Flying home from the first HIMSS Patient Engagement summit, I finished Atul Gawande’s book, Being Mortal. I found myself aggregating my thoughts on the conference and the book. They both highlighted how slowly medicine embraces change as we struggle to put patients at the center of the healthcare stage. My reflections revealed that as far as I’ve come, I’m still not there in many interactions with patients. It’s still difficult for me to be more than “Dr. Informative”, which is Dr. Gawande’s accurate portrayal of physicians who are uncomfortable with medicine’s previous paternalism but unsure how to unravel the patient’s goals. During the conference patient panel, Kym Martin, a patient experience expert and four-time cancer survivor, commented that health is not just about the disease process. Physicians, indeed healthcare as a system, must consider a holistic picture that includes financial status, relationships, family support, work issues, etc. Present provider and hospital goals seem to concentrate efforts on what what we, the system, identify as the patients’ goals. Those “should bes” in our eyes are often not the reality of a patient’s existence if all circumstances are taken into account. Dr. Gawande struggles to remember to ask the following of his patients: “What is your understanding of the situation and its outcome? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?” And while his book is concentrated on end of life decisions, isn’t this true for all our patient interactions? Then at 10,000 feet over Chicago it occurred to me–wait, this was what I was taught a million years ago in Family Practice residency–to understand the patient and all that individual has to deal with, not just the disease AND to guide that person through the tangle of the healthcare system. Now if someone will just tell me how to do that in the seven minutes I have with them…by
Mrs. Davis hasn’t seen me in over a year. It’s a burden for her family to bring her in but I haven’t yet been able to add house calls to my busy schedule. She recently turned 94 but lost the gift of cognizance some time ago. It’s only been a few months since her husband passed away though it is unlikely she is aware of that fact, she’s long forgotten who he was. She was once a respected professional, well-known in our city and a philanthropist of several now forgotten causes. She shuffles into my office, sitting with her head in her hands. She knows who she is, but that is all. She is well-cared for by family members who call themselves fortunate to share her home.
I look at her vital signs. The 15 pound weight loss jumps out at me. “Is she eating?”. Her caretaker responds, “bits and pieces of this and that, she’ll drink an occasional Boost”. “Does she appear to be in any pain?” “No, she sleeps a lot, doesn’t interact much.” I perform a not too-detailed exam and determine that she has no skin breakdown. In addition to her cachectic appearance, I notice a difference between sounds in the two sides of her lungs. One side sounds dull, though she breathes shallowly and perhaps it is the other side that is hyper-resonant. I look at her caregiver who is also a nurse. “She’s lost a fair amount of weight and there is a difference between the two lungs when I listen.” We lock eyes. After a few moments he responds, “And what would we do differently if we explored this.” I look at the patient. She looks a little tired but not uncomfortable. “Nothing, I would hope.” “Then we’ll be saying goodbye and thanks for refilling her meds.” I nod, ask him to call me with any problems and move on to my next patient.by
The definition of irrational behavior is “without the faculty of reason; deprived of reason” and it is presently rampant in my workplace. Every patient seen, not just individuals with fever or nausea and vomiting, is screened for exposure to Ebola. Every patient that walks through the door gets a(nother) form with three checkboxes asking if the patient lived in or visited a west African country within the last 21 days or was exposed to an individual who has the disease or is at risk of having the disease. I guess in a world where hype and panic prevail this is considered a reasonable question. Along the lines of this thinking, it would make a lot more sense to ask:
- Did they drive to the office? —chance of dying in a motor vehicle accident 1/491
- Do they have a gun at home? —chance of suicide using a gun 1/203
- Are they flying anywhere in the next week?— chance of dying in an airplane 1/8335
- Did they run to their car or home in a thunderstorm recently?—chance of dying in a storm 1/83709
Chance of dying of Ebola: 1/3,934,300
I await the unlikely event when one of my patients returns from an Ebola-affected country in the previous 21 days and comes to me for his hypertensive check. As I enter our newly created isolation room and do the visit in full protective gear, recognizing that touching an asymptomatic patient is of absolutely no risk to me, what in the hell am I going to say to this gentleman? “Have a nice day and please slink out the back door on your way out?”
