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Engage With Grace

By Michael D. Miller MD
November 26th, 2008

Many bloggers are posting information today about a initiative to encourage conversation about a very difficult topic: How we want to die. This collective effort to prompt discussions about this topic at the beginning of the holiday season is very timely, and it is a good complement to my post last week about empathy and compassion in healthcare.

What follows is essentially the same text that appears on many other blogs along with a picture of the “One Slide” listing the 5 conversation promoting questions that are at the core of the Project:

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Engage with Grace: The One Slide Project is an astonishingly simple idea that literally touches everyone. Alexandra (”Alex”) Drane, whose sister-in-law died in the hospital, (at age 32 of glioblastoma - seven months post diagnosis - grab your tissues and see the backstory), has set in motion a talking/blogging/thinking campaign to get us to deeply consider how we want to die.

Alex’s one slide has five conversation-starter questions about dying, really simple stuff like: given the choice, do you want to die at home or in the hospital; do you want medical intervention or not…etc (see below) - and then she did the networking thing. Now bloggers have agreed to post her message about the campaign as a Thanksgiving project. We’re all posting the same message - with a lead-in of our choosing on Nov 26 - and leaving it up throughout the holiday weekend (yay! an enforced break from blogging - my family will be so happy).

The One Slide from the Engage with Grace Project

There’s also a great video with Alex explaining how she used the very best of networking principles to keep this really really simple. We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don’t express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they’ve talked to them about their preferences.But our end of life experiences are about a lot more than statistics. They’re about all of us.

So the first thing we need to do is start talking. Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences.

And we’re asking people to share this One Slide - wherever and whenever they can.at a presentation, at dinner, at their book club. Just One Slide, just five questions. Lets start a global discussion that, until now, most of us haven’t had. Here is what we are asking you:

Download The One Slide and share it at any opportunity - with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let’s start a viral movement driven by the change we as individuals can effect…and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them. Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.)

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P.S. - I just wanted to add that I have had several friends and relatives succumb to brain tumors, so I have a personal connection this story and this project’s goals.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Public Health, Quality of Care & Safety | 1 Comment »

Proposals for Expanding the Full Range of Compassionate Care

By Michael D. Miller MD
November 20th, 2008

Two recent events made me think about how traditional medical care and medical education address the issue of compassion.

The first was at the annual dinner for the Kenneth B. Schwartz Center when they gave out their annual Compassionate Caregiver Award, and reviewed the accomplishments of  previous awardees.  These individuals have all made remarkable differences in the lives of patients and families through their empathy and personal connections.

The second event was reading about the passing of Florence Wald, the former Dean of Nursing at Yale who organized the first hospice in the United States in 1974 because of her interest in compassionate care at the end of life.

While there has been much discussion about:

  • Shortages of primary care clinicians
  • How medical school graduates are increasingly going into specialties
  • Medical schools are thinking of replacing the requirement that applicants have taken organic chemistry with requirements for more biochemistry or genetics
  • A survey of physicians finding that over the next three years 49% plan to reduce the number of patients they see or stop practicing entirely, and 60% would not recommend medicine as a career

All these relate to the structure and content of physician education and training.  And I have two proposals:

First, while  medical school education has progressively shifted from teaching in hospitals to more out-patient and community care, I think doing more to show medical students and residents the rewards of community primary care would be a good step for increasing the number and prestige of primary care clinicians.

And second, while medical schools require students to go through rotations in pediatrics, Ob/Gyn, medicine, surgery and psychiatry, I don’t know of any that require students to go through a hospice rotation.  This may be because medicine and society try to discount death as a failure, but a hospice rotation would be a great opportunity for teaching students about empathy and compassion, and shifting the discussion of death within the context of medical education so that it is viewed more as part of the continuum of life.  In addition, having medical students in a rotation where they are not reporting to (and trying to impress) senior physicians, but rather working with nurses and social workers, also might provide them with a better perspective on teamwork in healthcare delivery - as well as a dose of humility.

The value of hospice (or palliative care) rotations for students does seem to be growing.  An article from 2006 reported that the University of Arizona was thinking about requiring a hospice rotation.  And the American Association of Medical College’s web-site has an article from 2004 about how Mt. Sinai has integrated palliative care into their curriculum.

Does anyone know of any medical schools that require hospice rotations for medical students or have integrated these types of programs into their core curriculum?  (BTW - A major focus for the Schwartz Center is grand rounds and other educational programs about compassionate care and patient-caregiver communications for both established clinicians and students.)

