Vol. 76 October 15, 2012 The High Life and A Good Death

October 15, 2012

“Hey, D-u-u-de!”
-The Big Lebowski, 1998
.

“She had a good death.”
-traditional Irish Catholic saying

On Nov. 6 Massachusetts will vote on two medically related referendum questions: Medical Marijuana and Physician-Assisted Suicide.  In the spirit of transparency and to offer a break from mind-numbing candidate debates, I offer this short commentary on the two…and a proposal to combine them.

Ballot Question 3: “Do you approve of  a law that would eliminate state and criminal and civil penalties related to the medical use of marijuana allowing certain patients to obtain by a physician’s prescription marijuana  produced and distributed by new state-regulated centers,or, in specific hardship cases, to grow marijuana for their own use?”

Short name: Medical Use of Marijuana
A better name: “Marijuana by request of certain consenting adults”
Street spin: Very positive

Who’s against it:  AMA and Mass Medical Society – Concerns: “The slippery slope” What’s next? Legalization of marijuana?
Local police very concerned about increased cost of investigating and enforcing multiple backyard plots.
Anti-Smoking organizations.
When Congress passed the Marijuana Tax Act in 1937 making it illegal for anyone, including doctors, “to move cannabis without proper documentation”, the AMA opposed the bill!  (1)

Who’s for it: Lester Grinspoon, MD (2), most people under 50, and anybody who answers to the name, “Dude.”

What does the data show: Illegal marijuana is currently a bigger cash crop in Kentucky than tobacco. There are more medical marijuana shops in Denver than Starbucks. It IS (is NOT) a “gateway” drug…take your pick of positions…data supports both. 17 states have legalized medical marijuana.

Worst case scenario: Prescriptions for marijuana surpass number of prescriptions for SSRIs, Ritalin, and Oxycodone… or maybe that would be an improvement?

Economic implications: Could be a significant economic stimulus… in Kentucky, at least. The price of medical marijuana in California and Colorado is half the price that illegal marijuana was.

Possible future headline: “Legal Marijuana Aids Economic Recovery, Second Only to Casino Development.”

Ballot Question 2: “Do you approve of a law that would allow a physician licensed in Massachusetts to prescribe medication, at the request of a terminally ill patient meeting certain conditions, to end that person’s life?”

Short name: Physician Assisted Suicide
A better name: “Death with Dignity by request of certain consenting adults.”
Street spin: How can anything be positive about the term “suicide”? “Physician-assisted dying” is closer to the reality.

Who’s against it: AMA and Mass Medical Society; incompatible with the “curative and healer” roles of physicians – Concerns: “The slippery slope” What’s next? Lethal injections for psoriasis?
We can’t always be certain of which months are “the last 6 of my life”, but about 83% of hospice patients were right in one study.
Who’s for it: Many members of Ethics Committees in acute care hospitals who have helped patients and families endure prolonged, high-tech deaths.

What does the data show: Since its passage in 1997 less than 100 Oregon patients per year have requested end-of-life medications. In 2011 only about one-half of the people getting such prescriptions in Oregon actually took the pills. (Maybe it IS a question of patients’ desire for lost autonomy and control) In Oregon 90% of requesting patients were enrolled in a hospice program and nearly 90% had cancer.

Worst case scenario: Patients may desire more power over their medical life as well as their medical death.

Economic implications: May have positive impact on medical care costs if people choose not to go into hospitals and be admitted to ICUs in the last 6 months of their life.

Possible future headline: “AMA Admits Physicians Can’t Cure Everyone, Calls For More Dignity In Dying”

Proposed Ballot Question 4: “Do you approve of a law that would allow physicians to prescribe marijuana to end the life of a terminally ill patient?”