System administrators and politicians feed into the hysteria of the masses and frighten patients who are already freaked out by any number of irrational fears. As a consequence, heroes return from working in West Africa and are greeted with the loss of civil rights based on fear instead of science. I take umbrage at being forced to add to public paranoia by legitimizing a workflow designed for a real threat instead of this farce.by
As I write this post, my thoughts wonder if I’m being wooed to the dark side. Rarely (or maybe never) has an insurance company done anything that made my life easier or reduced my workload. A few days ago my medical assistant handed me a denial for a prior authorization (PA) request from a pharmacy. She attempted to do the PA online and was unsuccessful. It was a fairly straightforward diagnosis so it seemed odd that there was an issue getting the drug approved. Our patient has biopsy proven Barrett’s esophagus, a premalignant lesion for which a medication like Nexium is indicated. I sigh and flip through the denial papers to try and understand the reason and am amazed to see the name and phone number of the Humana physician who did the denial. I call her. It’s before 8 AM so I don’t expect an immediate response but a couple hours into the day I am pleasantly surprised (again) to get a return phone call from the physician herself. She tells me that the medication was approved for twice a day use but for some reason the pharmacy requested 90 pills for 30 days. It was only ordered for once a day so that’s an easy thing to fix with the drug store. Meantime I am thrilled. To be able to access a corporate physician quickly and resolve a problem for a patient in record time is a big step in improving patient care and transparency. Kudos to Humana! Don’t stop there please.by
On the portal this morning I received a great note from a patient. He’d seen two specialists and was checking in to tell me what had happened in those visits. His summaries were succinct, tell me exactly what I needed to know about what transpired. It took me about a minute to read them. Since the advent of EHR-generated referral letters I’m unsure that I’ve read a better referral note.
After reading it, I knew the assessment of the problem, the treatment plan and when he would be seeing them back. I did NOT receive one to ten pages of past medical and family history that I already knew. I did NOT receive a list of the medications he walked in the door on, which I already know. I did NOT receive his insurance information, which I already have. Etcetera.
When will EHR vendors be able to extract information and template a referral note that only contains what I need and not streams of unnecessary information that gets in the way of my being able to read what I do need to know? When will physicians help the IT department cut out all the useless crap in those letters? If they’d like the name of my patient to help them, please contact me. I’m sure we can work something out.by
Answer: When the insurance company decides it is not.
The definition of screening, from a health prevention viewpoint, seems pretty straight forward: “a strategy used in a population to identify an unrecognized disease in individuals without signs or symptoms.” Typically these services are covered at 100%. However, insurance companies avoid appropriate payments for their members by changing the coding of a preventive service (which is covered 100%) into a diagnostic procedure, which is paid based on whatever the patient’s coverage allows. This change in coverage occurs because a polyp is found during the exam, which is of course, the whole point of doing the procedure: Screening and removing a polyp so that it never becomes cancer. Patients with high deductibles suddenly owe several hundred dollars in unexpected healthcare bills for a procedure they were told was covered. This is ethical and appropriate corporate policy?
And I can’t help but mention that the insurance company fancying itself a “Healthcare” company, promoting health and well-being, is the worst offender.
Subsequent colonoscopies that must be done five years later for individuals with polyps, instead of ten years, can arguably be called diagnostic. But changing the definition of a procedure solely to avoid paying for an appropriate screening exam, is another example of non-transparency, regardless of how well you explain it in the patient’s policy description.
This morning an article caught my eye and then my imagination: The Dreaded Post-Visit Call. It describes a patient who becomes worried after getting a post-doctor-visit phone call. She doesn’t understand its purpose and calls her physician thinking something is terribly wrong. Apparently his healthcare system employs individuals to make these calls after every doctor visit to ensure “patient satisfaction” (THAT PHRASE!). At any rate, it got me thinking about the future of calls like this.
It is not outside of reality to envision other entities making post-visit calls. The doctor’s employer can use the data to determine bonuses. This call could be followed by a post-visit call from the patient’s insurer. These calls could collect data to be used to determine if an insurance company will continue to keep a particular physician in their network based on some sort of satisfaction algorithm. It’s not hard to imagine CMS (Center for Medicare Services) getting on board with this as well as private insurers. Maybe the federal government could get further involved to create a Patient Satisfaction Data Bank. That could be the patient’s third call. And since nothing seems to be private anymore, Healthgrades could make a post-visit call when a patient tweets or posts to Facebook that they were in Dr. Jone’s office. This would increase the number of individuals rating doctors and isn’t that a good thing? Or is it…Why Rating Your Doctor is Bad for Your Health?
Let’s get more anonymous individuals involved in patient’s care, ticking off boxes for corporate data gathering. Or maybe, healthcare systems could train and employ health coaches who do know the patient. Getting a phone call from someone who really cares if you understood what was said during the visit and that you know how to make changes to improve your health? The same person who scribed your visit maybe? This would also free up physicians from being distracted by a computer screen and help them make a better connection with their patients.