And lastly, it should also be recognized that expanding young physicians communications and empathy skills should help them work better with their patients, (and patients’ families), which could help reduce unnecessary and costly care.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Quality of Care & Safety | 3 Comments »

Another Humorous? Humana Video

By Michael D. Miller MD
November 17th, 2008

Last week I wrote about Humana’s YouTube videos designed to “explain” parts of the healthcare system.  Well they just put another one titled, “Some Doctors Cost More. Why?”

Two interesting points about this video: First, at the beginning they describe  insurance companies (like Humana) as “Providers.” (The narration uses the term “health coverage providers,” but the graphic shows “PROVIDER.”)

While physicians and other clinicians really dislike being called providers, I think they wouldn’t want to see that term used for insurance companies either, since it implies that the insurance company is actually providing healthcare.  (I usually reserve the term provider to describe broad groupings of clinical entities, such as, “providers of oncology care in the Chicago area,” - which would include physicians, nurses, hospitals, etc…)

And second, the title and content of the video doesn’t focus on the total costs of care or services provided by individual physicians, but mostly only patients’ co-pays - which are lower when they use the physicians that are in-network for their insurance plan.

And as the video’s tag line says, “Now you know.”

Posted in Clinician-Patient Relationships, Economics & Financing, Information & Communications, Miscellaneous, Private-Employer Based Health Insurance | No Comments »

Medical Homes, Hammers and Nails

By Michael D. Miller MD
November 10th, 2008

Medical homes are being promoted as a way to improve health care delivery by increasing the coordination of patient’s primary and specialty medical care.  The goal of medical homes is to ensure that patients’ care is comprehensive, appropriate and patient-focused.

One of the benefits to the patients and the healthcare system is that medical homes can help sort out the confusion that can arise from the phenomenon sometimes described as, “When you’re a hammer, everything looks like a nail.”

Hammer & Nails

In healthcare delivery what this means is that sometimes the diagnoses or treatment recommendations from specialized clinicians will reflect their expertise - and thus their may be inconsistencies or conflicts in the recommendations coming from several  specialists. The challenge for the patient is to determine the best course of action for them.  And that’s where the value of their primary care clinician in a medical home - they have access to all the patient’s information and can help coordinate and translate all this information for the patient, so together they can make the most informed and appropriate decision.

This coordinating and translating task is important for acute and serious illnesses, as well as for chronic conditions - particularly when their is no generally agreed upon standard of care, of if the accepted course of treatment does not prove satisfactory for the patient.

This situation arose recently for a friend at the same time there was an article in the New York Times where the author described her nearly identical series of interactions (and frustrations) with the medical care system when dealing with hallux limitus or rigiditus - basically, limited motion of the big toe, accompanied by pain caused by bone spurs and/or arthritis.  The “hammer sees a nail” phenomenon here is that the surgeon sees primarily a problem that can be solved with surgery, while the podiatrist sees primarily a problem that can be helped by an orthotic.  As the New York Times author discovered, there may be other options that could work for her.  But from her writing - and my friend’s experience - this was discovered because of the patient’s diligence and not from the coordinating role of her primary care clinician in a medical home.

Another way to view the function of the medical home is to look at a medical home as trying to replicate the close interpersonal relationship between each patient and their primary care clinician that existed decades ago, while still enabling the patient to take full advantage of medical advances.  In addition, such relationship building could help reduce malpractice costs since it should improve both the quality of care, and patient-clinician communications about the goals and expectations from possible treatment options.

Challenges to Creating Medical Homes
Building these homes faces several challenges, including the shortage of primary care clinicians who need to be at the center of the coordination process working with patients and other clinicians to define realistic and patient-specific goals and treatment plans. Another challenge to creating well-run medical homes is that specialists may balk at being part of such a formal coordination process.

Implications for Health Care Reform
What this mean for health care reform is that while medical homes should be promoted, they cannot easily be created for everyone from our existing resources.  Therefore, they should first be built where they can have the greatest impact - for people with chronic and multiple medical problems, while at the same time our overall capacity of primary care clinicians is increased.  These two initiatives can be complementary because creating successful medical homes should increase the economic attraction of primary care as a medical career, while also demonstrating to medical students and residents the value and attractiveness of primary care when practiced in a medical home type setting.

In addition, other important health reform initiatives such as electronic medical records, and turning the findings from comparative effectiveness research into actual medical practice, will support of the creation of medical homes that can improve the quality of medical care, help reduce waste and improve the overall efficiency of health care delivery.

