All posts by Susie Simpson

The Patient Becomes Acronymous

 

Whenever I read a patient history written by a relatively young physician, particularly the residents I teach, I am struck by the abundance of acronyms employed to describe the person:

This is a 44 yo aaf with T2 dm, hld,  htn, cad, hfpef, osa, copd who presents with acute sob and cough.  

For those of you who are not medical, the translation reads:

This is a forty-four year old African-American female with type two diabetes, hyperlipidemia, hypertension, coronary artery disease and heart failure with a preserved ejection fraction, obstructive sleep apnea, chronic  obstructive pulmonary disease who presents with acute shortness of breath and cough. 

If you try to type out all the words and not use acronyms, it takes you a lot more time.  Resident physicians and hospitalists are slaves to the electronic health record (aka EHR) so one cannot blame them for their extensive use of acronyms.  In addition, they are taught to include in their charts all the diagnoses they can come up with for every patient to facilitate accurate coding and billing.

When I entered medicine the medical academics generally were frowning on the frequent use of eponyms—the use of a surname, usually a dead, white, male physician, to describe a medical condition.  For example, Addison’s disease was replaced with adrenal insufficiency, Cushing’s Disease with adrenal hyperplasia and so forth.  Henceforth, acronyms began to reign. Coronary thrombosis was replaced with myocardial infarction which was replaced with MI.

In American English acronyms were seldom employed until they poured into the language from their spawning ground in the allied military of World War II.  They could be spoken words derived from a group of words, such as fubar  (f——d up beyond all recognition) or radar(radio detection and ranging) or they could be pronounced letters like GI (government issue).

Acronyms  are here to stay, both in the military and in medicine.  Yet when I hear a patient described in the manner of the patient above I always get the feeling that the pasta has just been thrown on the wall.   Yet when a medical resident tells me about a relatively young patient with all those specific problems I often ask the resident to cut to the chase and tell me how bad is the obesity of the patient.  And when we get to the bedside, as we did in this case, and find some poor person who is so obese that they can barely walk and breathe, I reflect on how depersonalizing this list of acronyms for disease states are and, in a sense, how inaccurate.  In the case of the above patient she is really an unfortunate lady suffering from hyper obesity and its attendant syndromes of crippling arthritis and…..(acronyms).  She does not have a series of medical problems that struck her from the blue, but a syndromic problem with predictable mechanical and metabolic sequelae. How she copes with all these problems usually does not appear in the record.

In a rush to acronymous description we seem to have abandoned the notion of personhood.  Histories in the past often began with a description of the person within a social context:
This is a forty-two year old hypertensive, moderately obese white man, a warehouse supervisor, married and the father of two children, who developed chest pain while lifting heavy pallets at work this morning. 

Such a description gives us a picture.  He is employed, he has children to worry about, he appears to have a life partner. Considering those issues and embedding them in the record, our literary depiction of the patient is how we embark on knowing the patient.  Acronyms can help us slog through the ravenous demands of an EHR but they can also, singularly pursued, become like bar codes in a check-out line, creating objects out of living and breathing souls.

– Peter S. Kibbe, MD, FHM

Babel Part II – For Whom the Bell Tolls

Recently I cared for a man suffering from gastrointestinal bleeding related to his gastric bypass surgery, which had been performed about eight months previously.  The medical problems he suffered prior to the surgery indicated his obesity was becoming fatal before he  embarked on the journey involving bariatric surgery.  He was hypertensive, diabetic and suffering from cerebrovascular disease.  His response to the therapy was awesome.  He lost one hundred and sixty pounds and expected  to lose more.  His diabetes disappeared, his blood pressure fell, his sense of well-being improved. His GI bleeding was fixable.

It was his personal performance in a complex program that began nine months before his surgery which impressed me most.  It included intense nutritional coaching, group psychotherapy, weight loss and preparation for dietary restrictions that would follow the surgery.  He was restricted for months following the surgery to protein “shakes,” then gradually advanced to other foods.  He found that some of his favorite foods now had no appeal, that foods he formerly disliked he now preferred, but he continued to lose weight.  He had good follow-up care. As he described this journey to me he seemed a man on a mission.  He had more weight to lose, a new job to enter that excited him, a new house to move into.  He wanted out of the hospital quickly.