Short name: “Physician Assisted Dying by Marijuana”.
Street spin: It will never happen. Marijuana is the ONE drug that can NOT cause a lethal overdose (unlike alcohol, aspirin, and the others). Dr. Grinspoon described it as “remarkably non-toxic”. He initiated his intensive research into the effects of marijuana when he observed its benefits in his son undergoing chemotherapy. (His wife got the marijuana for Danny in the parking lot of a local high school because Dr. Grinspoon was initially so skeptical of its effects).(1)

References:
1. “Where’s the Pipe?”, Casey Lyons, Boston Magazine, October 2012
2. Marijuana Reconsidered, Lester Grinspoon,MD; 1971 and Marijuana:The Forbidden Medicine; 1997

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Vol. 72 August 1, 2012 Obamacare and the Olympics

August 1, 2012

The Olympics, like Presidential elections in the U.S., occur every four years. Cities, like candidates, compete fiercely and spend lots of money to be the  winner of the “host” contest. No one really knows how much the hosting, or the Presidential term will cost, and no one is ever sure how it wil be paid for. Both always end up costing more than anticipated. The Olympic games, like our Presidential elections, often reflect the state of our world at the time.

The British opened their Olympic Games with a stupendous show that included a celebration of their National Heath Service! It must have been a Socialist conspiracy, something we would expect from China. Can you imagine that ever happening in America!? Medicare is almost as old  as the NHS (born in 1965 rather than 1948), is a great comfort to those over 65, and politicians attack its benefits at their own peril, BUT a celebration of Medicare during the Super Bowl halftime? I don’t think so! Maybe in twenty years.

America does have the best medical care in the world for most people, but I think that we are so busy explaining why it is so expensive and why not everyone has access to it that we never get around to celebrating it. Now that the constitutional fight over ACA has been resolved by the Supreme Court maybe we can begin to celebrate some of its positive aspects.

The extension of coverage on family policies to children up to the age of 26 proved to be so popular that most insurance companies announced that they would provide that coverage even if the court struck down the act. Likewise, providing coverage for pre-existing conditions.

Whether the penalty for not obtaining insurance coverage is a tax or not is still a political football, but the tax (according to the Supreme Court) will amount to about $95 a year in 2014. 26 cents a day seems to be a ridiculously small price to pay for counting on other tax payers to cover your medical bills if you lose life or limb.

Micheal Phelps did not win his record-breaking gold medal in the solo medley event, but did so in the four man relay. His solo event fourth-place finish should remind us all that despite supreme conditioning, a dedicated will, and a stellar record, the body does age and performance decreases. We will all be eligible for Medicare some day. Why not sooner than later if current Medicare subscribers think it so great?. Phelp’s team win reaffirms how performance can improve with the help of trained colleagues. The ACA incentivizes the formation of “Medical Homes” of primary care physicians, nurse practitioners, physician assistants, social workers, and others organized together to deliver patient-centered care. We will need such organizations of physicians and physician extenders.  A significant “unintended consequence” of the ACA, now just being discussed, will be the shortage of primary care physicians to provide the care for the newly insured under ACA.

What about that 5 foot weight-lifter 123 pound that no one ever heard of stepping up and lifting over three times his own weight?! Not much has been said about the Center for Effectiveness Research established by the ACA. It is no five-footer, but is one of those “sleepers” in the Act that could profoundly effect our health care by system by evaluating and publicising the benefits ( and costs) of new technology. Another “small item” in the ACA which may eventually become perceived as a giant is insurance coverage for mental health services, a first.

The Queen’s granddaughter’s equine competition has at least knocked the stories about Romney’s Dressage horse off the TV. Maybe Obama’s grandchildren will compete  in a future Olympics (women’s basketball?). Better yet, the opening show, like this year’s scene of the Queen greeting Mr. Bond, could feature the then-President turning in his chair and greeting his visitor with, “Welcome back, Dr. Berwick”.

By then we may know if Olympic athletes are genetically superior to us mere mortals. I am sure that we will be screening them for “gene therapy”. As Dr. David Jones states in his NEJM article on the medical history of the Olympics, “What’s the limit of human performance? We still don’t know”.

I say ditto for the ACA.


Vol. 71 July 15, 2012 When “Yes” Becomes “No” in Medicine

July 18, 2012

 

“PRIMUM NON NOCERE” – First, do no harm.

