ACP Internist

Wednesday, February 3, 2010

QD: News Every Day--Internists still seeing yet-untreated Haitians

ACP Internist's wrap-up of current events turns its attention back toward Hati, where 22 days after the earthquake, patients are still being seen for the first time for injuries. Peter Melchert, ACP Member, a hospitalist from Abbott Northwestern Hospital and Children's Hospital in Minneapolis, reports via internist and writer Craig Bowron, FACP. (MinnPost.com)

Health care reform
Amid a near-abandonment of broad sweeping reform, Congress members hope to salvage small victories. They are looking now at repealing the federal antitrust exemption for insurance companies to drive down prices in regions dominated by one company. Even this one small component faces Senate opposition, and the odds are even longer for the procedural maneuver of reconciliation, which is still being mulled in some pockets of Congress. Republicans want to start from scratch, while others have started drafting a compromise bill. And the clock is ticking as elected officials look to turn their attention toward other issues, such as employment, and as states assert their rights by drafting legislation that would bar individual insurance mandates. (Wall Street Journal, Politico, AP, AP/San Francisco Chronicle, AP/Boston Globe)

In case you missed it ...
Internists are discussing the pros and cons of e-mail diagnoses. Some see time savings, others see a time drag, or fear liability issues and the practice of "garbage" medicine (registration required). About 5% of patients used e-mail last year to talk to their doctors, but 51% looked up health information on the Internet. (Medscape, Reuters)

Labels: disaster response, health care reform, health policy, patient communication, QD

...and I Feel Fine

This post by Rob Lamberts, ACP Member, originally appeared at Musings of a Distractible Mind.

Primary care is dead. Long live primary care.

Wait a minute, I am in primary care. I am not dead. Not yet, at least.

Which reminds me of this Monty Python skit:

CART MASTER:
Bring out your dead!
[clang]
Bring out your dead!
[clang]
Bring out your dead!
[clang]

CUSTOMER:
Here's one.

CART MASTER:
Ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
What?

CUSTOMER:
Nothing. Here's your ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
'Ere. He says he's not dead!

CUSTOMER:
Yes, he is.

DEAD PERSON:
I'm not!

CART MASTER:
He isn't?

CUSTOMER:
Well, he will be soon. He's very ill.

DEAD PERSON:
I'm getting better!

CUSTOMER:
No, you're not. You'll be stone dead in a moment.

CART MASTER:
Oh, I can't take him like that. It's against regulations.

DEAD PERSON:
I don't want to go on the cart!

CUSTOMER:
Oh, don't be such a baby.

CART MASTER:
I can't take him.

DEAD PERSON:
I feel fine!

CUSTOMER:
Well, do us a favour.

CART MASTER:
I can't.

CUSTOMER:
Well, can you hang around a couple of minutes? He won't be long.

CART MASTER:
No, I've got to go to the Robinsons'. They've lost nine today.

CUSTOMER:
Well, when's your next round?

CART MASTER:
Thursday.

DEAD PERSON:
I think I'll go for a walk.

CUSTOMER:
You're not fooling anyone, you know. Look. Isn't there something you can do?

DEAD PERSON: [singing]
I feel happy. I feel happy.
[whop]

CUSTOMER:
Ah, thanks very much.

CART MASTER:
Not at all. See you on Thursday.

Now I would never suggest that the cart master who clubs the dead person represents, say, Medicare. It would not be in my nature to make such a suggestion.

But that is not the point of this post. While many complain of the death of primary care and declining reimbursement, some practices are experiencing quite the reverse: growth in income. I should know, because I am in such a practice.

We are not business geniuses in any stretch of the imagination, but we have been quite successful and raising our incomes substantially. Since I started 13 years ago, my income has doubled, and most of that increase has happened over the past five years, just the time that the death of primary care has been announced.

Our practice is almost totally outpatient (we still see inpatient pediatrics), and we earn very little at this point from labs and procedures. The vast majority of our income comes from regular office visits.

Here are some of the ways we have accomplished this:

We have focused on process. Using our electonic medical record, we try and find the most efficient ways to perform tasks in the office, involving the lowest possible number of staff. This has been a passion (see also: obsession) of mine.

We have focused on our patients. Our patients are our business, and so trying meet their needs (instead of the needs of the doctors) has resulted in a booming business. Here are some ways we have done this:
1. We have extended office hours. with a walk-in clinic (for acute problems only) every morning from 7:30-9:00 a.m. and every evening from 5:30-7:00 p.m. People don't get sick on a schedule and so we allow them to come in when they are sick. To do this, we had to drop most of our inpatient care (or have no life). This accounts for about 25% of our revenue that we would have otherwise lost to prompt cares or ERs.
2. We allow work-in visits. The patient likes to be able to see their doctor when they are sick (they get whoever is in clinic if they use our walk-in clinic). So even with a full schedule, I allow one "quick sick" visit every hour.
3. We do not tolerate patients being treated poorly. Doing so is considered a fireable offense. If a physician does so, they talk to the senior partner (which is me, but this really has not happened).
4. We strive for timeliness. Although we can never guarantee being on-time, we have done our best to have patients out the door within an hour of their arrival. This goal was modest enough to be possible, while allowing for the obvious emergencies.
5. We have a modified "open access" schedule. While I have too many chronic disease patients and scheduled follow-up visits to want to go completely open access, we do leave an hour of each afternoon open until the day of, so even complex patients can possibly be seen on the day they call.