This was a team approach.  He was appreciative of his surgeon’s skill but he spoke of his nutritional counselor as though she were his personal life coach and guru.  So this was a success story.  The patient had entered, armed with his own determination, into a systematic therapeutic endeavor.

The social facts of this man’s life, the fact that he was employed and had medical insurance that made his journey affordable were foundational to his experience and to his assertion of his own agency to change his health status and life expectancy.

In a room across the nursing station from him at the same time was another obese patient whose care I assumed, a lady who had been declining for months.  In spite of some chronic arthritic problems she had until a few months prior been active and outgoing, but she noted progressive weakness and found that walking and lifting, just getting out and about, were becoming impossible tasks due to weakness.  Unemployed, unable to afford medical insurance and age sixty-four, she promised herself that she would see a physician when she turned sixty-five in eight weeks and became eligible for medicare. And then she fell.  And she could not get up.  She lay on her floor, embarrassed for most of the day until she summoned help via her cell phone. Understanding how precarious her financial situation was I can imagine her not calling the squad because she knew how expensive that would be.

Due to the fall she suffered a nerve injury that left her with a foot drop.  From lying on the floor she had rhabdomyolysis and a kidney injury.  At first, with typical prejudice, I must admit I thought that she remained on the floor due to the sheer bulk of her person.  We assume things about very obese people at our own, and their own, peril.  We screened her thyroid and discovered, low and behold, that she was seriously hypothyroid.

So the clinical puzzle pieces fell into place.  Over the previous months she had gradually become hypothyroid but its manifestation was mostly a hypothyroid myopathy, a muscle affliction causing her gradual and progressive muscle weakness.  This had progressed to the point that she was no longer ambulatory. After her kidneys improved and we began to replace her thyroid she required transfer to a skilled nursing facility.

These patients are a tale of two medical economies.  One patient had insurance that gave him agency to tackle his medical problems even though the therapy is costly. The other fell through a hole. For one the medical machinery functioned well, for the other it was a goat rodeo.

The patient, without medical insurance could not have contemplated the bariatric journey of the first.  Even when she developed a problem that can be solved by a few office visits and simple thyroid testing she could not afford even this.  In her case we see the extreme costs of the medical care avoidance that has been noted and written about in people with no insurance or insurance with such high deductibles that even a bit of medical care can cause them to miss a car payment or fall behind in the rent.

And we all, when these easily treated disorders progress to disasters, pay for it.

When I was caring for these two individuals during the same week I was reminded of what is or used to be presented to most school children as a poem by John Donne, For Whom the Bell Tolls. In the poem, Donne asserts that we are all connected to one another.  The bell tolling due to the disease and death of any human he asserts is of concern to him, because we are all “part of the main.”

In fact, Donne did not write it as a piece of poetry but rather as part of a prose work he called “Devotions Upon Emergent Occasions, and several steps in my Sickness.”  At the age of fifty-one Donne, a poet, lawyer and Anglican priest, developed a severe and prostrating illness which he clearly feared would be fatal.  Some historians assert that it was recurring typhus as there appeared to be an epidemic of this at the time in London.  His illness lasted twenty-three days and for each day he wrote a “devotion.”  Each devotion includes a “meditation,” an “expostulation” and a prayer.  The seventeenth mediation includes what many know as the famous poem:

No man is an Iland, entire of it self; every man is a peece of the Continent, a part of the maine; if a Clod bee washed away by the Sea, Europe is the lesse, as well as if a Promentorie were, as well as if a Mannor of thy friends of thine own were; any mans death diminishes me, because I am involved in Mankinde… 

This meditation contains a spiritual thunderclap, an assertion that we are all connected, diminished by the misfortune and death of any other.

In 1623, the year of his illness, Donne, like all others in his age, was incapable of thinking of his illness in biologic terms.  In his “Devotions” he asserts that his illness is perhaps a blessing, offering a means of meditating on the spiritual.  For many in his age illness was considered a probable message from God and Donne seizes the twenty-three days of confinement to explore his own spirit.  The seventeenth meditation appears to assert a spiritual and social contract: we are all in this together.

