Another Irrational Ebola Response

The definition of irrational behavior is “without the faculty of reason; deprived of reason”[1] and it is presently fearrampant 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[2]

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.



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There’s a Physician Charter on Medical Professionalism?

Who knew? A friend sent me the link to an article in the New York Times entitled “Doctors Have Feelings Too” by Danielle Ofri. The subject matter of the article was interesting but what really caught my eye was the author’s reference to a document entitled “The Physician Charter on Medical Professionalism” that was created in 2004 by the American Board of Internal Medicine, the American College of Physicians Foundation and the European Federation of Internal Medicine. This document has been endorsed by numerous medical associations including my own, the American Board of Family Practice. So how is it that I’ve never heard of it? 

The Charter catalogues the essential elements of my profession. The Preamble begins with the obvious, that the physician’s contract with society demands that the needs of our patients are placed above our own needs. Judging by the stories I hear from patients who come to me and the letters I receive from specialists, this first responsibility is frequently lost in the noise of the economic, legal, political, technical and pharmaceutical messages that bombard us. Yesterday I saw the daughter of an 88-year old woman who broke her femur two weeks ago and had her leg stabilized with a metal plate. The plate has now slipped due to her severe osteoporosis and her orthopedist recommended that she undergo a total knee replacement. This recommendation was made in the context of a less than ten minute discussion with the daughter (her mom is too demented to participate). Thankfully, one of the nurses at her mother’s nursing home was horrified enough to suggest that this line of treatment be reconsidered. I can’t say what the orthopedist was thinking–my guess is that he is outrageously busy and therefore did not realize how demented the woman is, that the woman was unable to walk without assistance BEFORE she broke her leg and rehab following a knee replacement would likely be near to impossible. He didn’t ask if she was having any pain (she isn’t), he didn’t ask about her mobility before her fall, he didn’t think too hard about the morbidity associated with doing a knee replacement on this woman, he didn’t go over the pros and cons of this type of surgery with her daughter, in short, he did not fulfill the first clause of the above mentioned contract. I wish I could say this is an unusual occurrence but unfortunately, it is not. Oh, and yes, his professional society has endorsed this charter. He’s probably never seen it either.

After the Preamble is recorded the Fundamental Principles:

Principle of primacy of patient welfare. The principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

The first two of these are obvious but how many of us, myself included, are working hard enough on the last one? Just judging by the political slogans and candidates endorsed by the bumper stickers on the cars in the doctor’s parking lot, I’m guessing that most of them are not all that interested in actively eliminating health care discrimination. It might cause some change in the distribution of their own private resources.

The next area addressed by the charter is Professional Responsibilities which include:

  •  a commitment to life-long learning (seems obvious-who wants to go to a 20th century physician in the 21st century)
  • honesty with patients (the topic of the NYT article mentioned above)
  • upholding patient confidentiality (another obvious one but in today’s world of social media and HIPAA it can be tricky. Sometimes the hardest thing is getting information necessary to treat from other providers who are terrified of breaching PHI)
  • maintaining appropriate relations with patients (another straightforward responsibility–don’t sleep with your patient or otherwise take advantage of him/her)
  • commitment to improving quality of care and access to care. Quality of care seems straightforward but what about when doctors are seduced by peer-reviewed articles that encourage the use of pharmaceuticals that later are found to be no more improved than older medications or worse, more dangerous (see conflict of interest below)?
  • commitment to just distribution of finite resources. This responsibility addresses cost-containment issues. Really? Not only did I not realize there was a charter, but in it is addressed cost-containment! Amazing and it was written eight years ago. Hmmm…like I said, most physicians don’t know it exists.
  • managing conflict of interest. We are supposed to make clear all interactions with for-profit entities. Apparently this remains a problem in even our most prestigious journals–for example the BMJ which had to discredit a widely publicized article on autism and vaccines. There is ongoing evidence that big  pharmaceutical companies routinely suppress or fail to publish data that does not look favorable on their drugs. Another link…As mentioned above, this impacts quality of care.
  • a commitment to self-regulate. This concerns remediation, disciplining of failing physicians, and participation in the educational process both before and after a medical degree is conferred. 
Wow, this is a very complete document written by individuals who put a lot of thought into what our profession is about. I wonder if medical students are taught about it? Residents? I wonder if it was ever disseminated by my professional society, the AAFP. To repeat…who knew? Who knows? 

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Weight loss

Sometimes the bane of my medical practice day is talking to patients about weight loss. I hate it. They hate it. I dread it. They dread it. My medical assistant tells me how a patient will get on the scale and sigh, then say “Dr. Nieder is going to yell at me.” Now truth be told I do NOT yell. But I do try to be consistent with my advice and not ever let an obese patient leave the office without hearing that they would be better off to lose weight. With the overweight patients I try to encourage them to stop gaining weight now before it’s too late.

It’s not as painful with the patients who understand that one can’t gain weight on air, that too much intake and not enough exercise is why they are gaining weight. And it is harder to lose it as the years mount up. In my twenties if I wanted to lose five pounds I would just not eat much for a couple of days. For the last ten years I’ve been battling the same ten pounds. Five pounds will disappear with lots of effort and the minute I let my guard down, BOOM, the pounds have returned. It’s very frustrating. Losing five pounds takes a month of concentrated effort and I HATE IT! It is unimaginable to think of needing to lose 100 pounds.