We understand what is most important. While many practices focus on the complex higher-priced visits, we have understood from the start that the money we can earn per hour is much higher for ear infections and urinary infections. Plus, the majority of our patients are only going to use us episodically, so we want our office to cater to the larger population rather than the minority who are sick all of the time.

We are growing. My income went up when my share of the overhead went down. While our system worked fine for three physicians, it requires very few additional staff and space to run it with six. Adding new physicians and/or mid-levels has cut our overall overhead per provider dramatically.

We are planning. We know that pay-for-performance (P4P) and the "medical home" concept are probably going to happen. We have tried hard to keep our data good enough to be able to pounce on this once it is offered. So far, I have personally collected over $5,000 from P4P programs already, and their penetration is minimal. We know that once that wave starts, we will be in the front of it.

Quality is not compromised. We have done what we can to run the business well, but have tried not to forget that we are offering healthcare. The physicians in our practice agree to certain care standards and common practices. If we can all agree to what good quality care is, then we are far more likely to achieve it and we can engineer our process to accomplish it. For example, when National Committee on Quality Assurance certification became a means to increasing income, we were already exceeding the standards to become certified in diabetes care within a matter of weeks.

Admittedly, it has not been a smooth road to where we are now, and we are not without our problems (there is always a crisis somewhere), but from what I can tell, we have remained one of the less dysfunctional practices around. Given the unstable ground of U.S. health care, we certainly have no guarantees that this trend will continue, but I am doing my best to anticipate any trends in the system and set us up for capitalizing on this, rather than being caught off-guard.

Hopefully we are not facing any bridge of death in the near future. If we are, then perhaps we can start collecting shrubbery. I already have my electronic medical record programmed to say "Ni!"

Bonus points if you know the significance of the title. The answer is here.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: electronic medical records, humor, medicare, patient communication, patient-centered medical home, primary care, quality reporting, Rob Lamberts

Med students unfamiliar with electronic health records

Generation Y medical students are supposed to be the tech-savvy ones. As it turns out, they may be more familiar with Facebook than with the electronic health records they'll likely use in their medical practice. (Modern Physician, free-registration required)

Educators at the University of Illinois at Chicago College of Medicine assessed nearly 190 fourth-year medical students on their use of EHRs during a mock encounter simulating a cancer patient hospitalized with complications from chemotherapy.

Students were scored on their ability to find information crucial to the patient's case within the EHR and their ability to analyze the EHR without alienating the patient. While most couldn't access the information, they did interact with the patients face-to-face and even explained when they looked away to the computer.

Following more research, the school may incorporate class work on using EHRs.

Labels: electronic medical records, health information technology, medical education, patient communication

What role should a 21st century physician play?

Editor's Note: Steve Simmons, ACP Member, posted this blog entry originally at Better Health.

Some patients in the 21st century approach "modern" healthcare with the same expectations I bring into a deli for lunch: "I'd like the sinus infection with antibiotics and a note for work, please." I confess, when seeing such a patient I have occasionally acted on the impulse to ask if they would like fries with their order. Yet, these patients do have something to teach us about how to be a 21st century physician.

Eighteen years ago, while a fourth-year medical student, I registered for an elective class on the future of computer science in medicine. This was my first time to see the Internet and I was awed by the vision my instructors had for the future. They had no idea.

Today, I use a Droid or the phone uses me--the issue is still in doubt. However, during residency I put pen to paper charts and carried a pocketful of bright red metal clips to signal a STAT order on a chart. We used computers mainly for literature searches and checking lab results; palm still referred solely to the ventral side of one's hand.

But technology was invading fast. Shortly after starting my first job in 1996, computers began to be used for direct patient care and I watched two competent physicians choose early retirement over learning computer skills.

This all occurred before I had sent or received my first e-mail. The advancements over the first years of the new millennium boggle my mind as I look back over a time that saw PDAs, laptops, and cell phones ensconce us in a world colored bluetooth.

So, what role should a 21st century physician play? Since my phone doesn't have an app to tell us, I'll have to find another way to explain myself but I would suggest the answer lies, partly, in a different question.

What kind of patients do we find today? Three distinct types come to mind. The first is what I like to think of as Dr. Google, of whom I used as an example earlier. Dr. Google has searched the Internet, made his own diagnoses, and often decided on his treatment. Surprisingly, studies have shown that if the search is done right and with a lot of detail, Dr. Google can be right about half the time; sadly, that's not the worst average out there but I do aim higher for myself. Dr. Google is a challenge to care for and requires some tact (Tip: don't ask about biggie-sizing the visit).

I had the good fortune to meet the second type of patient this morning. He had used technology to inform himself and presented me with specific, pointed and difficult questions to answer. I was able to interpret for him and help him navigate towards his own goals. We forged a strong partnership in one office visit; this is my favorite type of patient.

The third type of patient can sometimes be identified by their use of a pathognomonic phrase: "You're the doctor." This was Dr. Welby's favorite kind of patient as he used a relationship based on a combination of implicit trust and deferred responsibility in decision making. Today, use of this phrase more often identifies a desire by the patient to defer responsibility than it would expose a deep faith in our profession. A 21st century physician will need to assume a leadership or shepherding type of role in helping this third type of patient navigate today's health care landscape.