No matter what one’s spiritual or social reflections, it cannot be a disputed that individual disease burdens, even though ignored and unattended due to a lack of social insurance, spread out and ripple through society. It costs us in many ways. It is a burden to families and businesses, a burden to public costs and hospital revenue. It leads to unnecessary death, a shrinking work force, falling life expectancy and worsening perinatal infant and maternal outcomes. It leads to bankruptcies and contributes to homelessness.  If you think that the struggles and illnesses and deaths of the poor, the opiate-addicted or people poisoned by pollution do not spiritually diminish you, they will likely diminish you materially.

And therefore never send to know for whom the bell tolls: it tolls for thee.

 

 

Babel….Peter S. Kibbe, MD, FHM

Babel

Hospital based internists treat many patients whose problems are frustrating because they are chronic and often incurable.  So we “manage” a bundle of disease states and attempt to keep people functional in spite of their underlying progressive problems.  In doing so we are always considering how we can improve our performance but our performance blends with how well the patients themselves perform.  Their performance is linked to the social supports which are available to them.  Medical insurance, its individual presence or absence, its real functionality in each individual case—the question of whether it actually offers a human an affordable means of obtaining medical care— is of course the most crucial support.

If in the United States if medical insurance plans or systems were languages they could be thought of as a tower of Babel.  We have Medicare and its various parts(A,B, etc) and we have Medicare plans administered by insurance companies(a means of insuring that the insurers get a bite of profit from our taxes).  We have Medicaid, which some states have refused to expand and which some states are trying to strangle. We have multiple private insurers that offer plans via employers and we have private insurance which individuals can purchase under the Affordable Care Act.  Then there is the insurance plan that covers active military and uniformed service members, there is the VA system, the Indian Health Service…the list appears endless.

All insurances do different things.  Some pay for a treatment that others do not, many include strict limitations on the clinicians the patient can see, no matter how far away those clinicians might be. Some require pre-certification for certain procedures, treatments, diagnostics or drug prescriptions, and it seems they all use different criteria to judge whether a patient is sick enough to be in a hospital. Attempting to practice medicine in such a system is crazy-making and is worthy of the work of Kafka.

For the patients it is worse. Some have such high co-pays and individual deductibles(a means of making an individual, in a sense, insure herself) that an individual will avoid medical encounters due to their potential financial “deductible” burden in spite of the notion that they have “health insurance.” These are a mass of people who appear to be insured but cannot really use the insurance because by the time they have paid the deductible they would be financially ruined.

Then we have of course, a huge mass of individuals who fall through all the cracks and simply cannot afford any kind of medical insurance.

I will not venture to discuss insurances for persons with mental illness, it would be too schizophrenogenic for me.   For clinician readers who are curious about dental insurance, just look very closely into the mouths of most of your patients and reflect upon the inflammatory burden that so many of them are carrying around embedded in their mandibular and maxillary regions because they are unable to afford dental care.

This Babel of insurance support or lack thereof creates in a sense multiple medical economies.  Thus we can perform one treatment for one patient but not the same for another.  One patient can recuperate in a skilled facility, another with an identical picture cannot due to his/her insurer’s discretion on payment.  One diabetic can get the highest quality insulin, another cannot due to differing pharmacy plans.  Insurance plans flood the desks of primary care physicians with forms they must submit to get various test, imaging or pharmaceuticals “approved” for their patients.  The inefficiencies of the current “system” are jaw-dropping. They repeatedly make what should be a fairly straight line from diagnosis to treatment turn into multiple circles of clerical insanity.  The medical avoidance that persons with paltry insurance coverage (or none at all) exhibit ultimately places further burdens on all of us.

In the next blog I will present two patients I cared for simultaneously who were at opposite ends of the medical economic spectrum, one who used his insurance to radically and successfully change his medical status and one who practiced medical care avoidance.

Complicating the Obvious or Why a Duck is a Duck by Peter S. Kibbe MD FHM

 A  doctor and a duck walk into a bar and the bartender says that they don’t serve ducks.  So the doctor says, “This isn’t a duck!” and… well, more on this below.