This quotation is considered to be the first rule for physicians, but it has a somewhat uncertain origin and a changing definition. The original definition of “harm” became more complicated and variable as medicine accepted the concepts of “risk vs. benefit” and “cost benefit analysis”. Since the values in these concepts are variable, the definition of “harm” has become more variable, more complex, and sometimes more relective of the bias of the definer.

Medicine is both an art and a science, and science, as we know, considers all of its “truths” as tentative. As new data is obtained these truths can change. Here are some recent examples of changes in medical recommendations based on new data AND new elements in“”cost benefit analysis” AND possible bias of the maker of the recommendation.

Men should not be screened for elevated PSA (Prostate Specific Antigen)
The initial excitement about this test for the early (“before symptoms appeared”) diagnosis of prostate cancer has been dissipated by data showing that positive tests (elevated levels of PSA) led to lots of referrals to urologist specialists, lots of biopsies, and lots of invasive surgical and radiation treatment which did NOT result in a reduced death rate or lessened disease burden from prostate cancer. Also, the interventions were associated with a bunch of serious complications.

Prostate cancer is usually an indolent disease. If a man lives long enough it will eventually appear in his body, but will rarely cause death or a heavy disease burden. PSA screening of asymptomatic men who have a normal digital (digital, as in finger) rectal exam and a negative test for occult fecal blood is now considered to cost more (in money, patient inconvenience, and medical complications) than its benefits. The PSA does not identify the less common case of aggressive prostatic cancer at a time that makes earlier treatment more effective.

Women under 50 don’t have to get an annual mammogram.
This 2009 recommendation caused a great deal of controversy because of the long term investments of several “stakeholders” in the mantra “get an annual mammogram to save your life.” But, by 2009, data conclusively showed that in order to save the life of one woman in her 40s from breast cancer, 1,904 women would have to be screened every year for up to 20 years. Because the U.S. Preventive Services Task Force judged that the risks of harm from false positives mammograms, subsequent biopsies, and overly aggressive treatment of indolent lesions that resulted from annual screening outweighed its benefits. Hence, the USPSTF panel’s recommendation that most women ages 40 to 49 need NOT get a routine annual mammogram.

Statins do not prevent fatal heart attacks in healthy people.
Studies in 1999 indicated that lowering cholesterol by taking statins (Lipitor, Zocor, etc.) in people who had had a heart attack reduced subsequent cardiac deaths in those people by 30% and reduced subsequent symptomatic coronary artery disease by 25-60%. This dramatic protective effect of statins in these high-risk patients was extrapolated to people without heart disease or risk factors and by 2008 half of U.S. men between the ages of 65-74 were taking statins. Last year a meta-analysis (a research analysis of a large number of studies) failed to show a reduction of death rates in healthy people taking statins.  “Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life.” (1)  More recent studies documenting the complications and side effects of statin use have also contributed to the change in this recommendation.

Colonoscopy for the prevention of death from colon cancer is no better than, and may be inferior to, flexible sigmoidoscopy.
Not so many years ago your primary physician would perform a screening examination of your lower colon with a flexible sigmoidoscope in his/her office, with just light sedation, no biopsy, and no annoying, rigorous bowel preparation. The reimbursement was modest. Since then, the norm for screening for colon cancer has become a colonoscopy, performed by a gastroenterologist or general surgeon in a hospital or an ambulatory surgical center with sedation heavy enough to warrant the presence of an anthesiologist and associated with an interpretation of the inevitable biopsy by a pathologist. The reimbursement all around is much more substantial.

