Archive for category Patient-Centered Care

More Clinic Visits for Diabetics — use the phone

stringphoneJune 3rd 2015 Kaiser Health News reported the ACA seemed to cause more provider visits for management of diabetes “More Patients, Not Fewer, Turn To Health Clinics After Obamacare”.   This is both good and bad.

The “good”:  more attention to a patient’s condition is likely to result in better diabetic management, fewer complications, fewer hospitalizations and longer life.

The “bad”:  since clinic visits can be billed to insurance, clinics make appointments and make money for each visit.  The payment for visits rather than outcome is expensive and a known problem in US healthcare (fee for service).  Diabetes can be managed over the phone in many, if not most cases — but there is no money for the provider in that approach.  Phone care has a much higher value for the healthcare system and the patient; but, low-cost high-quality (high value) care is not getting the incentive.

The care of diabetics is further compromised by the pharmacy.  A key piece of equipment for a diabetic is a glucose meter.  The manufacturer almost gives away the meter so they can make huge profits by selling the disposable test sticks.  The sticks are not interchangeable, not generic, sold in small lots, each lot sold with a co-pay, each lot requiring a visit to the pharmacy, and the use of gasoline to make the trip.  If you don’t have much money the speed-bump turns into a mountain.

The solution:  every few years mandate a generic test stick that manufacturers of glucose meters must support.  “Uncouple” the meter maker form the test stick maker.  And, sell the sticks in lots that last for at least 90 days, and that are sent to the patient by mail.   Adjust the payment to providers so that they must contact diabetics by phone to adjust medications at least 2 times per month in order to bill for a medium or high level clinic visit.  Also, each provider must obtain patient satisfaction data to prove the adequacy of service.


Addendum:  Here is a link to an interesting court case about glucose meters

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Do Hospital Amenities Impact Quality Care?

Acccrystalchandelierording to a study at Johns Hopkins (2/1/15) improving hospital amenities improve patient satisfaction with the facility but otherwise do not improve satisfaction with care.  This is important for two reasons:

  1. Patients really can tell the difference — a crystal chandelier hanging in the hospital room does not make nursing care better!
  2. Patient satisfaction measurement is a powerful tool to assess medical care — if the patient’s expectations are met, it is likely good care is delivered.

The tremendous building boom for hospitals is strange given this bit of science  — are CEOs trying to improve quality by remodeling?   Now it seems clear CEOs should focus money and energy on improving hospital quality until the level of quality is very high then if there is money to spare consider improving the physical amenities.

Increasing the distance a nurse must walk to see patients results in decreasing nursing visits.  This seems simple enough, but the current trend in hospital remodeling is to eliminate rooms with multiple patients.  The trend reduces RN visits, increases the need for nursing assistants, increases hospital cost and may increase falls for elderly patients.

The hospital that looks like a nice hotel seems to be the desire of hospital CEOs.  This may be fine for obstetrics but may be wrong for geriatrics.   A multi-bed ward with 4 patients allows one nurse to check on 4 patients quickly.  4 times the number of nursing visits makes it much easier to prevent falls.  When nurses still wore those pointy white hats they had this figured out.

Progress marches on.  American health care quality is as low as many 3rd world countries but at least we have nice surroundings in which to suffer the complications.

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Direct Primary Care — where’s the quality?

greedydoctorHappy doctors seeing fewer patients and making more money — what’s not to like?  According to author David Von Drehle’s article “Medicine Gets Personal” in Time Magazine, Dec 29/Jan 5, the results are “intriguing”.

The story is about Qliance Health in Seattle founded by two doctors who were dissatisfied with fee-for-service medicine and all the associated paperwork.  So, they developed a model of care where the patient pays $65/month and receives all the primary care they need.  And, as a twist, they also agree to see Medicaid patients for the same cash amount (the details of the arrangement were not stated in the article).  Of course, insurance and medicaid pay for all other services like tests, x-rays, drugs, hospitalizations and specialists.

The doctors are happy because they have less oversight from insurance, don’t have to collect any data to prove they are delivering quality care, get steady income, treat patients over the phone to minimize visits, and are able to “run” their own business with no boss.  For the libertarian-minded physician it’s nirvana.

Piece-work is indeed a hard life as physicians and many in the garment industry know.  A monthly salary is much easier on the worker.  And, the salary model is not new in terms of primary medical care.  The physicians working for the National Health Service (NHS) in the UK have had this system since WWII.  However, the NHS found it was necessary to add financial incentives to get the doctors to do enough work.  And, they found it necessary to monitor quality since quality slips without oversight.