Today, doctors will encounter patients armed with both good and bad information. A 21st century physician should be ready to lead, steer, interpret, teach and help when help is needed because 21st century patients need a guide, now, more than ever.

In my opinion, a modern physician working as a guide will see all of this technology for what it is--a useful tool to further the doctor-patient relationship--and when a long day leaves me feeling more like a short-order cook or paranoid lawyer than physician, I'll download a happy app.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: health information technology, patient communication, primary care

Should I call you doctor, doctor?

I used to live in a small town in Colorado where everyone called the local physician Dr. PJ. He was a hippie who marched in parades throwing out condoms, but even more formal doctors sometimes find themselves addressed by their first names, according to a column in today's New York Times.

The author seems a little distressed by this informality. "I wonder about these people. Are they trying to be chummy? Is it a power thing, making them feel less vulnerable while they sit half naked on the exam table?" It seems to me like a natural outgrowth of an increasingly informal society. Why should doctors be the only people addressed by titles?

Yet still, I conform to the practice. I always address my emails to Dr. So-and-so but sign them with my first name. Some docs write back with their first names but I rarely use them. Recently, though, I requested an interview from a doctor who I had spoken to many times before and decided to go for it and use his first name. He turned me down. Coincidence?

Labels: patient communication

QD: News Every Day--amid health care debate, fewer free screens

ACP Internist's daily digest of news and events continues with the Senate dropping an expansion of Medicare, and a few diagnostic mysteries to solve.

Health care reform
The Senate will scrap allowing those 55-64 to buy into Medicare in order to preserve a filibuster-proof majority. The decision followed what was called a tense, 90-minute meeting. If the Senate bill passes, it must be reconciled with the House legislation, which does contain a public option. Most of the finger-pointing is at Sen. Joe Lieberman, who spent the weekend explaining his opposition (free subscription required) and now stands accused of working on behalf of his key constituents--insurance companies. (Washington Post, New York Times, Wall Street Journal, Modern Healthcare, Christian Science Monitor)

While Congress debates reform, free screenings for breast cancer are facing shortfalls and programs are turning away women as unemployment and budget shortfalls accumulate. (AP/Atlanta Journal-Constitution)

In case you missed it ...
Internists love medical mysteries, and here's a case that would stump any doctor who's not also a presidential historian. And here's another medical mystery an internist recounts--whether to address patients by their first names and allow them to use hers. (Washington Post, New York Times)

Labels: health care reform, mammography, patient communication, primary care shortage, QD

Doctors, ditch the tie and the coat

ACP Internist has addressed doctors' dress before. Most recently, blogger Toni Brayer, FACP, dressed down doctors for wearing ties. Now, Ravi Reddy, MD, has taken casual dress to a new level--jeans and no white coat.

His sartorial choices are guided by his practice location--in Hawaii. It's a cultural thing, Dr. Reddy writes in the Hawai'i Medical Journal.

Studies done in the U.S. mainland show that most patients prefer their physician to wear a white coat, with a visible stethoscope and name tag. Attitudes are a little more laid back in Hawaii, explained Dr. Reddy. In public, many wear slippers (zoris) instead of covered shoes, and short pants and tee shirts are more common than long pants and collared shirts. Physicians favor an Aloha shirt or print dresses and slacks or skirts over ties and white coats.

So Dr. Reddy's front desk staff randomly surveyed 50 patients by questionnaire, asking if patients felt if their physicians wore slippers, scrubs, short pants, blue jeans, or a white medical coat. He then rated measures of trust and confidence.

Patients generally approved of scrubs (81%) and blue jeans (74%), but generally disapproved of slippers (57%) and shorts (69%). Patients preferred their physician not wear a white coat (52%). Regardless of their preferences, trust and confidence in the physician didn't vary much by physician attire, with the exception of the white coat. Those who expected to see one conferred a high degree of trust and confidence.

Aloha, casual everyday!

Labels: patient communication

Rethink pink: breast cancer screening evidence met politics and lost

The controversy started at exactly 5 p.m. Monday, when the Annals of Internal Medicine lifted its embargo on new breast cancer screening recommendations and the rest of the medical community simultaneously released opposing positions. With lines drawn and positions taken, a furor began ultimately pitted evidence-based medicine against political machinations. So far, medicine has lost.

The recommendations, issued by the U.S. Preventive Services Task Force, suggest that asymptomatic individuals with no family history or other risk factors could wait before starting mammograms and undergo screening every two years instead of annually. They balanced the benefits of less frequent screening against the harms of more frequent screening by reviewing the evidence and creating models.

The recommendations have since been on the pages of every newspaper in America, from the smallest locals to the biggest dailies. The American College of Physicians is tracking "impressions," as they're called, in the millions.

There's always a downside to new knowledge, and it's playing out in week following the announcement. It will take time for physicians to digest the new recommendations. It will take time to explain them to patients. In the meantime, public discourse has been messy.

Experts have told women to talk to their doctors about how evidence-based recommendations apply to individual circumstances. But other medical societies are sticking to their guns on annual screenings at earlier ages, and it's unsettling for patients to see doctors disagree and even more unsettling when shouting matches erupt on television.