And lastly, it is clear that there is a desire for medical home type services since this is basically the concept underlying concierge medical practices.  For those not familiar with concierge medicine, this is where the primary care clinician signs up a limited number of patients who pay $1,500 - $25,000 per year, and the clinicians commits to spending more time with them, will explain in greater detail their medical issues and options, and take on the role of coordinating their care amongst all needed specialists.  While I don’t have the data, I’m guessing that individuals who are are paying for these concierge services are not the patients who would receive the most clinical benefit from medical homes.  And clearly, with too few primary care clinicians, having these physicians limiting the number of patients they will see doesn’t alleviate that shortage.  So, while I understand the motivations and market forces driving the creation of concierge medical practices, given the current problems in our healthcare system, I don’t think they are pushing the use of limited resources in the best direction to benefit society overall.

Posted in Access to Healthcare, Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety | 2 Comments »

Patient – Doctor Communications

By Michael D. Miller MD
October 7th, 2008

In the last couple of weeks there were two interesting articles in the New York Times about patient-physicians communications.

Value of Empathy
In the first  piece, Dr. Pauline Chen discusses an academic article that explored the way physicians communicate empathy to their patients who have serious and life threatening illnesses.  The conclusion of the research, (which looked at the experience of people who had lung cancer), was that physicians miss 90% of the opportunities to connect empathetically with their patients.

The researchers speculated that physicians don’t engage patients empathetically because they are concerned that this would take too much time. However, according to Dr. Chen, the researchers found that “empathy, expressed throughout the patient-doctor encounter, may actually help alleviate problems with time.”  This occured because when empathy was not acknowledged at the beginning of the visit, patients would to try to elicit that type of support from the physician, which could actually extend the time of the visit.

Patients Make a List
The second article was from Jane Brody – a wonderfully gifted health writer – who wrote about ways patients can improve their communications and interactions with clinicians.  Her list had two parts: 6 things to keep written down and bring to your doctor appointments, and 4 tips on how to interact with clinicians.  Her list of 6 things you should keep written down is a good one, and in essence [with my annotations] it is:

  1. Questions for the doctor
  2. Diary of symptoms
  3. List of medicines, supplements and vitamins you take - with name, dosage and how frequently you take them. [Also, please tell your doctor if you are not taking the medicines as instructed for any reason, including if you are having a problem affording any of them.]
  4. Your understanding of how you are supposed to be treating your medical problems [Doctors may think that because they told you something at your last visit that you both understood what they said and are following their guidance.]
  5. Medical history for yourself and your immediate family
  6. Your use of alcohol, tobacco and any drugs not included in #3

The other 4 items on Jane Brody’s list are also valuable:

  1. “Be willing to see a physician’s assistant or nurse practitioner for routine care.”  [They will likely be able to spend more time with you on preventive and wellness care issues.]
  2. Ask if the doctor uses email for non-urgent issues and questions.   [Some physicians do and some don’t – possibly because they don’t get reimbursed for communicating with patients via email or over the phone.]
  3. If the doctor tells you to go to the Emergency Room because of your symptoms, don’t wait.  [Go right away.  Don’t wait for your TV show to be over, for the laundry to finish, or to put on makeup or shave.]
  4. If you are told you have a life threatening condition or you need surgery, get a second opinion.

Physicians Use Lists Too
Lists are clearly good things to use so that important things are not forgotten.  People involved with critical, safety-conscious activities like flying airplanes have used lists to make sure that everything is set before takeoff and landing.  After what has probably been too long, such lists are making their way into modern medicine in a more standardized way.

Last December, Atul Gawande wrote in The New Yorker about how such lists are being used to improve the quality of care and save live (and money) in Intensive Care Units.  The first standardized and studied checklist was for putting in a central intravenous line.  The results were remarkable – lowering infection rates in lines that had been in patients for 10 day from 11% to essentially zero.  Peter Pronovost and his collaborators have since developed many other such checklists, (or protocols as they may sometimes be called), and their use has expanded to many, but still probably not most hospitals.

While these lists are clearly beneficial and valuable, like many medical advances, they are first developed and used for the most critically ill patients in hospitals.  This makes sense, because for hospitalized patients a mistake - or action not taken - can mean the difference between life and death.  And hospitals are also places where systematic changes can be implemented and the results measured.