Both procedures reduce the incidence and mortality of colon cancer, but “as reimbursement moves from fee-for-service to bundled payments for episodes of care, there will be a renewed focus on delivering evidence-based interventions in a manner that optimizes resource use.” (2)

Daily low-dose aspirin does not reduce cardiovascular deaths in healthy people.
Use of aspirin to prevent a subsequent heart attack in people who have already had one DOES reduce their death rate from another heart attack. Extrapolation of this widely accepted fact has prompted many  healthy people with no history of heart disease to take low dose aspirin daily. In yet another meta-analysis of over 100,000 people “at risk for” but not having coronary artery disease, daily aspirin did NOT lower the rate of fatal heart attacks. The rate of non-fatal heart attacks was reduced by 20%, but more importantly the use of aspirin INCREASED the rate of non-trivial bleeding (GI bleeding, stroke, hematuria, and nose bleeding) by 31%, ie. the risks of daily aspirin use outweighed its benefits.
SPOILER ALERT: The study recommends that physicians and patients should decide on a case-by-case basis about whether to continue daily aspirin if you are already taking it. My own physician noted that in several of the international studies in this meta-analysis the dose of aspirin was up to 300 mg a day (one adult aspirin) but that in the U.S. the usual recommended aspirin “low” dose is 81 mg. ( a baby aspirin) daily The higher the dose of aspirin the more likely it is to cause bleeding.

DEET insect repellent is safe to use on anyone over the age of two months.
“The American Academy of Pediatrics states that insect repellents with DEET are safe to use on children as young as two months old.” Apply only once a day, but you can use any concentration from 7% to 25%. The higher concentration isn’t any more effective, but its protection lasts longer. DEET protects against tick bites too.

Statistics NEVER lie, … or can they?
Published medical research produces data that meets statistical standards of “significance” which reassures the reader that the findings are “true”. Meta-analysis studies ( a technique of comparing data results from different studies and treating them as if they are all from the same study) are the current epitome of statistical correlations. The interpretation of statistics, however, is not standardized, and epidemiology (the science of statistics applied to large populations) has been called by some cynics as “the art of lying on a grand scale.”  Here’s an example of the potential pitfalls in interpreting statistics:

700,000 physicians “cause” 120,000 accidental deaths per year for a rate of
.171% accidental deaths per physician per year

There are 1,500 accidental gun deaths per year and 80 million (yes, million) U.S. gun owners for a rate of .0000188% accidental gun deaths per gun owner per year.

THEREFORE, statistically, doctors are approximately
9,000 times more dangerous than gun owners.

We withheld the statistics on ….Lawyers !
for fear the shock would cause people to panic and seek medical attention! (3)

References:
1. Arch Int Med June 2010:170:1024
2. NEJM 366;25 June 21, 2012, pg. 2421
3.  thanks to Bob Harrington for picking this pearl off the web
4. Overdiagnosed: Making People Sick in the Pursuit of Health
H. Gilbert Welch, MD, Lisa M. Schwartz, MD, Steven Woloshin, MD
http://www.beacon.org/


Vol. 57 December 15, 2011 Four Ways To Speed Up Your Emergency Room Visit.

December 16, 2011

BLESSED ARE THE SQUEAKY WHEELS,
FOR THEY SHALL RECEIVE THE OIL. *

*Re-learned and confirmed by my recent 8AM – 4PM sojourn on a Monday in a community hospital ER helping a friend who had become unhinged and needed psychiatric help. 

.

.1. Ask for and write down the name of any physician, physician assistant, or nurse practitioner who treats you in the Emergency Room..

These are the only ER staff who can write the orders for your tests or treatments. If later you ask a tech, a nurse, a social worker, or a care manager why something hasn’t been done yet, they may ask you “who said you were getting that?”. Answering with a specific name gets you past that particular speed bump.

These people often come and go in the ER repeatedly during their shift as they deal with multiple patients in multiple areas, so knowing their names can help you reconnect with them if they are not visible. Usually you can spot your ER nurse(s) and hail them directly or point to them if someone asks you “who told you that”. When desperate for info or action you can also ask the nurse to page the physician, physician assistant, or nurse practitioner by name.

2. If you don’t know why you are waiting for something, ask anybody who comes near you: “Why I am waiting, or what am I waiting for?”. Ask every half hour, but increase the rate to every 15 minutes if you have been waiting for more than three hours. If nobody comes near enough to you to ask, push the call button and ask whomever responds; same frequency.