But neither the government nor insurers are rushing out to make dramatic changes to existing practice of medicine. To calm fears, HHS Secretary Kathleen Sebelius clarified that the doctors who drafted the recommendations, the U.S. Preventive Services Task Force, comprise an independent body of experts who review evidence but don't set policy. To calm fears, she stated that women should still go to their doctors to discuss their individual needs. Insurers aren't going to change their policies, either.

In short, the recommendations inform the talks between doctors and patients. They give physicians something to consider during the informed consent process. Consider the words of family physician David Baron, MD, who said, "I respect [USPSTF] a great deal. They've got no horse in the race. They are independent experts." Take it from practicing physician Jan Gurley, MD, who summarized in plain language how recommendations should impact encounters between physicians and patients.

This is in contrast to internist and TV commentator Elizabeth Lee Vliet, MD, who went on the attack about a "distant and impersonal 'review of data' from published studies." In an op-ed shopped around to media outlets, she further ranted that, "I am profoundly concerned that government 'experts,' far removed from the daily care of patients, are sitting 'on high' to proclaim that women don't need to start mammograms at age 40."

And of course, Dr. Vliet decried it as a cost cutting measure and as the start of "government-mandated, guideline-based rationing of health care." Those are her poorly chosen words. But she's not alone.

U.S. Rep. Marsha Blackburn of Tennessee bemoaned that, "This is where you start getting a bureaucrat between you and your physician." Rep. Michele Bachmann of Minnesota joined the misinformation brigade, starting her press conference on the task force recommendations by blaming President Obama and Speaker of the House Nancy Pelosi. Watch for yourself.

Hijacking evidence-based recommendations to further partisan debate is a semantic trick. And it's a disgrace.

Labels: cancer, evidence-based medicine, guidelines, health care reform, health policy, patient communication, patient education, women's health

QD: News Every Day--more time, more patients, more quality

ACP Internist's daily digest of news and events continues with a snapshot of health care reform, as well as a look at an ACP member's findings that doctors are spending more time with more patients, and still providing better care across nine quality measures.

Health care reform
The focus has now shifted to the Democrats for health care reform.
--Some Democrats don't think it slows health spending enough.
--Some Democrats think it pits young constituents against elderly ones.
--It's either pragmatic and flexible or just as good as it gets.

As the debate moves back to the Senate next week, there's five "flash points" to consider. (New York Times, Wall Street Journal, Politico, The Hill, Cristian Science Monitor)

Patient encounter
Doctors are spending more time with their patients--21 minutes in 2005 compared to 18 minutes in 1997, reports Lena Chen, ACP Member. And, primary care visits increased 10%, from about 273 million visits in 1997 to 338 million in 2005. Yet, quality is improving across nine performance measures. The population is aging, which requires more time, but also health care in general is more complex now. And, patients are better informed and more engaged. (U.S. News & World Report)

In case you missed it ...
Medical education is changing to focus on health care reform, the patient-centered medical home and patient communication, and leaving anatomy for later. Genetics, demography and the environment are being included. Students are helping design the curriculum, too. What's going on? (Washington Post)

Kaiser Health News looks back to 1977 for a familiar scenario--politicizing living wills that might lower unneeded or unwanted health care use at the end of life.

Labels: health care reform, living wills, medical education, patient communication, patient-centered medical home, QD

Which patients sue for malpractice?

There are a lot of myths out there about which patients are most likely to sue a doctor for malpractice. Many doctors think it is "poor patients on welfare." They would be wrong. Evidence shows that low income patients on Medicaid are actually less likely to sue than others. But there are some patients and situations that should raise a red flag for physicians that they could bring a lawsuit.

--Angry patients: A patient who is upset about the doctor-patient relationship, either because something didn't work out or they perceived a lack of caring, is more likely to sue the doctor. Plaintiff attorneys say that the majority of their calls come from patients who had poor rapport with their physicians. What works in a medical error? An explanation of what went wrong and, if appropriate, an apology!
--Money Issues: Now that more patients are paying out of pocket costs, if they feel overcharged they become less tolerant of errors. If patients know the approximate costs up front, they aren't surprised and outraged when that big bill arrives. We all know, however, how hard it is to find out anything about costs in advance. Big problem!
--Doctors Dissing Others: So many lawsuits have been filed because of one doctor or nurse making disparaging remarks about another; "How did such a thing happen to you?" It's easy to be a Monday morning quarterback.
--Lousy Service: Bad service goes along with poor doctor-patient rapport. It is hard for someone to feel respected and cared for, if they get bad service or the rooms are dirty or the phone call isn't returned. If a mistake happens, the doctor must be available to discuss it. An absent doctor or poor service turns patients and family members into "angry patients" (see number 1).

Medical mistakes happen because the human body is complex, treatments are complex and there are no guarantees in life. Most patients don't sue their doctors when a bad outcome occurs. The experts in risk warn us that the relationship is the most important prevention for lawsuits, followed by meticulous documentation in the medical record.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Labels: malpractice, patient communication

QD: News Every Day--the public option as a Straw Man

ACP Internist's daily digest of news and events catches up with newly appointed Surgeon General Regina Benjamin, MD, fears about adverse reactions to H1N1 vaccinations, and why one ACP member says hope for recovery isn't always the best for a patient.