So, this “Direct Primary Care” is not new in the world.  In fact, it may be an important part of an Accountable Care Organization (ACO) as being tried the US.  But, physicians need to realize they need to be part of a large organization to ensure quality care.  The future for primary care is to be an employee, not a mom-and-pop store.  Most of doctor’s patients work as employees, is that so bad?

$65 per month would be too much to pay for poor quality care (the cost of poor care is always too high!)  So what does “Direct Primary Care” need to do for patients and payers to be confident quality care is being delivered?

  1. Measure and report quality in a transparent way — like on the office website.  And, keep it updated.
  2. Deliver patient-centered care and prove it.  Survey patient’s expectations and record whether the expectations are met with office visits.
  3. Report quality indicators other doctors must do like for diabetes, hypertension and smoking.
  4. Report primary care specific indicators regarding the most common diagnoses — skin conditions, joint pains and respiratory infections.
  5. Take a financial stake in what is prescribed or ordered.  Pay some fraction of the cost of all medications prescribed and all tests ordered.  They need to have some “skin in the game”.  (So there is a connection to the larger world of health care cost — ordering a $1000 MRI scan for every ache and pain must have some consequence).

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5% of Patients, 50% of Cost — where to focus

EmergencySocialThe U.S. spends more than other countries for health care but the outcome is not as good as other countries.  Why?  Many feel it is a failure to respond to the statistic that 5% of patients consume 50% of health care spending.  And, those 5% are often at the bottom of the socioeconomic ladder — either they started at the bottom or drifted to the bottom because of health problems.  See the recent article in Manage Care Magazine.

The health care solutions for the top 95% don’t work for the bottom 5% — because the 5% are not well educated, have unreliable transportation, no phone, smoke cigarettes, and only have part-time jobs.  No matter how much research is done on new drugs and surgical robots if a patient does not have transportation to a health care provider it is money down the drain.

Face the facts:  Sweden spends more money on social services than health care.  The result:  infant mortality rate in Sweden is 1/6 th of the rate in the U.S.   Overall, Sweden spends less on health care and delivers much better results.

Here are the 2009 statistics from the Organization for Economic Cooperation and Development (OECD):



Countries with much higher health care quality (like the UK and France) spend at least twice the amount per person for social service as in the U.S.  The fragmented U.S. healthcare system fails to FOCUS on obvious problems — social service seems to be a lens to sharpen that focus.  It’s easy to see the return on investment for the system when social service provides transportation, navigation through difficult medical situations, health education, home vaccinations, and frequent contacts with pregnant women when needed.  Health care without social service is like building a house without one of the walls — looks great from one side only!

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Lung Cancer Screening — wheel of fortune

lung nodule

You smoked 2 packs a day for 20 years.  Your doctor orders  the low-dose CT screening (above).  Your doctor says you have a lung nodule, now what?  That’s a lot to think about but before anxiety builds too much you need to know that of all the people with a nodule on their first scan 19 times out of 20 it is NOT lung cancer.

By asking some questions it is possible to work through the complicated logic of what to do next.

What if I am that unfortunate 1 out of 20?

If you know for sure the nodule is cancer you would get that nodule removed.  Sure it’s a big surgery, hurts for weeks (sometimes longer), in the hospital for several days, and tons of risks the surgeon will recite.  No walk in the park but the odds of a cure are better at an early stage.  Lung cancer is a killer so it is easy to conclude:  get rid of that nodule

What if that nodule is a bad type called “small cell” cancer? 

Most specialists agree that chemotherapy is the treatment of choice.   Surgery for small-cell cancer is not helpful and may actually shorten your life.  A biopsy before surgery may help to avoid surgery for this type of cancer.

What if I am one of the lucky 19?

If all 19 get surgery there would be a lot of discomfort only to be told after surgery the nodule was just a scar or a harmless irritation.  Biopsy or follow-up x-rays are sometimes helpful to avoid surgery.

What if I get a needle biopsy of the nodule?

A shot of numbing medicine, a long needle between the ribs,  a tiny bit of tissue removed, and finally the pathologist sends a report.  Such biopsies are 95% accurate.  The wheel of fortune lands in one of 5 major categories:

  • No cancer found
  • Small-cell lung cancer
  • Non-small-cell lung cancers
    • Adenocarcinoma
    • Squamous cell carcinoma
    • Large cell carcinoma
  • Other cancers (much less common)
    • Mesothelioma
    • Sarcoma
    • etc.
  • Something which is not cancer

A needle biopsy answers critical questions.  If it shows non-small-cell lung cancer surgery is the next step.  If it is small-cell cancer the next step is chemotherapy.  If it is something else, like tuberculosis, then entirely different treatment is needed. If it is “no cancer found” then you are back to square one — meaning a nodule is present and the cause is unknown (possibly a cancer that was missed by the needle).