A physician friend of mine recently proved that he understood the saying that a physician who treats himself usually has a fool for a patient.  He showed me a picture of a rash he had developed a few days earlier on his arm.  He explained that he at first attempted to ignore it, then called his personal physician and sent the cell phone image of the rash to him.  My friend thought it was a rash typical of Lyme disease and his physician agreed that of course, it was and could be nothing else and immediately prescribed the proper antibiotic.  My friend was working in the woods around his house, developed the rash, malaise and fever.  Almost no other infection has that typical rash as a sign, none in an Ohioan who has not been traveling to the Southwest of the U.S.  It could be nothing else.

All laboratory tests at this point would be academic.  It is what it is.

Many clinical syndromes present this way, glaringly obvious from the history and physical examination alone, yet we appear, at least in the environments where I practice, to complicate them for our patients.

I would argue, as have many,  that much of the testing, imaging and other diagnostics we order for patients should be seen as a burden we place on them.  This burden can be emotional, engendered by anxiety and fear while awaiting the test results, and as well it can be a physical burden—the radiation delivered with CT scanning, the physical discomfort experienced with certain imaging procedures or the negative consequences of the sedation required for certain procedures.

Being placed in a hospital bed can be a burden as well in terms of financial loss, lost time, disturbed sleep and dietary patterns and, for the elderly, the rapid deconditioning they experience by being made immobile.

Not long ago I was referred a patient for admission for observation who, I was told by the emergency department clinician, had experienced a syncopal episode while standing in her kitchen.  She was a very healthy and active 80-something whom I encountered with her husband.  The history was a bit more complicated but the history alone pin-pointed the cause of her brief faint.

She, for several months, had been experiencing severe pain in the right hip, a joint that had been replaced several years prior.  The pain was not a problem when she was active and did not interfere with her  routine of daily and very long walks.  She got in a couple of miles or more.  She loved to cook and she found that after prolonged standing at her kitchen counter the pain would become disabling.  It was relieved by sitting and when I first encountered her she was pain-free.  On the day of her presentation she was making one of her complex culinary favorites when the pain began and it progressed.  Her husband found her in distress, standing and grimacing, and as he helped her to a chair she briefly lost consciousness without any other sign or symptom, and then very rapidly awakened.  The inevitable CAT scan of her brain was obtained which was negative.  She was fully ambulatory. Her vital signs were normal.  Her hip was not tender.  Her past medical history was, other than bone and joint problems, a blank.  Her electrocardiogram was normal.

So, how could placing this person in a hospital bed tethered to a cardiac monitor be to her benefit?  It could not. Radiating her head would not help either.  She had an orthopedic problem which caused a vasovagal syncope.  Intense pain often causes the blood pressure to drop, cerebral perfusion transiently drops, brief syncope ensues.  My old chief of medicine used to call these “house call” or “black bag” cases, meaning all you need to sort things out is your brain, a stethoscope, a sphygmomanometer, maybe a reflex hammer and light source.

In complicating the simple we often  forget the old saw that “If something looks like a duck, walks like a duck, swims like a duck  and quacks like a duck,  it probably really is a duck.

 

The Dutch Cousin – Peter S. Kibbe, MD, FHM

Now and again I see in the press a report regarding physician-assisted suicide or legislation proposed to enable the same.  The arguments for and against stir little passion in me, but they do provoke memories.

In a North Carolina hospital where I practiced some years ago there was a native Carolinian obstetrician, experienced, bright and very grey and gangly.  He had the North Carolinian capacity to tell a good story, to “hold forth,” to capture a group of doctors in the doctors’ lounge with a story, often humorous.  I loved to listen as, draping his thin frame of close to seven feet across an arm chair, he entertained us.

One day he rambled in as some of us were drinking coffee or pecking away at the computers, threw himself into a chair, and told us about his recent phone call with a friend in Holland.