Surgeon General confirmed
Newly confirmed Surgeon General Regina Benjamin said preventive medicine will be her priority, following her confirmation by a unanimous Senate vote late last week. Month before, during a press conference announcing her nomination, she had spoken about losing relatives to lung cancer, diabetes and other lifestyle-related illnesses. (al.com)

Health care reform
For all the fuss over the public option, the Congressional Budget office estimates that 2% of the nation, 6 million in all, would enroll in it. (AP/The Washington Post)

Barry Izenstein, FACP, Governor of ACP's Massachusetts Chapter, writes that health care reform should cover all Americans, create more primary care doctors and reform medical liability. (The Springfield Republican)

Meanwhile, Peter Boling, ACP Member, is undertaking his own effort at health care reform by falling back on the old-fashioned house call. The House and Senate are considering such measures as part of the "Independence at Home" provision of current legislation. (AP)

H1N1 influenza
Independent experts started today tracking adverse events from the H1N1 vaccine to spot any real problems quickly, explain false alarms and separate normal disease rates from potential yet real risks. (AP/Boston Globe) There's a basis to the fear of H1N1 vaccination, and it's generational, says one psychologist. (Psychology Today)

In case you missed it ...
Sometimes, it's better to lose hope for recovery, University of Michigan researchers said.

Peter Ubel, ACP Member, teamed up on a study that noted while it's important not to lose hope, it's also important to realize that hope might make some people unhappier because they fall into a holding pattern of sorts, waiting for their condition or chronic pain to wane before moving on with their lives. They compared outlook among patients who'd just had colostomies. Some were told the procedure would be reversible, and some were told the procedures were permanent. He explains more about hope's "dark side."

Labels: H1N1, health care reform, patient communication, QD

Why can't we be friends ... on Facebook?

Doctors may have nothing to fear about patients reaching out for medical advice via social media.

CNN profiled patients and physicians who've used Facebook to stay in contact with their patients--either for information or for routine clinical contact such as prescription refills. Social media has been a subject of much discussion but not much clarity. While a majority of ACP members use some form of social media personally and professionally, they also have expressed their concerns about privacy and trying to diagnose patients who need face-to-face visits instead.

Plenty of doctors have avoided patient contact even over e-mail, thinking it to be just one more unreimbursed time-drain. (Others have adopted it wholeheartedly: see here and here.)

But doctors may have nothing to worry about after all. Although the article cited surveys that found half of consumers want to be able to e-mail their doctors, a reader survey on CNN's home page showed that, among 240,000 respondents who'd voted through mid-day Friday, only 11% responded that they would want to contact their doctor through social media.

Labels: patient communication, social media

Patients just as likely to sue after apologies

Apologizing for a medical error in full and accepting responsibility may boost patients' perceptions of physicians but may not stop them from suing, according to simulations conducted at Johns Hopkins and reported in the Sept. 1 issue of the Journal of General Internal Medicine.

Researchers created simulated scenarios of three medical mistakes: a year-long delay in noticing a malignant-looking lesion on a mammogram, a chemotherapy overdose 10 times the intended amount and a slow response to pages by a pediatric surgeon for a patient who eventually codes and is rushed to emergency surgery. Actors played out levels of physician apology (full, non-specific and none) and acceptance of responsibility (full or none). 200 adult viewers then evaluated the simulations and reported their impressions. Sample videos used in this study are online.

Viewers who thought that the doctor had fully apologized and taken responsibility gave the doctors much higher ratings (81% vs. 38%; P<0.05) and would refer the doctor (56% vs. 27%; P<0.05), but weren't significantly moved not to sue (43% vs. 47%).

What's not reported in this study was whether the doctor could avoid being named in the eventual lawsuit. ACP's news magazines have reported in the past on ways to apologize and how it affects malpractice litigation.

Labels: malpractice, patient communication

Paging Dr. Big Brother

Patients who fail to take their medications properly suffer unnecessary complications, raise health care costs and drive their physicians nuts. We've written articles suggesting potential solutions to this problem, like motivational interviewing. But now those clever R&D guys have come up with an answer that will avoid the effort of patients and doctors actually talking to each other.

"Proteus Biomedical Inc., is testing a miniature digestible chip that can be attached to conventional medication, sending a signal that confirms whether patients are taking their prescribed pills. A sensing device worn on the skin uses wireless technology to relay that information to doctors," report the Wall Street Journal.

Yes, that's right. No longer will you have to ask patients whether they've been compliant with their prescriptions. Just plant a bug in their drugs and wait for the transmissions. And we thought the replacement of internists with computers was just fiction.

Labels: drugs, patient communication

Survey shows clinical use for social media

About 60% of ACP Internist readers acknowledged using some form of social media, using it not only personally and professionally but clinically as well.

ACP Internist polled its readership online, through its Web site, weekly e-mail update and through the College's Facebook and Twitter accounts, which probably skewed results.

But results did show that internists are just like other social media users, with 90% using it to keep track of birthdays, anniversaries and marriages, or sharing pictures with friends and family. It's social media, after all.

But social media are increasingly being co-opted professionally, and nearly 70% of respondents use it to reconnect with distant friends or former colleagues, to promote health policy information, or to compare the legal and financial aspects of the practice of medicine. One respondent said social media "helps keep me in touch as a military physician stationed overseas--tough with the time change."

And almost one in four respondents used it clinically, keeping up to date on medical news, sharing cases through Sermo, or responding to questions as a health expert, such as using a blog for patient education. Respondents use social media to communicate lab results, or measure patient improvement or clinical response.

