Patients–do you consider yourself a leak problem?

Healthcare Leakage

Healthcare Leakage

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 Screenshot 2014-09-14 18.52.51blocked. 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.

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Vaginal Estrogen–a High Risk Medication in the Elderly?

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:
2.Biological Effects of Various Doses of Vaginally Administered Conjugated Equine Estrogens in Postmenopausal Women

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Yes Cassie, there is a future in Primary Care

My daughter recently introduced me to a friend of hers via email. She is a newly minted fourth-year medical student who asked me the following question:

“I would love to hear your thoughts about the future of primary care and what it is like to work as a family medicine doctor in Louisville.”

To start, I’d encourage you to read this recently published New York Times review of the state of primary care.  If you began in practice today you would quickly find yourself with more patients than you can adequately care for having just left residency and not expecting to see 25-30 patients daily. In Louisville, you will probably be employed by one of three healthcare systems. All of them have compensation based on patient volume and RVUs–I hope someone has showed you what RVUs are but I bet they haven’t. Relative Value Units are supposed to measure the “time, skill, training and intensity”[1] of patient care and compensate accordingly. Unfortunately they are heavily skewed toward proceduralists. As Dr. John Mandrola, john-mandrolaa Louisville interventional cardiologist, observes in his excellent post Thirty Dollars…Really?, a doctor is paid a lot more to do a coronary catheterization than to talk about the causes behind coronary artery disease. To understand a little more why the RVU is skewed that way, here is an excellent post on the Kevin MD blog that summarizes it nicely: The Relative Value of How Physicians are Paid Needs to Change. So in today’s environment you need to see more patients than you are comfortable with, spend less time than you deem adequate with them which will promote pill-pushing over explanations. This will mean your risk of burnout will be significant. It is estimated that 43% of Family Practice physicians are burnt out according to a Medscape survey done in 2013.[2]

There is some good news. Value-based care, which bases compensation on how well you take care of patients rather than the number of patients that you see, is coming. In our corporation, systems are being put in place that will help primary care doctors take quality care of their patients and compensate those that do it well better than the ones that don’t. Of course how one is measured is controversial as evidenced by this NEJM article from November: Grading a Physician’s Value. And data can’t be gathered without an integrated EHR (Electronic Health Record) and those are far from prime time. Being a digital native,  you’ve likely already noticed that EHR software on your rotations is not up to the gaming software standards you are used to.

Social Media, regardless of what city you ultimately practice in, will be the best means of keeping up with the ever-changing landscape of medical advances, political hot potatoes and healthcare tech so if are not following healthcare thought leaders already on Twitter I’d advise you to start that today. Begin with Primary Care Progress (@PCProgress), Berci Mesko (@Berci), Screenshot 2014-07-23 14.57.20Mike Sevilla (@DrMikeSevilla), John Mandrola (@drjohnmd), Kevin Pho (kevinmd), the Society for Participatory Medicine (@s4pm) and me (@docnieder), of course. If you haven’t found ZDoggMD, that’s another must.

Primary Care is alive and, if not well, at least no sicker than the rest of healthcare in the world but I see better things on the horizon. If I were fresh out of residency today I would get my feet wet as an employed physician for a couple of years, making sure your non-compete clause does not include going into private practice but only prevents you from moving to a different healthcare system across the street. Then I’d look long and hard at the DPC movement (Direct Patient Care) and make that my goal. Taking care of patients in an atmosphere that values the doctor-patient relationship above all other business needs is what we go into medicine to do. Physicians in DPC are happier and so are their patients. While it remains a patient care area where it is difficult for lower income patients to access, this may change as this successful way of caring for patients brings down costs and increases quality. I believe that government entities will find ways of incorporating this model into their systems. The  DPC model can be affordable for people who can’t afford health insurance but still make a modest living, giving them an option for excellent healthcare at low costs. For now, a physician can use the time generated by working in an upbeat and efficient model to volunteer at community health clinics like theScreenshot Family Community Clinic offered by St. Joe’s on East Washington St. in Louisville.

  2. Lifestyle and Burnout: A Bad Marriage. Peckham, Carol. 3/27/2013.
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Unintended Consequences: How HIEs force patients to quit their PCPs.