More Use of List by Physicians
Physicians treating patients outside of hospitals often have lists too, but they are often incomplete and are certainly not standardized.  For example, the charts for most patients have problem lists, which list the individual’s medical problems.  However, it is up to the physicians to refer to them, otherwise, the only problem that may be addressed by the clinician will be the one that brought the patient to the office that day – so any needed preventive or wellness care (like an annual eye exam for someone with diabetes) might be overlooked. This is one reason why the list recommended by Jane Brody is so important.

So while physicians may have their own lists, and they know the reason why each patient has come to see them that day, they might be better served by making a list for each patient’s visit so they can make sure to cover all the things that are needed for that individual patient – and of course, that list should also include a reminder to connect empathetically to the patient.  (This is the same concept as having an agenda before any business meeting that not only lists the topics to be covered, but also states an overall objective and concludes with a wrap-up of actions to be taken – a practice I try to follow and force others to do when I’m invited to a meeting.)

Optimism for the Future
In the future, more diagnostic and treatment protocols and guidelines will be developed and configured into standardized checklists to be used in the outpatient setting.  Integrating these into electronic medical records (EMRs) – which include prioritized problem lists with links to recommended preventative exams and monitoring tests – will certainly help improve the quality of care and control the growth in costs.  Of course, this is predicated upon the development of EMRs that can provide such information in ways that are easily used by physicians and their associates.  (This too might be an area where the medical IT industry can learn from those designing airplane information systems.)

While physicians have railed in the past about guidelines and protocols forcing them to practice cookbook medicine, I hope that in the coming years they will welcome them as a way to standardize and simplify their practices so that they can actually work to individualize care for every patient, and connect empathically with them as individuals.  In decades past, that was one of the primary functions of the local doctor, and perhaps if that function again rises in prominence, the interpersonal rewards of practicing primary care medicine will help it grow in popularity with graduating medical students and residents.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Information & Communications, Quality of Care & Safety | 1 Comment »

Questions and Answers About Pay-For-Performance (P4P)

By Michael D. Miller MD
August 14th, 2008

An article in the July/August Health Affairs about Massachusetts health plans implementing Pay-for-Performance (P4P) incentives for physicians raised more questions than it answered.

The study found that P4P programs from 5 private sector payers “wasn’t associated with greater improvement in quality” compared to the overall upward trend in the factors measured.  But the study didn’t address some overarching questions and basic realities about P4P, such as:

  • How the payers P4P incentives to the physician groups was actually translated into incentives for the individual physicians - or smaller groups of physicians inside the larger groups?
  • How the P4P incentives compared to the other financial incentives the physicians are facing?  For example, seeing more patients or doing more procedures could increase their income more than meeting the P4P standards. (The Health Affairs article states that P4P incentives for Massachusetts physician groups averaged 2.2% of their income.)
  • The quality measures used in the study were all performance based, rather than actual outcomes, e.g. cholesterol screening rates rather than patients’ actual cholesterol levels, HbA1C screening rates in diabetics rather than their actual HbA1C levels, or asthma medication use for children ages 5-17, rather than ER visits or hospitalizations for these same children.  What impact does that has on physicians’ behavior, and the value of changing their actions to meet these process standards?  Would physicians be more responsive to incentives tied to clinical outcomes?

Making Incentive Programs Successful:
While the study concluded that the P4P incentives program instituted in 2002 may not have produced dramatic changes in the HEDIS process measures, that does not mean  they were ineffective or that P4P is not a useful tool.

First, while collecting process measures data is easier, since clinical outcomes are what patients (and their physicians) should really care about, shouldn’t P4P incentives be based upon actual clinical outcomes? Process measures are easier to monitor by using billing data, but as the prevalence of quality electronic medical records systems grows, collecting and analyzing data about clinical outcomes will become much easier.  In addition, measuring a small set of any factors – process or outcome – presents the pitfall of driving physicians to focus on those diseases and measures to the exclusion of other important things.  For example, in the Health Affairs study, there are a number of preventive services in the process measures, but what about flu vaccinations, colonoscopies or smoking cessation?  This “managing what is being measured” behavior is why the number of factors used for P4P incentives should be as broad as possible.  (But this does not mean that they all have to be measured at every interval, or for every compensation period.)

Second, as any psychologist (or parent) will attest, the time between the actions and the reward (or penalty) is very important for changing behaviors. The Health Affairs article indicates that the bonuses are paid to the physicians groups annually.  Having the incentives paid annually, (or even quarterly), would be unlikely to provide adequate feedback to physicians to prompt them to change their behaviors.  An alternative blended methodology would be to provide physicians feedback on their actual performance against many of the possible measures on a weekly or bi-weekly basis, while making the P4P payments on a monthly or quarterly basis.