Physicians' cited privacy as their main concern, either releasing too much information online, or outright hacking of personal data, followed closely by the perceived lack of quality of clinical information online. Others worried about how social media might change the doctor-patient relationship.

"I do have patients that have asked to 'friend me,'" one respondent said. "I have always accepted these requests. I am more careful about my postings with that in mind." Another responded, "I would never use it with patients--there is a need to keep personal and professional lives as separate as possible."

And doctors are also aware of the pitfalls of trying to practice medicine online, with the potential for patients to oversimplify their symptoms online when a comprehensive, in-person exam would be warranted. "People may get too comfortable with using the Internet and neglect normal means of communication," one person said.

Labels: patient communication, social media, social networking

Apologizing for errors halves malpractice suits

University of Michigan Health System reports that admitting medical errors and offering compensation before being sued resulted in malpractice claims falling from 121 in 2001 to 61 in 2006, with corresponding savings in costs per claim.

The Associated Press profiled the hospital system's efforts not only as a business decision but also an ethical one that benefits patients, while not exposing the system to further litigation.

Apologies aren't easy, but ACP's news publications have offered advice to make them easier:
--"Internist searches for answers when test results go missing," ACP Internist, April 2009.
--"Apologize like a pro," ACP Hospitalist, January 2008.
--"To err is human ... to not plan for it is trouble," ACP Hospitalist, December 2008.
--"Owning up to a mistake takes courage--and practice," ACP Internist, April 2009.

Also, PIER offers an entire module on disclosing medical errors, and Annals of Internal Medicine looked at the state-by-state efforts to implement shield laws for physicians who disclose errors.

Labels: ethics, malpractice, patient communication

Doctors discuss the consequences of misleading medical news

Doctors have to spend a lot of time correcting patients' misimpressions of medical research based on mainstream media reporting, readers told ACP Internist in a survey.

Mainstream media coverage of medical news overstate results and include too few details, according to ACP Internist's poll, "Your Thoughts Exactly: Media reporting of medical research."

According to the poll results, all respondents voted that mainstream media reports of medical studies were exaggerated "extremely," "very much" or "moderately." There were no responses of "somewhat" or "not at all."

When asked to rate the level of detail of medical stories in the mainstream media, all but one respondent thought there was "somewhat" or "way too little" detail in coverage.

The poll is based on a study in Annals of Internal Medicine that concluded the public relations departments of academic medical centers overstate results or don't include important caveats when pitching study results to the media. Authors questioned if this was being passed through to mainstream media reports, which patients then carry into their visits with physicians.

In the daily grind of medical practice, doctors reported a "time drain" of calming patients who'd seen a news report, or deflecting false hopes and over-expectations from others.

One poll respondent summed it up perfectly: "Medical news is almost always distorted, and leads to false hopes and expectations from patients. However, it's part of my daily job to provide patients with accurate and useful information about their medical conditions."

Also, another respondent chastised the media for the lack of distinction made between test tube studies and phase 3 clinical trials, and also the lack of explanation that discoveries about the mechanisms of diseases do not immediately translate into treatments that can be made available.

"Dramatic results are not often carefully noted to be preliminary and unreproduced," another respondent said. "This leads patients to believe findings are ... established. This often requires time to properly balance the whole of the existing (or non-existing) data. Patients don't get the language of 'may be' that is usually reported in the media."

"Fortunately, patients trust their doctor more than the media," one concluded.

Perhaps the best way to overcome poor medical reporting is to do it yourself. One doctor successfully reports medical knowledge to his patients by appearing on TV as a medical commentator.

Labels: patient communication, patient education, patient information

When test results go missing, an internist searches for answers

Ethics columnist Paul S. Mueller, FACP, discusses a case study that would bring chills to any primary care provider: what happens when an internist orders test results, and then never sees the results?

From an actual case file, Dr. Mueller discusses a 61-year-old asymptomatic man seeing his internist of 10 years for a check-up. When reviewing the medical record, the internist sees PSA test results of 11.8 ng/mL. Surprised by this finding, the internist digs further. A year ago, the PSA was 8.2 ng/mL and three years ago it was normal. The patient was never told; the internist is certain she never saw it. She wonders what to do next.

Click on "More" below for advice on how to handle the disclosure of previously missed test results.

Clinicians experience negative emotions when they realize they have committed an error, Dr. Mueller writes. Nevertheless, they are ethically obligated to disclose errors to patients.

First, clinicians should act in the best interests of patients. Explain the nature of the error and its implications and continue to provide professional and compassionate care.

Second, respect for patient autonomy requires that clinicians disclose errors to patients to allow for informed decision making.

Finally, justice requires that patients be given what is due to them, such as information about their medical condition and, if injured, appropriate compensation.

In this case, the internist met with her patient and his wife to tell them that the prior PSA test result was mishandled. The patient was upset, angry and felt helpless, which internist acknowledged. However, the patient later stated that he appreciated the internist's honesty. Together, they developed a follow-up plan.