So I can commiserate with patients who are frustrated but what I can’t do is go home with them or go to the grocery store with them. Honestly, it would be a helpful and educational thing to do, for both of us. I stand in line behind 220+ pound people at Kroger’s and look at the contents of their baskets. What do I see? “White mushy bread??? 4 cases of soft drinks. Hot dogs (eeeww!) Whole milk. Hamburger helper. Canned vegetables. Cap’n Crunch (I LOVE Cap’n Crunch but I NEVER buy the stuff). Potato chips. No fruits or vegetables unless they are in cans, no whole grain anything, lots of processed foods and all dairy products are full of fat. Seriously?

Yes, it’s hard for me to lose those five pounds but I suspect the glass of wine in the evening, the french fries I had for lunch, the con queso I had for dinner last night or the peppermint bark cookie I ate for a late night snack may have contributed to the problem. Your hormones, your thyroid and your mother-in-law did not cause your weight gain. Your diet did. Your lack of activity made it worse, but it is what you put in your mouth that caused the problem. The sooner you can face that and move on, the easier it is on everyone. Tell me that you know you need to lose weight and that you are your own worse enemy and I can empathize. Tell me that you NEVER eat anything, that you’ve been starving yourself for years and it’s very hard for me to help you. No controlled study has ever backed up any claim that people gain weight on air.

People want a “kick start” with pills which occasionally I will acquiesce to. Nine times out of ten, this helps them to lose about five pounds and then they stall out, quit the pills because they are also not the quick fix they’d hope for and five months later they’ve picked up another five to ten pounds.

After 20+ years of practice I can agree that diets really don’t work. Only life-style changes do. Or sometimes, a gastric bypass or similar surgery. When patients ask what the best way to lose weight is, I tell them Weight Watchers because it is a lifestyle change. It is the most successful weight loss program I can attest to after all the years I’ve been in practice. People who stick to it, lose. Not 20 pounds a month. Sometimes not even five pounds. But consistently over months, the weight comes off. Add a good six days a week exercise program and suddenly people feel great and look great. BUT, it is HARD work. Very hard work. Of course most good things in life are hard work.

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Seriously, any problem reading this?

Unsurprisingly to me, a recent study published by the Journal of the American Medical Informatics Association (–study-finds) determined that there were the same number of errors with electronic prescribing as with written prescription. Same number, but the errors were different. Unsurprising to me because now that I’ve been e-Prescribing for more than five years I actually make MORE errors on-line than I do when I write them out. Of course this is partly due to the very strict Catholic sisters who oversaw my writing development in the 60’s, ensuring that my penmanship was legible. If you don’t believe me, ask any of the east-end Louisville pharmacists who have to fill my prescriptions. They LOVE them because they can read them.

Having said that, the study did imply that most electronic prescription errors are correctable IF the software is properly designed. In my own practice, using  an Allscripts product, I make certain errors on a regular basis (sigh):

  1. The script is sent to the wrong pharmacy. This is a software error I have bugged Allscripts about for a couple of years now, but it falls on deaf ears. The default setting is to send the prescription to the local pharmacy. There should not be a default, the physician should have to choose either a mail order pharmacy or the local one. This happens weekly and the patients are angry when their medication doesn’t show up in the mail (they ignore the reminder call from the local pharmacy). Ultimately, when the medication never shows up in the mail, my office gets an irate call from the patient wanting to know why Dr. Nieder sent the script to the wrong place and now they won’t get their meds on time and they will have to pay extra for a 30 day supply (or more likely–go without). But for some reason Allscripts doesn’t think this is a problem…
  2. It’s the right medication but the wrong dose. I often look on the medication list in the chart to choose the dose and if it’s not been properly updated the patient gets the wrong number of milligrams. This is usually an easy thing to fix by cutting the pill in half or doubling it, but annoying none-the-less. Hopefully this will improve with electronic medical record documentation…then again, GIGO.
  3. The prescription is sent from my computer but never makes it to the pharmacy. This typically occurs with mail order pharmacies. I don’t know why it doesn’t go “through” and Allscripts hasn’t yet provided the physician with an adequate way of knowing when it doesn’t make it. Hopefully communication processes will improve and I’ll see a little flag on my desktop someday as a notification. As it is, the patient calls and informs us, we go through a lengthy process in the system trying to see what went wrong and then resend it, crossing our fingers that THIS time it works. Yet another situation where the patient will go without or get a temporary supply at the local pharmacy until their medication is mailed.

Ultimately e-prescribing will be a safer alternative for prescribing medications but it isn’t quite there yet. It irritates me that there is not a board of prescribing doctors that routinely report to the Allscripts software development group to help make the process more physician-friendly. Instead the company relies on a “Client Connect” on-line community. If you’re at all tech-savvy you know that this process is only as good as the people “patrolling” it and since these are not physicians, clinical issues may not be obvious for the IT guys to “get” what the fix needs to be. I’ve already had this experience talking to the support people with Allscripts.

Soon, I won’t just be electronically prescribing, I’ll be documenting like many of my colleagues. Something I’m not looking forward to because so far, none of my peers have been happy with the process or the result, all of them have been frustrated and few see the light at the end of the tunnel as anything but a train…

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