healthcare has been very slow to adopt the technology. RWJF reports 50% of office practices have a “basic” system and 59% of hospitals have at least a “basic” system (25% of hospitals have a comprehensive system). To give perspective, a “basic” system contains medical reports and medication lists but no physician notes.
Barriers stand in the way of progress:
- Medical data is a very valuable business asset. EHR companies are threatened if such data could be easily transferred to a competitor.
- Fear of losing control. Doctors and hospitals don’t want their data to be too available to insurance companies or regulators. Quality problems could be easily exposed.
- Self-determination. Health care entities want to make their own systems — the CEO would rather manage than cooperate.
- Lack of governmental action. Doctors and hospitals are licensed by States — just putting the license at risk is all that is needed to make EHRs mandatory.
- High cost of building an EHR. Every office practice and hospital needs a financial system. But, really, only one EHR is needed in a State or perhaps only one in the entire US. Hundreds of EHRs across the country is a waste of money — they all do the same thing, and they can’t “talk” to each other.
- Failure to embrace a “cloud” computing solution for a large scale EHR.
Ask your doctor:
- Please show me my chest x-ray on the computer screen in the office exam room.
- Please electronically send all my records to a specialist across town.
- Please show me a record of all the prescriptions I had filled this past year and which pharmacies filled them and how much they cost. (surely you can trust your doctor with that small bit of financial information).
- Can I send you a secure email and expect a response?
- Can you securely send me the results of my tests?
- Can you easily look up the discharge instructions from my recent hospitalization on your office computer?
- Do all the doctors and hospitals and pharmacies in town share the same medical record system — why not? It would be very good from a patient standpoint.
NO answers exemplify the current data problem. The US has a far better tax system than a medical record system and a far better post office than a medical record system. Contrary to the story in the Washington Post this is NOT OK.
Death can be caused by not having a car. If a sick person does not have transportation the effects can be serious. And, lack of insurance makes the problem worse.
A new study reported in Health Affairs finds closure of inner-city ER facilities causes more deaths. Poverty, advanced age, immigrant status, and lack of insurance were correlated with the increased mortality.
Poor people count on the ER as the clinic of last resort — our health system is designed that way — call an urgent care clinic and ask what services are available — “it depends on your insurance” is the answer — “you better go to the ER” is the advice if you have Medicaid or don’t have insurance.
Why wait until the last minute? Because, there is always hope the health problem will get better, the chest pain will subside, the blood in the stool will stop or the arm weakness will vanish. Once the heart attack hits, the bleeding is worse, or the whole side of the body is paralyzed the chances of death are much higher.
If you don’t have money one of the greatest concerns is NOT getting admitted — how do you get home, how do you pay for outpatient medications and how do you pay for the ambulance ride ($1000)? The logic is simple: wait until you are REALLY sick.
The ambulance-to ER-to-operating-room is usually a very profitable supply-line of patients, so lots of resources have been lavished to make the system work. If the ambulance-to-ER system brings diabetes, pressure ulcers and urine infections it drains a hospital’s resources, and finally leads to ER closure.
A good health system would provide transportation, guaranteed urgent care, medications and transportation home for a low-cost package price. The unloading of the ER might actually save the ER, save patients with true emergencies, and save poor patients who get care earlier. Wow — and what if that urgent care center was right next to the ER so if there really was an emergency it could be handled.
But no, all that would require planning and a health system where hospitalization was an overhead expense, not a profit center. So, the only viable solution in the US: include vouchers for ER visits with Cadillac purchases or golf club memberships.
Grand poobahs, long robes, ivory palaces, exulted wise men — is it the Arabian Nights? — no, it’s graduate medical education in the US. Finally, a voice of reason — coming from the Institute of Medicine (IOM). The surprising report released 7/29/14 says doctor training is not meeting the needs of the country.
The problems: $18 billion per year going to academic medical centers without adequate accountability. Money lavished on the Northeast fails to trickle down to community training programs elsewhere. Self-serving training of an academic workforce but not main-street primary care.
The US has never had a coherent plan to train doctors — academic medical centers have been making decisions that should have been made by ordinary people, people who don’t like waiting lists. A huge manpower shortfall has been expected for a long time. The IOM expert committee is calling for big changes to the system. The hope of the country, West of Harvard, is that Congress will follow the recommendations — the report is not asking for more money (which would be a stake in the heart) just a rational use of funds to meet obvious needs.
A primary care doctor does not need to go to Harvard to be a very good doctor and the US does not need to support super specialty programs at the expense of towns lacking a doctor. The cost savings by diverting funds to community training programs could be huge, possibly training 2 or 3 physicians instead of one in Boston.
Funding of training needs to be tied to providing service where service is needed. What better way to train doctors for Iowa (or other areas needing doctors) — train young people in the communities where they live.