Even if the person you ask doesn’t know the answer, he or she will find someone who does if you keep asking. ERs are busy and most of the staff are caring for multiple patients simultaneously, so sometimes you need to reclaim their attention to move along.

3. If you are waiting for a decision or a service of any kind and the time is close to 6:30 AM, 2:30 PM, or 10:30 PM start asking for clarification or expediting every 10 minutes until the next hour arrives.

Nurses change shift normally at 7 AM, 3 PM, and 11 PM and when the nurse that has been working with you for the past few hours leaves, that change can result in a reduction of a sense of direction or urgency that you have been working hard to establish. So, push for decisions and/or disposition before the shift change. Social workers and  care managers usually work 9 to 5. Physicians work all kinds of shifts, so don’t be afraid to ask him or her when they go off, and push for decisions and/or disposition before they do.

4. If you are in the ER as a patient or as an advocate for a patient seeking behavioral or mental health services, do NOT be quiet, cooperative, and docile. The noisy, agitated “mental” patient gets faster treatment and disposition (or at least a quieter, more removed room to wait in)

One has to be moderate about using this last technique, but it is worth being more noticeable.  If you are perceived as a very cooperative patient or as a polite, passive  patient advocate you may be enabling a slower pace of action. This could be even more of a factor when several patients are awaiting psychiatric referral, evaluation, or placement. However, you don’t want to push this behavior to the point where they call Security or consider injectable medication.

For more details read on:

THE PROCESS: Inefficient, time-consuming, tiring and somewhat irritating to the patient and advocate, but probably “better than usual”.
8AM arrive in ER.
9:15 AM Social worker interviews patient for 10 minutes, and says she will ask the team intake person to evaluate
10:30 AM Team intake nurse interviews patient for 30 minutes. She says patient needs placement and someone will come to evaluate him.
11:30 AM Psychiatric Nurse Practitioner speaks to patient for 5 minutes. She says he needs to stay in the hospital, and they will start looking for a bed.
1:30 PM Patient’s advocate (me) goes to social worker desk to ask about progress in looking for bed. (See above for her response.) Discharge planner at the same desk seems to be hearing this news for the first time.
2:00 PM Patient’s advocate asks for update from discharge planner. Response: a possible bed at facility A 50 miles away.
2:30 PM Patient’s advocate asks for another update. (see above for critical timing). Response: No bed at facility A but possible bed at facility B 90 miles away.
3:00 PM Patient’s advocate reports to discharge planner that patient is getting restless and that the advocate has to leave. (More than a slight exaggeration for effect) Response: Let us know when you leave because “we will have to institute a one-on-one staff observation on him at that time”. (An expensive inconvenience for the nursing staff) Patient advocate requests a move of the patient to the quieter Psych holding area to get him out of the increasingly crowded and noisy ER before the advocate has to leave. Response: There is no room in the holding area.
3:30 PM  ER nurse reports that a bed has been found in facility A, and that patient will be moved out of the ER into the Psych holding area awaiting transport. Patient is taken into the Psych holding area where 3 out of 4 beds are empty.
4:00 PM Local private ambulance company comes to the Psych holding area and packs patient up in 5 minutes to go to facility A.

THE OUTCOME: Excellent
The patient is placed in an appropriate Geriatric Psychiatry Unit with a good reputation in a community hospital 50 miles from home.


Vol. 38 February 1, 2011 Health Care Reform in the U.K. and U.S

February 1, 2011

 

“England and America are two great nations separated by a common language.”
-attributed to both Winston Churchill and George Bernard Shaw

In 1965 I spent the summer of my third year in medical school at the General Practice Teaching Unit of the Royal Infirmary in Edinburgh, Scotland because I wanted to learn more about the National Health Service (NHS). My impression then was that both the U.K. and U.S. medical care systems were evolving toward the same end result from very different directions. (1) That viewpoint has been reaffirmed by recent events. Both countries have embarked this past year on significant health care reform. Both countries are seeking to reduce costs, improve quality, become more patient-centered, and invest in health information technology (HIT). In both countries the majority of patients are highly satisfied with the NHS or Medicare and are vigilant about not giving up any of its benefits.