Wow–a real win-win for patient care and engagement!
Yesterday my feed sent me an interesting article on the iMed Apps website. The Slideshare below by David Sobel, Director of Patient Education and Health Promotion for The Permanente Medical Group and Kaiser Permanente Northern California, is intriguing. Looking through the slides, they resonated in me. Burnout has crept back into my daily existence and some days it’s as if I’m fighting it tooth and nail, yet not making much headway. The slides are worthwhile to see for patients and doctors alike, both searching for the motivation to make lives better–our own and the patients that we care for.
My LinkedIn update this week referenced a term I recently became acquainted with when it was used by an administrator in my system. It seemed vaguely offensive at the time but I couldn’t quite get my head around it to understand why. It’s called leakage. When this article, “How to reduce patient referral leakage” popped into my inbox, it hit me–is this going to be one more set of numbers administrators can threaten me with? I understand this is a term used in other industries to refer to the consumers they are losing to competitors and I’m fine with that. However, what does leakage mean to a doctor? It’s what aging bladders do. It’s what comes out of an infected wound sometimes, or an imperforate anus. When doctors use the term leakage it is not a pleasant visual. Maybe a tube is blocked. An organ is swollen. The idea that my patients are being referred to in this way is offensive. I’d like to do a study with my patients. “Tell me, how do you like being referred to as leakage if you go to another healthcare system or an independent imaging facility for your healthcare needs?” Somehow, I suspect I already know the answer to that question.
The way we use words is important. Leakage is simply not an appropriate term to use in healthcare. If I didn’t have faith that my system employs some of the best doctors around and takes extraordinary care of patients both inpatient and outpatient, I wouldn’t be working for it. Unless my patients request otherwise, and they seldom do because they trust me and they trust my system, they are referred within. But how much trust would they continue to have in me if they knew I was being pressured to refer in-system? Let’s stop talking about leakage and instead attract the best doctors to take care of our patients because they deserve it. Let’s make our system one where the best doctors want to come and know their patients will be well cared for. Let’s put our patients first and they will continue to come back to us. Let’s be careful with our terminology. Just because other industries use a term that does not mean it is appropriate to use it in healthcare.
When the chair of the board brings his daughter to me and she needs to see a cardiologist do you think he’s going to want me to choose the physician she sees based on who employs her? I suspect not. And next time he or anyone else uses that term around me, be prepared for an earful. My patients are not leakage. You will not refer to them as such in my presence.by
There is a wonderful expression used by the French when referencing an older woman. She is “a woman of a certain age” (une femme d’un certain age) Recently. a patient who fits in that category, began suffering from vaginal dryness causing burning and pain. This is impacting her sexual function as well as being just plain uncomfortable. So I prescribed a vaginal estrogen which serves to increase the vascularity in the area and “plump” up the cells. This improves things in general and reduces the discomfort of sexual activity. Her insurance company, a prominent one in our city, requested that I obtain a Prior Authorization but still denied payment for the prescription because it is a “high risk medication in the elderly.”
Oral estrogens are high risk in the elderly, defined as over 65, increasing the risk of stroke, breast cancer and memory problems. This woman is not at all elderly in the sense of being infirm. She walks daily, volunteers weekly, travels widely, has an active sexual life with her husband and could no doubt run circles around half the people involved in the denial of her medication. The lowest cost vaginal estrogen preparation costs about $168 a tube and there isn’t a generic alternative. In an article published in the American Journal of Obstetrics and Gynecology in 1981, there was NO systemic absorption with low dose vaginal estrogen.(1) A study in 1983 published in the Journal of Clinical Endocrinology and Metabolism showed essentially no changes in the systemic markers of estrogen.(2) While I suspect that no one at the insurance company is maliciously denying claims, did their pharmacy committee bother to do its homework regarding the difference between vaginal estrogen and oral meds?
Low-dose topical estrogen is significantly safer in women over the age of 65 than oral preparations. This should be a choice between a patient and her doctor NOT a “member” and her insurance company.
1. American Journal of Obstetrics and Gynecology. 1981 Apr 15; 138(9):967-8. – See more at: http://www.popline.org/node/385377#sthash.kkgLZIvI.dpuf
2.Biological Effects of Various Doses of Vaginally Administered Conjugated Equine Estrogens in Postmenopausal Women http://press.endocrine.org/doi/abs/10.1210/jcem-57-1-133