Last week, a patient who has seen me for more than 20 years called my office for an appointment. She signed up for one of the new HIE insurance plans but we are not a provider on that plan. She is a healthy woman, rarely needing my services and expected her new insurance to be her backup in case she became seriously ill. She was willing to pay cash to see me but this is unacceptable under Kentucky rules and considered “insurance fraud”. The reason given to her and our legal representative, by the Kentucky Healthcare Exchange (KYNECT), is that if a patient can afford to pay for a routine doctor visit then they shouldn’t need insurance. What? How does that follow? Since when does the ability to pay cash for a single visit mean that a devastating diagnosis and subsequent treatment would not wipe a patient out financially? One would assume lessoning that risk would be one purpose of the new insurance exchanges given that medical bills are the #1 cause of bankruptcies[1]! Insurance doesn’t need to be for routine visits. In fact, the entire basis of the DPC movement (Direct Patient Care) is to cut out the middleman of insurance from routine primary care visits.

Because I work for a healthcare system, my staff could not tell the patient what physicians and healthcare advocates “in the trenches” recommend, which is to hide your insurance status from your doctor’s office. There’s a great article entitled “Insured Patients Can Save Money by Pretending to be Uninsured” from the The Self Pay Patient website that explains how this works to many patients’ advantage.

I wonder, is this solely a Kentucky problem or is this an issue seen across the US? If anyone knows please leave a comment in the section below. In the meantime, if you are my patient and I don’t accept your new KYNECT insurance, well, I’m just sayin’…

1. LaMontagne, Christine. NerdWallet Health.

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A Short EHR Rant

No argument that EHRs began as billing platforms, though I will argue that they work just as poorly with charging as they do for communicating patients’ stories or making better decisions in patient care. After two years our EHR still isn’t used for billing and even if it were, since it has no Natural Language Processing capabilities, the doctor would have to manually enter the correct CPT code.Medical_Software_Logo,_by_Harry_Gouvas

My rant today is a brief one about how physicians document in an ambulatory EHR. On paper, we documented the patient’s story, any pertinent medical history and/or family history, the physical exam, our assessment and the plan (better known as a SOAP note). This was a short, succinct and usable communication device (assuming you could read the doctor’s handwriting). Today’s physicians, in the hopes of better compensation, pull in every possible bit of information into the note including their great great great grandmother’s penchant for getting hangnails. OK, that’s hyperbole, but it is almost that bad. And then complain that the EHR is a terrible way to communicate and that everyone else’s notes are too long.

Having been the “champion” for the EHR in our system I have a request to make — Hide, or have your assistant hide, all that past medical history. You didn’t put it in your paper note and IT DOESN’T NEED TO BE IN YOUR ELECTRONIC NOTE EITHER. If it’s a matter of training or you don’t know how to take it out, please ask your friendly IT trainer and they will gladly help you.

There, I’ve said it and I feel so much better!

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Living with the Line

My home and office is full of art work done by the artists I have lived with over the last 30 years. My husband makes wonderful creations out of glass.IMG_4983




My younger daughter paints Georgia O’Keeffe-styled paintings for gifts and designed a beautiful canvas that sits behind my desk at work. IMG_1215


My older daughter designs programs for her medical school class and cards for her grandmothers. As a gift to me she drew a family portrait that captures each family member’s special character. IMG_0722

Surrounded by this talent, about five years ago I began to draw, hoping to do it well enough that my sketches would be recognizable in my journals, especially with travel. It’s been a slow painful journey but recently I began Sketchbook Skool, online classes founded by Danny Gregory, an artist I’ve admired for years. The first class began with an intimidating assignment – draw with a pen. The purpose of the exercise is learning to “live with the line”. Multiple times in the last six weeks I began a drawing and wanted nothing more than to tear it out of the book, get rid of the line and start the sketch over. But I had to persevere and since it was an assignment I kept working with it. Amazingly, as I continued with the drawing it would take shape and become something I really liked. My mistakes were not only livable, many times they were my favorite drawings when finished.

Porch Wall Hanging

Porch Wall Hanging


There are corollaries to be made in healthcare–perseverance for example, of which most family practice doctors need a healthy dose of every day. But the acceptance of imperfection, is that even safe in medicine? How do you accept, even more, celebrate the difficulties of practicing medicine today, especially in primary care? With drawing it’s a matter of going beyond ignoring the line–it’s using it to “bend” the reality of a picture, thereby creating something that resembles the object but is different, still recognizable but different. The corollary in my practice is helping patients become participants by using tools like social media, whiteboards and smart phone apps. But I’m an apprentice artist compared to the DaVincis of medical care:   The DPC movement with physicians like Dr. Robert Lamberts, and models like Turntable Health are “bending” healthcare practice to create better care for patients, and in the doing, taking physician practice to a point where it once again feels like Art.