Both health care reform acts are being criticized for being too timid, or too bold, or too incremental, or too radical. The U.K. plan is being attacked by some as a disastrous turn toward privatization while the U.S. plan is “another step toward socialism”, i.e. very little change in the tenor since 1965. Vocal U.K. critics on the left decry the proposed move away from regulation (NHS) toward competition and market-place economics while the vocal U.S. critics on the right warn against more regulation and movement away from reliance on competition and market-place forces.

Increased Primary Care Support
The basic foundation of the NHS has always been General Practice physicians (GPs) who have no hospital privileges and refer all patients needing hospitalization to full-time hospital specialists (Consultants). (2) In 1965, and in 1996,  such a separation of outpatient and inpatient medical practice was threatening to community physicians in the U.S. (3) Today it is difficult to recruit primary care physicians (and some specialists) to a community unless the hospital has hospitalists to care for inpatients. The community-based internist in U.S. is now more like the GP in U.K. then ever before, and that is not a bad thing.

Accountable Care Organizations (ACOs)
In the U.K. regional Primary Care Trusts (PCTs) have been responsible since 1948 for “commissioning” (purchasing) care beyond primary care; hospitals, specialists (consultants), ambulance service, maternal health. GPs advised these trusts, but did not run them. By 2013 they will. 141 GP Consortia will commission (purchase by contract) all patient care services for a defined population and will control the allocation of 80% of the NHS budget. Secondary care providers (hospitals and consultants/specialists) will be competing on quality grounds for the contracts. Prices will remain regulated nationwide by the NHS. Sounds like a physician-run Accountable Care Organization (ACO) doesn’t it? (Remember 50% of U.S. medical care services are currently paid for by our government; Medicare, Medicaid, VA, or Federal Employee Health Benefits).

Medical Home
Since most GP practices have been closely connected for years with visiting home care nurses, social workers, and other ancillary social services through the Local Health Authority and every patient needs to “register” with a GP, GP practices closely match the newly-coined U.S. definition of “A Medical Home”; i.e. a multidisciplinary primary care unit that manages, but does not provide, all aspects of the patient’s care. Now the GP referrals will more directly affect the flow of money.

HIT Investment
A $20M (million) program started in the U.K. in 2003 to develop digital patient records and hospital administrative systems outsourced to two national major vendors its imhas been poorly implemented  . The new plan calls for incentives for more local and regional initiatives from the Trusts/Consortia to move HIT along.
“Improving IT is essential to delivery of a patient-centered NHS”..a modular approach based on”connect all” rather than “replace all”.
The government proposals call for an NHS-wide “information architecture” set around standards, improvements in data accuracy, and the opening up of records to patients online. The NHS looks to saving $32B (billion) by 2015 by implementation of the revised HIT plan. There is a concern about the Trusts/Consortia having enough HIT expertise to do this is. In the U.S. the establishment of 70 Regional Extension Centers and HIT Workforce Development Grants will help implement the “meaningful use” of HIT. Neither the U.K. nor the U.S. plans have established national standards for connectivity; standards that need to be “transparent and centrally mandated” to reduce complexity. This lack of connectivity will be an increasingly vexing problem for both providers and patients in both countries.

Bottom line: Both U.S. and U.K. are evolving toward a similar mixture of public/private health care schemes from their different historical directions. They share common objectives and common problems., and neither country is finding the path to be particularly smooth. Since EVERY country’s health care system is different, and critics of health care reform on both sides of the Atlantic are whipping up fear of the “other system”, it is time to move on and expand our vision by trying to learn more from France and Germany’s experiences.