He was of Dutch extraction (although you could not tell from his drawl), spoke the language and maintained family connections in Holland.  “I just got off the phone with a friend in Holland who told me about a cousin of mine.  Told me they were going to have a wake for him this Saturday. He said he knew I probably couldn’t make it, but he just wanted me to know.  Well, I said, ‘Hell, I didn’t even know he was dead yet.’ And he told me that he isn’t dead yet, but he is going to die on Friday.”

Then he explained that his cousin had a very advanced, painful and untreatable malignancy and was taking advantage of the Dutch laws which permit patients such as his cousin to employ physician-assisted suicide.  A discussion followed regarding how practical the Dutch were, how they respected human rights and that this man was exercising a right to exit the world of pain in which he was living at a time of his choosing.  There is much to be said in respect to that argument.

I have other memories, although not many, of certain patients living in such horrible pain, untreatable pain, whose lives I might have assisted them to end without a shred of remorse.  I recall a man whom I cared for in a nursing facility who had the most painful form of dementia I have ever encountered.  He was completely unaware of his external environment, fed through a PEG tube, bed-bound and unable to speak coherently.  Worse than any of those impairments, his dementia had rendered his psychic or cerebral environment into some kind of never ending hell.  He screamed and wailed whenever awake, as though some harpy were pulling at his entrails or as though he were on some psychic rack which was tearing apart his cerebral bones and joints. I could find no source of physical pain.  I treated him with a psychiatrist and our only recourse was to keep him so sedated that he was barely ever truly awake.  When he broke through the sedation the howling would renew itself, his tormentors would return, the fires of his psychic hell would flare.

Opportunities presented themselves for him to exit the earth with some dignity—a pneumonia or some other infection, and I advised his wife that we should treat him only with whatever comfort measures he appeared to need.  She was adamant that he be kept alive and be bundled off to the hospital.  I felt that I had become a conspirator in torture and battery. I wondered if he had beaten and abused her.  Was this her vengeance?  In fact, I stopped attending to patients in nursing facilities because of this and similar cases.

Regarding physician-assisted suicide, the line is thin between the admitted and controlled fact of how the Dutch do it, and the de facto fashion in which we often employ palliative morphine to prevent discomfort in the dying patient.  We all know that when someone is dying and is uncomfortable it is often best to exit the earth in the arms of Morpheus, oblivious to suffering.  Yet are we helping the dying soul by permitting Morpheus to slide the patient off into the netherworld? At times I do not know.  It does not rise, for me, to the level of a moral argument.  It is a more viscerally or perhaps soulfully determined act.  As my father-in-law, an eminent physician would say of certain cases, “It is time to bring out the morphine.” Most of us know when that time comes.

As to whether we in the United States could enact legislation to permit physician-assisted suicide, I doubt we could do it. Some states have passed laws that permit what they call medical aid in dying, but a national consensus is probably not possible. We lack the practicality of the Dutch. We cannot do the work to save and preserve New Orleans or Houston from the storms we know will strike them, while the Dutch have been preserving their land from crippling water catastrophes for centuries.  If some part of their landscape is likely to flood, they won’t allow buildings there.  They turn those areas into a space, such as a park, which could capture flood water and still have human use when dry.  We build again and again on landscapes predictably endangered.

Could Americans fashion a way for people such as the Dutch cousin to make their exodus reasonably?  As in the way we attend to New Orleans we would probably muck it up. In the end, Americans in general would rather go to Disney Land.

Peter S. Kibbe, MD, FHM

Driving a Screw With a Hammer Peter S Kibbe, MD, FHM

August 1, 2018

I have worked for some years now with hospital administrators who use HCAHPS scores of individual hospitalist physicians as indicators of the communication performance of these individuals.  I have worked also with some who use the scores of an entire group of hospitalist physicians to judge the communication performance of the group.  Both of these approaches are flawed. 

As Leslie Flores points out in a June edition of the official blog of the Society of Hospital Medicine, “Regulators never intended HCAHPS to be used to evaluate the performance of individual doctors, nurses or other hospital staff, or to attribute scores to any physician (or physician group)….HCAHPS is not measuring you on your patient experience performance, contrary to what many of you are being told by hospital and health system leaders.” (emphasis the author’s)

The fact that these scores are not useful in evaluating individuals or groups of individuals such as hospitalists seems self-evident by the manner in which groups of doctors care for individual hospital patients.  We know that the majority of our patients come through the emergency department where they see a doctor and they might then be admitted by one of our group members, then seen by a consulting physician, then be seen and discharged by another member of our group of hospitalists.  The usual method of assigning a physician to be “responsible” for the patient’s responses to the questions on the survey regarding physician communication is to assign the responses to the discharging physician.