I am willing to take some risk to avoid procedures.

We started this discussion with a 1 out of 20 chance of cancer.  Is there some way to improve on the accuracy of that prediction?  1 out of 20 does not sound so good.  But, if the odds of cancer in your situation are 1 out of 100 that would be more favorable.

Improved risk assessment

Canadian Annette M. Williams, MB and others reported in the New England Journal of Medicine in September 2013  an improved mathematical prediction method.  Most pulmonary doctors and radiologists can readily provide the statistic.  Basically, if the calculated risk score is below 5% then the chance of cancer is about 1 out of 100 .

If the risk is low  you might just choose to get a CT scan every few months.  If the size of the nodule does not change for 2 years then it is harmless.  One sure thing, cancers grow.  No growth means no cancer.  But, if the nodule does grow you could change the plan and get the biopsy or surgery — there is a risk to letting a cancer grow for a few months (it could spread) but there are risks to biopsies and surgery as well.

If the cancer risk is high you might want to go ahead with a biopsy.

nodule shape

The above are the outlines of nodules 1) round  2) lobulated  3) irregular and 4) spiculated.  Cancerous nodules can take any shape but tend toward the spiculated (spiny) form.

The improved statistical method is based on a few details about the nodule.  Sex (women are more likely to have malignant nodules), size (the larger the nodule the more likely it is malignant),  location (upper lobe nodules are more likely malignant) and spiculation (see diagrams).

If you want to calculate the risk statistic yourself, have a calculator and know the details listed above then click this: Calculate Risk.  But, be warned, this calculation only applies to people who have a risk for cancer to begin with, not the incidental nodule found in a lifetime non-smoker or someone who only smoked a few years.

The forgoing material is intended as education, not a substitute for the evaluation and advice of your health care provider.  If it seems helpful print it and take it to your provider for discussion.  Medical care changes with time so always get up to date information.

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DIY Medical History — helpful and accurate

scroll of med record (1)Your medical history is very important because health care providers use that information as the foundation for medical decisions.  Who has more interest in the accuracy of your information than you do?

You might say: writing the medical history is the doctor’s job.  You are right.  But, have you actually looked at the product of that work? — most people have not.  Patients who read the doctor’s version of a medical history are astounded by the number of errors and the amount of missing information.  To be fair, health care providers are goal oriented — as they hear the medical history they make diagnoses and once a diagnosis is made the details become less important.

Health care providers absolutely love a new patient that hands them a concise medical history.  They love it because:

  1. They save time
  2. The information is more accurate and complete than usual
  3. They can take notes directly on the paper
  4. It is an aid to write their own version or enter data into a computer

The do-it-yourself (DIY) medical history is great for patients because:

  1. You don’t need to repeat it on forms, just write “see attached Medical History”
  2. You can print a copy when you see a new doctor or specialist
  3. You can take a copy to the emergency room
  4. You can keep it up to date with a wordprocessor
  5. You can store it on your computer or “in the cloud”
  6. Your health care visits can focus on current problems not old records

As helpful as this DIY medical record seems there are some important points:

  1. The record must be constructed the way health care providers expect — otherwise they will not read it or use it.
  2. The record must be concise — try to get it on one page (not more than 2 pages)
  3. You must not omit diagnoses or include any self-made diagnosis
  4. Avoid duplication — if you include something in one section do not put the same information in another section.
  5. This is not a test.  You can “cheat” by copying from the medical history created by one of your health care providers.  After all, it’s your medical history.  Make sure you get copies of any “History and Physical” done by your providers.