References:
1. Mathewson, H.O.. “General Thoughts About General Practice: a medical student’s view of the future of general practice in the United Kingdom.”  J Med Educ. 1968, Jan;43(1):36-41.
2. David J. Kerr, M.D., D.Sc., and Mairi Scott, M.B., Ch.B., “British Lessons on Health Care Reform” , September 9, 2009, at NEJM.org
3.Wachter R, Goldman L. “The Emerging Role of ‘Hospitalists’ in the American Health Care System”. N Engl J Med 335 (7): 514–7. 1966


Vol. 32 November 1, 2010 Laying on of the Hands

November 1, 2010

It appears that except for physical therapists, masseuses, and priests no one lays on the hands anymore. Certainly contemporarily trained physicians do not.

Recently I went to my local ER because a 2-day old pain in my back “due to a strained muscle” from a gym work-out was now, at 11:00 PM, causing me to be quite short of breath and unable to lie down. The ER reception desk was empty and, as the sign instructed, we picked up the phone and announced our presence. An ER nurse came out, signed me in, registering me as a new patient, escorted me back to a cubicle, recorded my vital signs, took a short history, listened to my chest (“A few crackles there in your back”), started an IV, ordered an EKG and a chest x-ray, and drew a whole bunch of bloods, one tube of which revealed that I was probably having pulmonary emboli (clots to my lungs). The CT scan confirmed the diagnosis of “multiple bilateral pulmonary emboli”.

Then I saw my first doctor. While standing at the bottom of the bed juggling a clipboard that was barely controlling various colored sheets of paper, she took a short history, listened to my chest (“A few crackles there in your right posterior chest”), told me that the CT scan was positive, and that the admitting hospitalist would come to see me soon. The nurse explained that the ER doc was busy with a very sick patient being transferred into town.

The admitting hospitalist was a true gentleman. He even sounded like a gentleman with his clipped British accent and Eastern Indian last name. He took a longer history, listened to my heart and lungs (“A few crackles on the right side there”) and outlined what was to happen next; a stay in hospital for three days at least, immediate anticoagulation, and tomorrow an ultrasound of the legs and an echocardiogram looking for a source of the clots. He explained things very clearly, was reassuring, and answered my questions succinctly and thoroughly. I felt that I was in good hands, …but I was a little uneasy that no one had done a complete, or even a semi-complete, physical exam.

What has happened to all that we were taught in second year Physical Diagnosis?

No one stretched my calf looking for a positive Homan’s sign. No left lateral decubitus positioning to listen for that subtle, easy to miss heart murmur. No confirmation that my extraocular movements were normal. No listening intently for a carotid artery bruit. Forget looking for splinter hemorrhages on my retinas or even under my fingernails. My abdomen could have been hiding an enlarged liver or spleen, but no one would have discovered it that night. Come to think of it, I do remember the admitting hospitalist briefly pushing two fingers against my shins and commenting, “trace edema”.

After a day shadowing a physician in a program sponsored by our local medical society, a banker summed up his impression with, “A physician’s job is a day-long quest for credible data”. I agree, and it is clear to me that the physicians caring for me that night were doing just that as efficiently as possible. Why bother checking for Homan’s sign when an ultrasound tech the next morning will tell you if there is a clot in the leg, its location and how big it is? The echocardiogram will give so much more information about my heart dynamics than an application of a stethoscope for a minute or two. With a dramatic CT scan showing all the clots and some pleural fluid, and with me having significant pain every time I took a breath, why spend a lot of time percussing my chest, feeling for vocal fremitus, or switching back and forth from bell to diaphragm on the stethoscope?

As technology has advanced, objective test results have replaced many physical findings as the foundation of a correct diagnosis. The job of the physician has become in large part that of deciding which test will give the best information. That is not bad, but I remember that our Physical Diagnosis professor won more “Best Teacher” awards than any other faculty member, … or any imaging machine. He not only provided us with our first glance into the real magic of clinical medicine, but he imprinted us with the appreciation that “laying on of the hands” was a vital part of a respectful relation with the patient.

I received excellent, efficient care. I was diagnosed quickly and treated appropriately, courteously, and was fully informed. But, in remembering Eliot Hochstein, MD I have to say that as a patient I sure do miss some parts of the “good old days”.