In a research paper on physician coaching and its effect on patient experience, Sieler, et al. point out that studies show that less than a third of hospitalized patients can correctly name their physicians.  They also point out that in one large study the discharging hospitalist physician was responsible for only about one third of the patient’s physician encounters.(1)

Some hospital administrators fashion “work arounds” in order to attempt to make the HCAHP surveys reflect individual physician communication performance.  They might insist the discharging hospitalist physician inform the patient that the survey questions regarding “the doctor” are a reflection only of the discharging doctor.  They might also adopt the position that the group of hospitalists is uniquely responsible for raising the scores of the entire hospital medical staff.  They also often publicly publish individual physician scores.  They often financially incentivize hospitalist groups according to their scores.

This is like attempting to drive a screw with a hammer. 

In a May, 2016 JAMA article, 3 CMS officials including the CMS Chief Medical Officer make it clear that HCAHPS surveys were designed to give hospital administrators an aggregate, not individual, picture of patient perceptions.  “Although designed to measure hospital-level performance, some hospitals may be disaggregating their raw HCAHPS data to compare, assess and incentivize individual physicians, nurses and other hospital staff…there are reports that some hospitals link individual physician or physician group financial incentives to performance on disaggregated HCAHPS responses.  This is contrary to the survey’s design and policy aim.  HCAHPS is not suitable for evaluating or incentivizing individuals or groups within a hospital.” (2)

An attempt to raise physician scoring, therefore, cannot be accomplished by attempting to reward or punish individuals or groups.  Improving the patient communication skills of a hospitalist group is laudable but insufficient if the same excellence in communication skills is not expected of all the facility’s physicians and staff.  If the culture of the hospital is consistent with providing a platform for physicians who perform procedures without consulting with and communicating well with attending physicians and the patient and families—working as a team to get to what is the best for the patient—hammering away at the individual scores of hospitalists will not be successful.

Changing the hospital culture of communication is often the indicated measure.  I would argue that it not only includes improving physician communication skills but demands excellent communication among clinicians.  If a consultant is relatively mute in explaining to patients, it is highly likely he or she will be the same with his or her colleagues.

  1. Physician communication coaching effects on patient experience, Adrianne Seiler, et al., PLOS One, July 5, 2017
  2. Measurement of the patient Experience

      Clarifying Facts, Myths and Approaches, Lemeneh Tefera, JAMA, May 24,   2016

The Patient is Not a Complaint — Peter S. Kibbe MD FHM

“Nothing will sustain you more potently than the power to recognize in our humdrum routine… the true poetry of life – the poetry of the commonplace, of the plain, toil-warn woman, with their joys their sorrows and their griefs.”  – Sir William Osler

At morning rounds recently I listened as a first year resident presented the case of a young woman admitted to the hospital.  As the presentation became more complicated by a curious past history I interrupted and asked, “Who is this person?”

The other residents stared in silence.

I explained that a nurse care coordinator who I had worked with would always pose a similar question when presented with a new case during rounds. If we were discussing an elderly patient who had been admitted with diverticulitis, she would ask, “Does she have anyone who loves her?”

Her question asked if we had identified anyone who helped this person through life.    The answer involved finding out about the person, asking questions or “going to where the patient lives.” So the “who” of the patient I was concerned about was a request that the resident delve into the patient’s “narrative,” her life.    Was this young woman married, did she have a partner, have kids, go to school, did she work, care for an ill parent, had she gone to college, did she like her job, hate her job?  What was her affect? What were her fears?  If the patient has obvious impairments who helps her—who loves her?