Third, many large companies structure their bonuses for their senior managers around a minimum of 20% of compensation.  If incentives for P4P programs only represent a small percentage of physicians’ income, then it would be unlikely to change their behaviors – particularly if they can make up for any lost income by increasing volume.  However, if physicians are being paid a fixed (capitated) amount per month to provide a certain set of services to a patient group – either primary or specialty care – then the volume part of the equation disappears, and P4P programs could be much more effective, even at a lower fraction of their potential income.

And lastly, and most simply, the insurers would not be spending time and money developing and implementing these programs if they didn’t think they provided some benefit – even if it is only financial - so they must be getting some benefits, or at least learning some things to make these programs beneficial in the future.

Conclusions:
18 years ago I wrote a book chapter that focused on structuring incentives for physicians.  Since then it has been hard to move payers and clinicians toward using more focused financial incentive systems.  But the P4P concepts are important, and to be successful they need to be implemented in a way that works for payers, physicians, and patients.  Unless these and other stakeholder groups buy-in to the purpose and practice of such incentives systems, they are unlikely to have the desired effects.  And the result will be more of the same – rising costs, variable quality, and limited access for many patients.

Posted in Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Economics & Financing, Health System Reform, Information & Communications, Therapeutic Substitution & Interchange | 1 Comment »

Literacy, Communications and Star Trek – Cores for Reforming Healthcare

By Michael D. Miller MD
July 30th, 2008

In talking to people about the problems with the US healthcare system, two fundamental truths have become apparent.

First, people really want the type of healthcare that is envisioned in science fiction such as Star Trek, where almost any ailment is treated with a single injection or pill, or a few waves of a healing wand. Unfortunately, medical science hasn’t accomplished that, except in a few instances – antibiotics for a bacterial infection, or perhaps relocating a dislocated finger or shoulder (and those still require weeks to heal and therapy to regain strength and mobility).

And second, the ongoing problem of healthcare literacy and communications may be getting worse as the complexity of medical treatments increases.  Literacy and communications problems impair good healthcare when patients don’t understand what their doctors are telling them, how to take their medicines, or what disease they have.  When this happens  patients have much greater difficulty properly taking care of themselves.  A few examples and data:

  • The American Academy of Family Physicians has a Literacy Toolkit which they promote with the twin facts that only 50% of “patients take medications as directed,” and “nearly 90 million American adults have difficulty understanding and using health information.”
  • A July 9th ABC news story reported about an Annals of Emergency Medicine article showing that 78% of Emergency Room patients had some misunderstanding of their doctor’s instructions, but only 20% realized that they didn’t fully understand the instructions.
  • More patients are misusing medicines in dangerous ways. The actor Heath Ledger’s accidental overdose was the most recent high profile example of this. And CNN reported Monday about an Archives of Internal Medicine study showing that deaths of this type have increased 700% in 20 years.

Star Trek directly addressed communications challenges in a Next Generation episode, (Darmok and Jilad at Tanagra), where the crew of the Enterprise encounters an alien race whose words are understandable, but none of it makes any sense. It turns out that the alien’s language is based upon metaphors, and since the Enterprise’s crew doesn’t understand the context for the metaphors – the mythology and stories behind the metaphors – communications is nearly impossible….. until of course Captain Picard figures it all out in 60 TV minutes.

Unfortunately clinicians and patients aren’t able to resolve communications challenges like TV characters. When clinicians use words and concepts that their patients don’t understand, patients can’t correctly follow their instructions, and end up relying on what they think they heard or understand.

A classic example of this is that many people think taking antibiotics makes them resistant to antibiotics.  While it is true that antibiotic resistance is an issue of concern, it is the bacteria that become resistant to the medicines – not the patients. But patients who believe that they will become resistant may not take the full dosages of their antibiotics, or for as long as the doctor has prescribed – inactions that can actually increase the rate of bacterial resistance and not adequately treat the patient’s infection – bad outcomes for both society and the individual.

This is just one example of how misunderstanding a disease or a treatment can produce adverse consequences. Similar misunderstandings about diseases like diabetes and high blood pressure also lead to inadequate treatments and poor outcomes. For example, many patients believe they can tell when their blood pressure is high – and only then do they take their medicine. But high blood pressure (or hypertension) is called the “silent killer” because people can’t feel high blood pressure – except sometimes when it is dangerously high.