Dr. Mueller suggests these steps when disclosing medical errors
-Speak in private with the patient, his or her loved ones, and essential members of the health care team present. Avoid interruptions (such as pagers) and allow time for questions.
-Discern the patient's perception of the problem before disclosing the error. For example, you might ask, "Do you recall the results of your PSA from a year ago?" Such questions allow for correction of misinformation.
-Speak clearly and check for comprehension (such as, "Is there anything I can clarify?"). The patient should understand what happened and the consequences of the error.
-Avoid attributing blame (such as, "The laboratory must have forgotten to call me about the result"). Patients desire a sincere apology and want to know how the clinician and organization will act to prevent future errors.
-Acknowledge the patient's emotional response to the disclosure by using empathic statements, such as, "I can see that you are upset by this news."
-Formulate a plan for further assessment, treatment, and follow-up and how you will work to prevent future errors.
-Document all discussions related to the error and its disclosure.

Dr. Mueller contributes to Ethical Dilemmas, a regular column appearing in ACP Internist.

Labels: ethics, Grand rounds, patient communication

Fight back against feedback

Doctors dissatisfied with their online ratings are seeking to have them removed. One advisor suggests asking patients to sign waivers not to post reviews online.

This issue isn't new. Two years ago Texas doctors took a stand against insurers' rankings by ranking the insurers.

While it's important to protect a practice's good reputation, the best way to get a good review is to offer a good experience. If it's time to brush up on patient management skills, here's some suggested reading:
Make the wait shorter and nicer
Reduce bottlenecks
Consider ACP's Center for Practice Improvement and Innovation
Greet your patients properly
Don't be rude

Labels: patient communication, practice management

Making medicine politically correct

Here at ACP Internist we've had occasional debates about the PCing of medical writing. For example, patient advocacy groups would have one say "people with diabetes" instead of "diabetics" so as not to make the disease more of a focus than the person. But when you're writing about diabetes, and therefore, only mentioning said anonymous, unnamed person because they have diabetes, is it not socially acceptable, and vastly less cumbersome, to refer to him or her as a diabetic?

As the NY Times reports today, the International Longevity Center has raised the standard of PC medical language even further by publishing a list of forbidden synonyms for "old." Not only should we not refer to those with more chronological life experience than us as "coots" or "hags," but "elderly" and "senior citizen" are also to be axed. The experts suggest instead the problematically nonspecific (from a medical writer's perspective) term "older adult."

As one commenter to the NYT article noted, would not our effort be better spent trying to correct the pejorative connotations associated with being "elderly" or--to continue the parallel, the negative consequences of being "diabetic"--than repeatedly changing the terminology? After all, how long did it take for "special education" to go from polite euphemism to children's insult?

Labels: patient communication

To email or not to email

In a response to an ACP Internist article about patient web portals, we recently asked InternistWeekly subscribers whether they communicate with patients online. The results showed that our readers (or at least those who responded to the survey) are ahead of the curve with patient email: 38% said they communicate with patients online, and another 19% are interested in the idea. The remaining 43% said "No, and I'd like to keep it that way."

As a follow-up, the survey asked why the respondents do or don't use online communication. Not surprisingly, the answers revealed time, technology and money to be the biggest hurdles to implementation. Many readers saw no reason to mess with the status quo and add potential complications with HIPPA, encrypted email or malpractice risk. "The phone works fine and actually talking to a patient is far preferable to email," a commenter said. Or as one succinct doc put it, "Think it would double my workload."

Another saw a wide range of risks inherent in emailing: "Increases risk of misunderstanding and potentially increases liability. Increases tendency to carry out 'telephone' medicine with the lack of hands on, visual, and intuitive clues to the real underlying problem. It is time-consuming in aggregate and adds to an already overloaded schedule. There is no evidence that engaging in this type of communication will improve medical care or decision making, reduce liability, reduce workloads or increase income."

The physicians who do use email would likely disagree with that reader. Several mentioned that they limit their online communication to brief messages, like sending test results or setting up appointments. Listed benefits were the ease of communication, avoidance of phone tag, and savings on postage. And then there was the most unusual reason for using email: "It also intimidates enough people to not pursue silly things." Perhaps a selling point that EMR vendors will want to add to their pitches.

Want to add your two cents? Click Here to take survey

Labels: patient communication

Getting the gist

In my last ACR session (the convention continues through tomorrow, but our blog coverage finishes today), a psychiatrist spoke about explaining statistical risk to patients, a topic I've covered before.

One of her key points was that patients need to understand the gist, rather than the specifics, of risk. She used a clever example to make this point. Two patients are offered a surgical treatment that carries a 2% mortality risk. This risk is explained to them several weeks before the surgery, and then they are asked about it immediately beforehand. Patient A remembers the risk as 10%, while Patient B remembers a 0% risk. Even though Patient B's recollection is numerically closer to correct, it's less useful, because Patient A has correctly understood the gist that the surgery holds some mortality risk.

So what's the practical import? When talking to patients about risk, worry more about whether they seem to have gotten the general idea (aka the gist) rather than whether they can recite stats back to you verbatim.

Labels: patient communication, rheumatology

The patient who ruins your day

At ACR yesterday, Dennis Boyle, MD, led an entertaining, interactive session on dealing with difficult patients. In addition to clips from Cool Hand Luke, he offered some perspective on the visits that no one wants to have.

First, recognize that you bring your own issues to the encounter, which will affect how you respond to the patient. Dr. Boyle described how he used to complain about his problem patients to a psychiatrist friend until the shrink asked, "Did you realize that all your difficult patients remind you of your mother?"