When I was in medical school a world famous rheumatologist on our faculty would comment on his patients during rounds by first describing them psychiatrically.  I can still see him at grand rounds, looming large in front of the crowd of staff and students, cigar in hand describing the personalities of the people he treated.  He did so for good reason.  He understood how their personalities and psychiatric profiles colored how they cared for their individual chronic illnesses.  Some were passive aggressive, some depressive, some outgoing.  They were people.  They were souls.

No one suffers illness that is not contextualized by who they are and where they stand in the complex social arrangements of their lives.   Recently I was rounding with residents who were getting ready to discharge a man in his middle fifties who had had some complications from gall stone pancreatitis following surgery.  This was my first encounter with him and I asked him about his life.  He had recently lost a job, was divorced with no children, shared a rental apartment with a roommate, had no car and had medical insurance through Medicaid.

As we were walking down the hall I asked the two residents I was working with what they felt about his life and they seemed bewildered.

Given what he told me, I explained that I saw this man’s life as “Precarious.” A lone, unemployed man in middle age with no assets and no social support structure always makes me worry. It should raise their eyebrows as well. They must see the whole patient. There is a lot of “precariousness” going about these days.

The social history should not be just a series of questions.  It has been boiled down to questions regarding illicit drug use, smoking and drinking alcohol. The functional pressure of the physician to get the patient processed cannot explode the art of using the history of the patient to guide the treatment and diagnostic course.  This pressure is partly due to the transformative effect of the electronic health record in which the clinician role is warped into a data entry job—one seeks out, in communicating with the patient, what one must point and click in the patient note formats.  The patient becomes a complaint, a problem list.

I would further argue that many of the work environment demands bearing down on the physician in the hospital (quality metrics, billing metrics, coding metrics, use of order sets metrics, attestations, time metrics for discharge, individualizing physician patient  satisfaction scoring, stroke alerts, sepsis alerts) may have negative quality effects on patient care, as they vampirically suck out the physicians’ time.  Every moment a physician has to spend feeding the beast with a screen is a moment of patient communication lost.  Often a piece of information from the patient or the family, if one has the time and technique to get to it, alters dramatically a course of therapy or diagnostic planning. 

Burdens that come from above and onto the shoulders of physicians and nurses arrive without much concern or investigation about whether the clerical or procedural burdens, multiplying each year, can reasonably be born.  In many instances their benefits are not very clear.

Black humor abounds regarding the situation, such as the characterization of a physician’s hospital life as a “death by a thousand clicks.”

Perhaps the time for humor is over. Perhaps it’s time for revolt. We have people to care for, souls to assist.

 

 

 

 

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Going Third World

            When I walk along your city streets and look into your eyes
            When I see that simple sadness that upon your features lies
            If my spirit starts to sink it comes as no surprise
            It’s been a long way from anywhere like heaven to your town, this town
                                                                              –   James Taylor, Anywhere Like Heaven

Some years ago I worked at a hospital in a unique small city on the inner banks of North Carolina.  With a population of only about 30,000 and at an inconvenient distance from the more swank and upscale centers of the North Carolinian economic boom regions (Raleigh, Durham, Chapel Hill, Charlotte) the city had nurtured the growth of a very respectable hospital that served the needs of a population of 100,000 people.

The quality of care was really good, I would say better for many conditions than the quality of care in Cleveland, where I work now.  Although we could not offer certain services that were cutting edge and could not pretend to be a tertiary care center, the rapidity with which patients were sorted out and cared for was remarkable.  The hospital was also free from much of the political infighting and turf wars one encounters in the Cleveland area, and that was probably a reflection of the fact that all of us who were physicians and surgeons were stuck with one another and had to find the means to cooperate to the patients’ benefit.  The chief medical officer was not so much interested in whether you as a physician brought patients to the hospital or not. He had an uncanny way of addressing problems by systematically looking at them and bringing everyone who had a part in a solution together.   Performance and patient safety were valued above market share.

That said, the surrounding rural communities, particularly at the periphery of our catchment area, were medical care deserts.  Historically this region had always been poor.  Indeed, one local historian noted that at the beginning of the European conquest of the region it had tended to attract people with little cash and coin, because they could sustain themselves from the abundant aquatic life and the fertile soil.