When you see a new health care provider you should take 2 things:

  1. A copy of your DIY medical history.
  2. A small piece of paper with the 3 concerns you want to talk to the provider about

Now, to the nuts and bolts of the DIY medical history.  Here are the categories:

  1. Identifying information:  Name, Date of Birth, Address, Phone number
  2. Past Medical History:
    1. various diagnoses with dates of any hospitalizations and causes
    2. recent blood tests, x-rays or other tests with results (or attach report)
  3. Past Surgical History: name of surgeries with date, surgeon, and hospital
  4. Childhood illnesses:  birth defects or serious illnesses when a child
  5. Obstetrical History (women):  pregnancies and outcome, number of children
  6. Psychiatric History:  depression problems etc. and list of hospitalizations
  7. Family Medical History: just parents, siblings and children
  8. Social History:
    1. where you live, with whom, occupation, when retired etc.
    2. habits including smoking and alcohol consumption
    3. advance directives (living will, 5 wishes etc.)
  9. Medications:
    1. drug names, strength, how often taken, for what
    2. pharmacies with phone and fax numbers
    3. Drug Allergies
    4. Drug Intolerances or side-effects, what drug and when it happened
    5. Food or Inhalant allergies
  10. Immunizations:  which vaccines and when
  11. List of current health care providers:  primary care, pediatrician, ob/gyn, and specialists
  12. Prefered hospital in case hospitalization needed
  13. Emergency contacts:  names, relationship and phone numbers

See the example history:   (PDF) (DOC)

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The Reverse Operative Consent — a pipe dream

No Surgery Oops

Surgeon to sign at bottom of page.

The reason you need to have surgery is:  _______________________

The name of the surgery is:  _____________________

I have done this same surgery on about ____ patients in the past 3 years.

There is a (circle)  poor, fair, good, excellent chance the surgery will resolve your problems.

The surgery will not fix the following things:

Expect the following short term effects of surgery:

Expect the following long term effects of surgery:

Diagram of surgery:

location of incision

Although I believe the proposed surgery is best, the next best treatment would be the following:

I have accurately told you the most frequent complications of surgery but I do not expect any complications.   Complications are not random events and they always have a cause.   I will do my best to prevent complications and errors by:

  • Following evidence based guidelines
  • Using a pre-op check list
  • Working as a team with everyone in the operating room
  • Following recommendations from the pharmacy and quality improvement departments
  • Being honest about errors and informing you of them immediately
  • Being available for any problems that arise
  • Calling specialists to help with difficult problems

When you are fully awake after surgery I will personally go over the findings of the surgery.  If there are any outstanding test results when you leave the hospital we will call you later to let you know those results.

Our hospital has surgical hospitalists who are available 24 hours a day. Whenever you, your family or the nurses feel immediate attention is needed — just call the following number for their help ____________.

If you need to be in a critical care unit of the hospital I will ask a critical care specialist to consult and coordinate treatment.  I fully support the team approach to severe illness which includes a multidisciplinary rounding program.

Before you leave the hospital we will review all your medications and make sure you know the correct ones to take after you get home.  I will FAX (or send by computer) a full report about your surgery and medications to your primary care doctor on the day of discharge.  And, I will send a copy to you.

We will write down all instructions when you go home but feel free to call me at this number if you have questions or problems: __________________

My nurse will call you the day after discharge to make sure everything is going well.  Your follow up appointment will be just a few days later.

I expect to be away from the hospital during this time: _______________
My associate ______________ will fill in for me during that time, but rest assured, I will take the time to personally go over your situation with my associate so they can fill my role without difficulty.

Signed Dr. __________________________  Date __________________

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Diagnostic Errors — symptom to treatment disconnect

DX Doc

Making a diagnosis is difficult.  And, doctors sometimes get it wrong.  “Wrong” is often harmless, usually expensive,  and sometimes deadly.

An article about incorrect diagnosis appeared this month in the British Medical Journal Quality and Safety which has been widely reported, including by the Wall Street Journal.  Dr. Tehrani and his co-authors  correlated health insurance claims (diagnosis) with malpractice suits.  They found “diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes.”

One might think the errors happen because the underlying problem is very rare.  On the contrary, the bulk of errors happen with common conditions.

Another article this month in JAMA Internal Medicine  by Dr. Singh and co-workers reported on common types of diagnostic errors — many of which were common in primary care:  (italics are blog examples)

  • Pneumonia
    • no chest x-ray for cough and high fever
  • Decompensated congestive heart failure
    • no BNpeptide checked
  • Acute renal failure
    • no check of basic metabolic panel for fatigue
  • Cancer
    • ignoring Mammogram findings or blood in sputum
  • Urinary tract infections
    • not checking urinalysis or treating soon enough

The flaw in the process that contributed to the wrong diagnosis included:

  • Inadequate patient encounter (too short or not focused on problem)
  • Not seeking referral when needed (like not getting a cardiology consult for chest pain)
  • Patient related factors (not returning for follow-up)
  • Not taking risk factors into account (like family history of colon cancer)
  • Losing track of test results (urinalysis report filed but not viewed)
  • Not getting the right test (not getting a chest x-ray for shortness of breath)

Problems at the time of patient encounter are a major contributor:

  • Poor history taking (provider did not listen or ask questions)
  • Inadequate examination (provider did not examine problem area — like a breast nodule)
  • Inadequate testing (not considering a colonoscopy for blood in the stool)

When a person has a health problem the whole idea is to connect the dots …problem…diagnosis…treatment.  If the diagnosis is not correct then good treatment is disconnected.