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On Call Dilemma

emergencyTypically my call weekends are light. I don’t get a lot of messages. Saturday there was one remarkable only in my inability to do much for the caller. My associate’s elderly patient was in the ER, sent there by her physician. He is 94 and was falling more lately, had reduced appetite, just didn’t feel well with occasional episodes of shortness of breath. His daughter called because they were “40 patients deep” in the queue and she wanted to know what could be done to improve the chance that he would be seen more expeditiously. I thought about it. I certainly understand why she was concerned about her elderly father sitting on hard chairs in the emergency room with goodness knows what illnesses surrounding him. At the same time it didn’t sound like there was anything emergently wrong, as opposed to urgently.  He might have a pneumonia or urinary tract infection, so common in the frail old patient. Was it  appropriate to try to push the emergency room to see him ahead of the other 39 people who no doubt also felt that their problems were of utmost importance? I explained to the daughter there was no certainty anything I said would get her father seen more quickly and she responded that her experience was when a physician called things got done. Sometimes that is true if I have knowledge the ER is lacking as to why a patient is seriously ill. But I didn’t really have that. How quickly does one wear out their welcome with the ER if I cry wolf? On the other hand the patient is 94, sounds frail and certainly was at risk to sit in emergency room for several hours. My own mother is not too far from that age so I intimately understand the daughter’s concern. What was the right thing to do?

What would you do?

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Patient Partnerships and Patient Satisfaction — are they the same?

If you had to deal with a “spousal satisfaction score” on a monthly basis, would this improve your interactions with your spouse? How about a “colleague satisfaction score”? Would you find it helpful to your psyche or would you resent your colleagues monthly critique? Increasingly this is how I feel about patient satisfaction surveys and physician rating sites. How much value are those instruments? Interesting a study from UC-Davis demonstrated an inverse relationship between patient satisfaction and good care. It makes sense, especially in an ER setting with hurried, relatively impersonal care, patients whose surveyexpectations are not fulfilled will be unhappy. The classic example in my world is the patient who comes in with a viral upper respiratory infection insisting on a “Z-pack” antibiotic. Seriously, it still happens. Will they leave and go to Angie’s List and give me a bad grade? Did I do the right thing by refusing the antibiotic AND discussing why? Did I try at great length to help them understand the danger? Despite my explanation, were they still upset they didn’t get the med they wanted? Fortunately I am not yet discussing Press Ganey scores in the hospital lounge with my colleagues but we do offer a Target gift card to random patients who take a survey from my office.

Partnering with patients does not imply that we are always satisfied with each other, just as I am not always satisfied with my spouse’s behavior. We work together to improve healthy behaviors, we trust each other to find the best path and we compromise expectations by taking into account factors that impact health. If I am worried about satisfaction, it is easier to hand out that antibiotic script than spend time explaining why a viral illness doesn’t require one. Or give the patient that antidepressant she expects because the TV says she’ll feel better, instead of understanding the reasons behind unhappiness that doesn’t require medication.

In spending enough time with patients to hear their stories, see their body language and listen to the undercurrents in their lives–this might improve my satisfaction scores and ratings, but not necessarily. It will enable me to give the best care regardless of my score. This is my goal. Hopefully, no one will push me toward another.

1. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Fenton JJ; Jerant AF; Bertakis KD; Franks P. Arch Intern Med.  2012; 172(5):405-11 (ISSN: 1538-3679)





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Death Stalks Me Tonight

My children are no strangers of death. They understand the cycle of life and have said goodbye to pets, mourned with their friends who have lost parents and grandparents. My youngest stood by one of her closest friends who lost her younger brother  unexpectedly of a heart problem. My girls have know acquaintances who suicided or died in accidents but tonight is the worst.  My daughter calls me, sobbing “They found his body”–a friendship forged in high school at the  Governor’s Scholars program, a young man–handsome, intelligent, gone missing two days before. A hate crime. My daughter is 2300 miles away. I cannot hold her. I can only cry with her from the distance, feel her pain and wonder how and why this happens.

Tonight I try to calm the vitriol that rises in my own throat, knowing that is not the answer but is of the same poison that killed this young man.

But it is hard.


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Feeling the void

Many years ago, a wise family practice mentor said to me “One of the nice things about being a physician for many years is that my patients have grown old with me. Unfortunately that means I am losing more of them.” Those words came back to me recently after the loss of my third male patient in six months, all close to my age. Two of them, avoidable deaths but work and inflammation came before healthy habits and lifestyle changes. The third was from a quick and devastating disease that was not avoidable.

The wife of the third man came in for a visit yesterday. We talked a little bit about his disease and its quick progression. She talked about the usual things–their 30 year marriage, children, hopes for grandkids. I told her that I would miss him after our many year patient-doctor relationship. I hesitated, then shared with her that it had been a rough year with patient losses and that he was one of three men that died much too young–at 70 he had been the oldest. She looked at me and said “then you feel the void.”

Obviously, not the same way that she does, but indeed, I feel the void.

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