Which brings us back to Star Trek. One of the great things about the one-dose cure is that the patient doesn’t have to understand their disease or remember to take their medicines for the treatment to be effective, so literacy and communications problems are less of an issue for quality of care.

Lessons for Healthcare Reform
The lessons here for health reform are twofold: First, producing one-shot cures will require a lot more research and development – which needs to occur at the same time as we are improving the healthcare delivery system. And second, a fundamental area for improving healthcare delivery is communications and literacy. If patients don’t understand their disease, how to take their medicines, or modify their lifestyle, etc., then that is not their fault – that is the fault of the healthcare delivery system, and we should be able to find ways to fix it because this is not a new problem.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety | No Comments »

Vacations - Poker - Diagnostic and Research Skills

By Michael D. Miller MD
July 21st, 2008

What’s the point of vacations?  As a consultant that’s something I often ask myself since with the internet, cell phones, etc., it seems almost impossible to really “get away” and not be connected to work.

So what’s the value of vacations?  I think I’ve found the answer at the poker table.  As Ricky Ricardo used to tell Lucy, “Lemme splain!”

The point of vacations is to recharge by being in a different environment that presents a new context for viewing our normal “reality.”  A great practitioner of this principle was Teddy Roosevelt.  He would travel to the wildest and most dangerous parts of the world, and hunt the largest of animals. After these experiences he probably came back to Washington DC and the political world, and said to himself, “Hey, this jungle and these animals really aren’t so bad or ferocious.”

As a consultant, I often find my vacations are pieced together days, (or pieces of days), that often include work “time-outs.”  For example during a recent 5 day trip to visit family in Seattle, aside from the many emails, I had two 8 am conference calls, and a 6 am telephone presentation.  Trips like this have forced me to schedule “vacation” time like I schedule exercise time – in 2-6 hour chunks.  The challenge is making these mini intra-day vacations count.

Which brings me to the poker table.  I had gone with some friends to play at a local casino a few months back, and we all had a good time.  I also found that while playing I could completely focus on the game, and not keep drifting back to ongoing work projects.  I later realized that this was a mini-vacation which provided a refreshing break from the work mindset – a cranial reset if you will.

But there is more to it than just a diversion, because a good movie provides that same 2 hours of alternative focus.  What the poker table provides is an intellectual and rather fast-paced set of interpersonal interactions.  This is when I realized the two connections between poker and clinical medicine:

First, playing cards for many years has helped me learn how to read people – an essential skill in poker, and very useful in clinical medicine where non-verbal communications are a big part of the clinician-patient relationship.  This is similar to teaching medical students about art as a way to improve their observational-diagnostic skills.

And second, while playing poker I get the most gratification not from winning a hand, but from tossing down a hand I had started to play but then decided was probably not going to win.  This latter “skill” is essential to playing good poker, and is also related to good diagnostic skills.  Lemme splain.

In clinical medicine, the diagnostic process starts with gathering the first round of information – by talking to the patient, reviewing their chart, and doing a physical exam.  (This is like looking at the first cards you are dealt.)  Then, as more testing and inquiry are done, you and the patient learn more about their medical problem.  (In poker this information comes in the additional cards in the hand.) And then, as the patient tries different treatments, even more is learned about their condition and how best to treat them.  (This is similar to what happens with the betting in poker – each bet tells you something about the other players and their cards.)

Thus, by seeing the cards as they are dealt and the other players’ bets, (and their responses to my bets), I learn about how my cards stack up against theirs.  And with this additional information I can make a better diagnosis – and decide whether or not my cards are likely to win.  By correctly folding my cards in the middle of a hand, I have in essence made the right diagnosis – which is the ultimate goal of any clinician.  It is an essential step for helping patients – and at the poker table, for limiting losses from that hand.  Conversely, winning or losing a hand – no matter how big the pot – doesn’t carry the same thrill since the intellectual options have been exhausted and all that’s left is to get ready for the next hand – or get back to work.

The clinical analogy to staying in until the end of the hand is that the patient has no more options; every test has been done and treatment considered, and either a treatable or controllable condition has been diagnosed – or not. Medical research strives to expand these options by providing patients and clinicians with more and better diagnostic tests and treatments.  Successful research gives patients the opportunity to draw more cards and play more hands.  And just to come full circle here, medical research is very much like poker in that the skill to correctly fold research spending on an experimental compound or diagnostic test is very valuable – hundreds of millions of dollars valuable.