Providers often do not consider enough possible causes for abnormal findings.  Those possibilities are called the “differential diagnosis”.  There are books and several free sites on the Internet that provide such lists.  One such site is DiagnosisPro.  If you like other sites leave a comment please.  Some electronic record applications include a differential diagnosis automatically — nice feature which should always be installed.

So, what is the solution?  Most experts agree, the quality of the provider-patient interaction must improve.  Providers need to follow known guidelines plus use differential diagnosis aids.  Patients need to look out for themselves by using the Internet or books to  understand symptoms and test results.  The best solution is a stronger partnership between patients and providers.  See earlier posts in this blog about shared decision-making and patient centered care.

Can all errors be prevented?  NO.  To err is human.  The point is to minimize the errors, and there is obviously a lot of room for improvement.

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Patient Centered Care — not a political statement


Patient NON-CENTERED care is a physician looking at a computer rather than the patient, not letting the patient have a minute to express what they are concerned about or not making follow up appointments for diabetes.  Patient centered care is better care.

computer doctor

The International Alliance of Patients’ Organizations (IAPO) has listed the  “Five Principles”  of patient centered care.  The list includes:

  1. Respect
  2. Choice and empowerment
  3. Patient involvement in health policy
  4. Access and support
  5. Information

Four cultural phenomena  are at the root of the patient-centered movement.

  1. Doctors are not always right and communicate poorly.
  2. One third of US citizens are illiterate about health issues.
  3. The Internet has exposed items 1 and 2.
  4. People are wary of the government changing the healthcare system

The slippery slope for many patients starts when doctors tell patients what to do, patients don’t know enough to ask questions, treatment is given , advice is not followed and the outcome is not what the patient wanted.

Patient-centered care may be the solution.  Focus on the provider-patient interaction, improve provider-patient communication, educate the patient about the problems at hand,  and let the patient have a larger say in their own health care.

There is a political side to patient-centered care which is the battle between the public good and the patient’s wishes.  There is plenty of work to be done at the point of interaction between the provider and the patient.   Worry over fluoride in the water,  organic vegetables and workplace dangers are different topics, important, but not patient-centered care.

The insinuation fee-for-service medicine is somehow more patient-centered than other health-care systems is not logical.  No matter what health care system is in place the notions of good communication, patient education and patient autonomy remain critically important.

Patients will suffer the consequences of their decisions.   So, providers should never agree to bad medical care.    The purpose of patient-centered care is not to “give the patient what they want”.  But, rather  to listen to the voice of the patient,  communicate the best evidence-based guidelines and be a partner with the patient to make good decisions.

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Shared Decision Making — shared with whom?


What is Shared Decision Making (SDM)?  It is a process for patients to make good decisions about tests, medications, surgeries and just about anything health care providers might suggest.  What it is, and what it is not — some examples:

A patient has frequent headaches and has a visit with a provider.

Scenario 1:  The provider says “a CT scan of the brain is needed, so get that done and come back for a follow-up visit.”  (Old school, doctor knows best)

Scenario 2:  The patient wonders if a CT scan of the brain would be a good idea to make sure there is no brain tumor.  The provider says “sure, the nurse will schedule it tomorrow.”  (Consumerism, do what the patient wants)

Scenario 3:  The provider says “there are a number of options including a trial of migraine medications or getting a CT of the brain.”  Then the provider gives the patient a handout that lists independent sources for additional information.  And, says “I will call you on Monday, after you have had a chance to review the information so we can decide what to do”  (Shared Decision Making)

Group Health Cooperative in Washington State has made a big push to support SDM.  The Group has made information available on the Internet to assist the patient for many common situations.  91% of patients who used the system found it “very important” or “extremely important”.  Click to see an Example of shared decision-making by Group Health Cooperative.

Pros and Cons:

  • The process takes longer than just doing what the provider says
  • Usually the SDM comes to a decision the patient will support, so they will follow instructions and treatments more than an average patient.
  • As long as the information reviewed by the patient is based on evidence based guidelines (well researched advice) then good decisions are possible.  And, usually the decisions are less invasive and less costly.

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