One part of the “good old days” hasn’t changed. At about 1:30 AM after all the tests that night were done and I was being prepared to be moved upstairs to a bed, I was still really uncomfortable because  I had not yet received any pain medication. I asked for some, and got my first dose at 2:00 AM.

References:
1.Physical Diagnosis, a textbook and workbook in methods of clinical examination 
by Elliot Hochstein and Albert L. Rubin. Published 1964 by Blakiston Division, McGraw-Hill in New York .


Vol. 28 September 1, 2010 Computer Error or Patient-Centered Care?

September 1, 2010

The saga continues, but morphs from a discussion of computer error into patient-centered care (1).

In my last two posts I tell my story of trying to speed up a six-hour infusion of intravenous medication by correcting a “computer error”; a “failure to update reference information” in the computer available to the nurses. My first clue was the discrepancy between the medication’s package insert and the computer information. Discussion with the infusion nurses and a call to the Hospital’s chief pharmacist caused a review of the computer info, the package insert, and the hospital’s Pharmacy and Therapeutics Committee minutes.

The package insert stated that “after the initial 30 minutes without a side-effect the infusion rate could be gradually increased to the maximum rate.” The infusion nurses’ interpretation of “gradually” was a infusion rate step-up every 30 minutes resulting in a six-hour infusion. My preference was for a two hour infusion. I looked diligently, and in vain, for the manufacturer’s definition of “gradually”, so I called its 800 number . A very knowledgeable and accommodating RN in the Professional Services Department ( I identified myself as a physician) explained that they did not define “gradually”  because they wished “not to be too proscribing, realized that individual patients varied, and respected each facility’s responsibility to set their own protocols.” It sounded like pretty good risk management (avoidance of increased liability) to me.  She went on to say that many facilities had used a rate step-up schedule of 15 minutes rather than 30 minutes without increased side-effects and offered to send us the articles describing this.

Going to a step-up rate 0f every 15 minutes rather than 30 minutes would result in a four and a half hour infusion instead of a six hour one; still longer than my initially hoped-for two hours. Could the change in duration be labeled a triumph of “patient-centered care”? If so, was it worth all the time and effort?

As a physician, I am more informed than the average patient. As the retired Medical Director of the hospital where I was receiving the treatment, I knew and had good working relationships with my nurses and the pharmacist. As a physician seeking clarification about administration of their drug, I was accommodated and happily helped by the drug manufacturer. This process involved several discussions, local and long distance phone calls, sending of faxes, reviewing of minutes, and patience on the part of both providers and patient over several days; all for a rate of 4 1/2 rather than 6 hours for a just single medication. Was this negotiation worth it?

Don Berwick “uses his own wits to safeguard against errors” and now urges the adoption of patient-centered care to restore his dignity as a patient in the current medical world where “provider trumps patient” almost every time. (2) Negotiation between patient and provider from EQUAL bases seems to be the essence of patient-centered care.  The line between requesting and demanding can be a thin one. We successfully avoided defensive stances and threatening attitudes and never felt that we were engaged in a “dispruptive shift in control and power.” (3) Is it reasonable to expect the average patient and the busy provider to conduct such successful negotiations most of the time? That is a tall order, but I hope that healthcare systems will be able to  support the process without bogging down the providers and frustrating the patients.

References:
1.  “Patient centered care means meeting patient’s needs and preferences through shared informed decision-making which will reduce unneeded and unwanted services” – See Institute of Medicine, Institute for Healthcare Improvement, Robert Wood Johnson Foundation, The Commonwealth Fund, The Joint Commission, and Patient-Centered Outcomes Research Institute websites and publications.

2.  Remarks by Don Berwick before the plenary session of  the International Forum on Quality and Safety in Health Care, Berlin 2009    http://www.youtube.com/watch?v=SSauhroFTpk

3. “What ‘patient centered care’ should mean: Confessions of an extremist.” Don Berwick, Health Affairs 2009 Jul-Aug 28 (4)


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