Posted in Clinician-Patient Relationships, Innovation, Miscellaneous | No Comments »

E-Prescribing – Good? E-Dispensing Bad!!

By Michael D. Miller MD
July 10th, 2008

With two notable government actions in the last couple of weeks there has been significant movement towards increasing the use of e-prescribing.

DEA Proposed Rule
The Drug Enforcement Agency (DEA), proposed regulations on June 27th that would make it possible for controlled substances to be prescribed electronically. Interestingly, this was released right after a National Journal article on this topic.

The DEA’s proposed rule is very important, because while it is appropriate to place stronger safeguards on medicines that are likely to be abused (which is the criteria for being a DEA scheduled medicine), having controlled medicines prescribed by pen and paper while all other medicines are e-prescribed would be a logistical problem and obviate many of the potential benefits of e-prescribing.  And technologically, if banks and others can provide secure login systems and other security measures, I would think that e-prescribing systems could be similarly secure to make sure that unauthorized people aren’t electronically writing themselves prescriptions for thousands of narcotics pills using a legitimate doctor’s DEA number.  (See more about this in the e-quackery section below.)

Medicare Bill Contains Carrots and Sticks for E-Prescribing
The Medicare bill which passed Congress yesterday included a provision to increase the incentives for physicians to use e-prescribing technologies.  These incentives are a small percentage add-on to allowed Medicare charges for physicians who are e-prescribing starting in 2009, and a cut to payments for allowed Medicare charges starting in 2011 for physicians who are not e-prescribing.

Movement in a Good Direction
Together these actions move the US healthcare system towards greater e-prescribing, something that if done right, should increase efficiency (with lower administrative costs), and improve quality of care and patient safety by creating a better system for detecting and preventing adverse drug reactions from known drug allergies and drug-drug interactions.  The use of computerized prescription order systems for patients in hospitals has been shown to accomplish both of these improvements, but how e-prescribing will work in the outpatient world remains to be seen.

Challenges to Making E-Prescribing Increase Efficiency and Improve Quality
There are many challenges for e-prescribing in clinicians’ offices.  Like electronic medical records, they have to buy and install the systems, learn how to use them, and then keep them updated – since new prescriptions keep getting approved etc.  Because of these challenges, it is estimated that only about 6-7% of physicians’ offices are currently using e-prescribing systems.

Optimally e-prescribing systems should be an integrated part of the office’s electronic medical records system so that it could identify potential problems with drug allergies, or the need to alter dosages for patients with impaired kidney or liver function.  And at a minimum, a free standing e-prescribing system should be able to keep track of each patient’s prescriptions to flag drug-drug interactions, otherwise it may become nothing more than a sophisticated fax machine – which some could argue (but I wouldn’t) is a rudimentary form of e-prescribing.

While, e-prescribing systems should provide alerts about drug-drug interactions,  potential allergic reactions, and the need for dosing adjustments, systems that constantly flash up reminders for such things when they’re not relevant, leads users to ignore them altogether. I take a lesson about this hazard from my brother who works on designing aircraft information systems. Clearly pilots need to know certain things at the right time, but I doubt any pilot would fly better or more safely if they kept getting an alert about it being unsafe to land the airplane because the wheels were up – even with the plane at 30,000 feet.  OK – that may be a bit of an extreme example, but if the e-prescribing system doesn’t know anything about the patient, it may send similarly useless alerts and lead those using it to ignore all alerts – which could be worse than having no alerts at all, since it having them pop-up and be ignored could provide a false sense of security.

This illustrates what most people involved with healthcare reform recognize - improving the quality and efficiency of healthcare in the US requires making the systems work better since our practitioners are generally already pretty good.  But giving these good people flawed systems won’t help them, their patients (i.e. us), or our overall healthcare system.

This brings me to one last point.  How many e-prescribing systems will each clinician’s office need?  I certainly hope that every pharmacy chain/group won’t require their own version of an e-prescribing system, nor will each payer, insurer or regulator require a different electronic or paper output of the prescription information for reimbursement or quality auditing purposes.  If that becomes the case, then e-prescribing will face even greater hurdles.