More seriously, he reminded attendees that most angry patients are actually more afraid or sad than angry, and that open-ended questions ("Tell me why...") should be used to get their story. It's also important to actually listen to them when they're talking, and use reflective listening ("It sounds like...") to make patients feel understood, to control rambling stories, and to help you remember details for later charting.

Labels: patient communication, rheumatology

Say what you're thinking

There's never going to be a happy way to break bad news. But, as a recent column in the New York Times points out, physicians' efforts to perfectly stage their delivery may actually backfire and make things worse.

I can vouch for this. When I saw my primary care physician for an undiagnosed problem last year, she had a couple of my labs back, but a few more were still on the way. Without all the labs, she wouldn't speculate about a diagnosis. When she called a few days later with a diagnosis, she thought she was breaking bad news, but I was actually relieved because the silent, worried look with which she scruntinized the labs had convinced me that I was probably terminally ill.

So, to sum up, don't underestimate your patients' ability to read your poker face...or their hypochondria.

Labels: patient communication

Do we need a talking cure?

The New York Times has just launched a new blog, "Doctors and Patients Start Talking," with the goal of healing the confidence and communication gap between physicians and patients. It's a laudable objective that has attracted a lot of web traffic, and maybe I'm being too cynical, but I don't see how airing more complaints from both sides (patients and docs) is going to fix a problem whose causes are systemic.

A new article on Slate gets at this issue, by pointing out that the cause of ER overcrowding is not illogical misuse of the emergency room. Rather, people are using it for non-emergent problems because it is, for them, under the current system, the most efficient and cost-effective way to get care. The authors rightly conclude that structural changes are in order, although they, too, make some odd suggestions of individual solutions to the problem ("Next time you call the dermatologist and they say, 'We'll see you next summer,' you could cry foul." Good luck with that!).

What do you think? Are there things that you'd like to tell all patients that would improve overall health care? And do they have any complaints that you haven't already heard?

Labels: patient communication

What do patients want?

Three recent items point out to harried internists what patients really want when they see their doctor--communication.

Along comes the American Board of Medical Specialties, who released a survey that bedside manner outranked certification as a reason why patients like their doctor. Good communication was important to 95% of respondents, as opposed to certification (91%). Not to state the obvious, but it's important when the body that certifies physicians says their raison d'etre is second place to patient communication. Actually, they explain how one is related to the other here.

Next, from the trenches of good primary care, comes Dr. Rob, who has posted six commonsense rules for working with patients.

Finally, the cover story to July's ACP Hospitalist examines the difficulty of balancing being right and being polite. Says one doctor (and he is not alone in his opinion) "You're training me to be an expert and now you're going to ask me to be nice about it at the same time? As physicians, we're not trained to deal with a lot of this stuff."

How can internists balance everything they have to do and then relate it to the patient in a 10-minute visit?

Labels: patient communication

ACP Internist hosted Grand Rounds on June 16, wrapping up the best of the medical blogosphere. Click here for the complete wrap-up.

Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

db's Medical Rants
Robert M. Centor, FACP, contributes short essays contemplating medicine and the health care system.

Everything Health
EverythingHealth is designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Getting Better with Dr. Val
Getting Better is the continuation of Dr. Val Jones' previous blog at Revolution Health. It is devoted to helping people understand health issues from a balanced, scientifically sound perspective.

HealthHombre
A roundup of health policy news drawn from a database of hundreds of Web sites.

Interact MD
Michael Benjamin, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

Kevin, MD
The alter ego of Kevin Pho, ACP Member, is the closest thing to royalty in the medical blog world.

LSUHSC-S Medical Library Evidence Alert
Major guidelines, systematic reviews, meta-analyses and/or major reviews by national and international organizations.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by a doctor.

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Friday, January 29, 2010

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Tuesday, January 26, 2010

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Wednesday, January 13, 2010

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Tuesday, December 15, 2009

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QD: News Every Day--amid health care debate, fewer free screens

Tuesday, December 8, 2009

Doctors, ditch the tie and the coat

Thursday, November 19, 2009

Rethink pink: breast cancer screening evidence met politics and lost

Tuesday, November 10, 2009

QD: News Every Day--more time, more patients, more quality

Thursday, November 5, 2009

Which patients sue for malpractice?

Monday, November 2, 2009

QD: News Every Day--the public option as a Straw Man

Friday, September 4, 2009

Why can't we be friends ... on Facebook?

Wednesday, September 2, 2009

Patients just as likely to sue after apologies

Tuesday, August 4, 2009

Paging Dr. Big Brother

Friday, July 24, 2009

Survey shows clinical use for social media

Tuesday, July 21, 2009

Apologizing for errors halves malpractice suits

Thursday, May 28, 2009

Doctors discuss the consequences of misleading medical news

Monday, March 30, 2009

When test results go missing, an internist searches for answers

Wednesday, March 4, 2009

Fight back against feedback

Thursday, February 12, 2009

Making medicine politically correct

Thursday, December 18, 2008

To email or not to email

Tuesday, October 28, 2008

Getting the gist

Monday, October 27, 2008

The patient who ruins your day

Friday, October 3, 2008

Say what you're thinking

Friday, September 12, 2008

Do we need a talking cure?

Friday, August 8, 2008

What do patients want?

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