Since they do good work in this area, I also want to include the eHealth Initiative’s  summary of the challenges for e-prescribing systems:

  • Financial burdens – Physician practices face varying financial burdens related to e-prescribing, including covering the implementation, training and maintenance costs.
  • Workflow changes and change management – Although e-prescribing efficiencies and time savings are gained in the long run, introducing e-prescribing, and electronic health records (EHRs), can be difficult, time consuming, and requires adequate planning, training, and support, particularly in the beginning.
  • Continued needs for greater connectivity – The infrastructure exists for connectivity among pharmacies, physician practices, payers and pharmacy benefit managers (PBMs), but some pharmacies, payers/PBMs and mail order pharmacies are not yet connected.
  • Medication history – Although e-prescribing is an improvement over relying on paper medical records and patients’ memories, the information that is available may not always be comprehensive or accurate and therefore tools to adequately reconcile medication histories from multiple sources are needed.

E-Dispensing – Bad!!  And E-Quackery – Bad Too!!!
One of the other challenges for e-prescribing may be the practical and policy interactions between physicians’ e-prescribing and internet sites that sell medicines directly to a patient without a prescription.  While e-prescribing potentially can improve efficiency and quality, e-dispensing can lead to bad fiscal and clinical outcomes from patients getting fake, adulterated or dangerous pills and potions.

Information on the worst examples of e-dispensing is in a recent report from Columbia’s National Center on Addiction and Substance Abuse (CASA).  Their recent annual report found that the number of web-sites selling controlled medicines without a prescription has decreased from the start of 2007 to the start of 2008 - from 581 to 365.  The CASA report also found, “Of those sites not requiring prescriptions, 42 percent explicitly stated that no prescription was needed, 45 percent offered an “online consultation,” and 13 percent made no mention of a prescription.”

I’m not sure if anyone knows what the total number of patients using these sites is, or the number of prescriptions they are filling, so it’s unclear if this reduction represents a real decline in the “industry,” or just its consolidation and maturation.  What CASA also found - and that I find especially worrisome - is “an emerging practice of Internet sites selling prescriptions for controlled drugs that can be filled at local pharmacies. The report also found sites selling online “medical consultations” which enable Internet users to get controlled drugs online without a proper prescription.”  I call this e-quackery, because this is physicians acting inappropriately, or non-physicians acting in the role of a physician and practicing medicine without a license by writing prescriptions.

Other notable findings from the CASA report include:

  • Of the few sites that require prescriptions, half permit the prescription to be faxed, allowing significant opportunity for fraud.
  • Benzodiazepines (like Xanax and Valium) continue to be the most frequently offered drugs for sale with 90 percent of sites selling them; followed by opioids (like Vicodin and OxyContin) at 57 percent of sites, and stimulants (like Ritalin and Adderall) at 27 percent of sites.
  • According to DEA estimates, in 2007 eleven percent of prescriptions filled by traditional pharmacies were for controlled substances compared to 80 percent of prescriptions filled by Internet pharmacies.
  • There are no controls blocking access to these sites by children and teens.

Conclusions
Just to bring things full circle – clearly e-dispensing and e-quackery are bad, so perhaps the greater use of legitimate and appropriate e-prescribing will help to clamp down on these illegal and dangerous activities.  And from a personal perspective, I can also only hope that it will reduce the ongoing flow of spam emails for on-line medicines - and the similar onslaught of spam blog comments to this blog that you never see because I delete them, but which like spam emails, just chew up time from every day.

p.s. Sorry about the long post – but this is an important and complicated topic.

Posted in Access to Healthcare, Clinician-Patient Relationships, Delivery of Healthcare, FDA, Information & Communications, Miscellaneous, Public Health, Quality of Care & Safety | No Comments »

Updates on Vitamin D

By Michael D. Miller MD
June 27th, 2008

Since I wrote about the importance of Vitaim D a few weeks ago, some new information has come out.

A report was released this week from researchers in Australia about Vitamin D reducing the risk of all causes of death.  The study was in the Archives of Internal Medicine, about their evaluation of 3,258 men and women scheduled to have a angiogram of their heart arteries.  They found that the people who had below average Vitamin D levels had about twice the risks of dying than those with levels in the highest 25% of the group.

While looking for the report of the Austrlian study, I found another study from a group of reserachers in Boston, that looked at 18,225 men who had no diagnosed heart disease.  This study found that during 10 years of follow-up, the men who were deficient in Vitamin D (?15 ng/mL) were about twice as likely to have a heart attack as those considered to have sufficient levels of Vitamin D (?30 ng/mL).

It may be coincidence that both studies found a 2:1 effect from high/normal v. low levels of Vitamin D, but there seems to be growing interest and consensus that Vitamin D is important for overall health.  What do you think?

Posted in Clinician-Patient Relationships, Innovation, Nutrition, Public Health | No Comments »

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