So physicians in the countryside were always scarce and the poverty was remarkable.  Anyone who imagines that legions of poor people subsist on welfare checks for life should disabuse themselves.  For decades supplemental cash support for the impoverished has basically not existed and North Carolina appears to have taken a certain pride in how little it supports a public health infrastructure and how little it supports public education.  Obtaining medical insurance via Medicaid is very restricted and the North Carolina politicians have proudly refused to expand Medicaid coverage in spite of the fact that the Federal government would foot the bill for almost all of an expansion.  My sense of the general situation of the wealthy and poor in that region was that the very poor worked very hard just to be poor.

I experienced an evening of clarity regarding this when a friend of mine, a nurse in retirement, invited me to become the supervising physician of a free clinic run once a week in the county public health offices of a small community near the coast of the inner banks.  She had recently agreed to become the clinic director.  While I had to tell her I most likely would decline due to time constraints I did agree to drive down to see what one of their evening clinics were about.

It was in a community with a main street, down at its heels, a courthouse, some gas stations, some fast food outlets and empty buildings.  Like much of the housing in those environs, the trailer home is ubiquitous.  The landscape is flat and agricultural and from the road out of town the vista affords views of an occasional well-kept vegetable garden and seasonal roadside stand contrasting with collapsing old farmhouses beside questionably habitable trailers.

I arrived at a tiny set of offices jammed with people who were standing, packed in corridors, waiting rooms or smoking in the darkness of the parking lot, waiting for encounters with physicians who were all retired, one a robust man of 80 years.  I was much amazed at the sheer number of patients. Then they waited at the make-shift pharmacy run by a retired couple who were pharmacists and who had, as if by magic, stocked the room from floor to ceiling with common medications they had obtained through various connections with industry.  All medications were dispensed free of charge. The clinic had an agreement with the hospital where I worked in which lab tests and simple x-rays could be obtained via the hospital free of charge.

The people were pleasant and polite and racially mixed.  Their facial expressions were varied, but fatigue and sadness seemed predominant.  They were poorly clothed and their vehicles in the parking lot, essential property in a region with no public transit, had seen much better days. These were of the expanding class of American working poor.  Most of the patients were middle aged, most were there to control their diabetes, hypertension, asthma and heart failure.  The clinic was held at night because these were working people with no medical insurance to cover what they could not possibly pay for, and jobs which, I suspect, would not allow them a few hours off to see a doctor. Do not mention the health of their mouths or their eyes. Like many Americans these are people who almost never have dental disease treated.  For most of the patients whose oral cavities I examined it appeared that they lived most of their lives with a mouth of deteriorating, infected dentition.  Their plans for dental care were to wait for the day when they had the money for full extraction and the creation of dentures at one of the well-advertised denture clinics one spots on the highways.

I left that evening with both an admiration of what the community was trying to accomplish and a deep sense of dread, a sinking spirit, a sort of foreboding.  Before me there was fact, revelation that American civilization is fading, its multitudes of poor slipping into the status of the poor of what we used to call the Third World.  Like some community of the Third World, desperately this little community was trying to claw its way, in terms of basic medical attention, into the twentieth century, in the early years of the twenty first.

Civilization depends upon taxation.  In western culture this has been understood since the ancient Greek philosophers pondered questions regarding politics and citizenship.  From taxation flow the funds through which good governance provides for what our constitution names as a bedrock responsibility of the government it establishes—the general welfare of the people.  We have now arrived at a place where a tiny few enjoy unimaginable wealth and see their taxes dramatically diminishing.  For them the economic question might be where to buy their next extra luxury house.  For a growing multitude the economic question is more like where they might find the heaven of any decent dwelling, more like where they might find their next bag of groceries or when they might find the money to have all their teeth extracted.

 

She That Shall Live This Day, and See Old Age…

In Shakespeare’s Henry the Fifth King Henry rouses and encourages his troops to do battle with the French at Agincourt.  In the famous “band of brothers” speech he assures his men that “he who sheds his blood with me today shall be my brother.”   He also assures them that posterity will not forget what they do that day, a day in the Christian calendar known as St. Crispian’s Day:

This day is called the feast of Crispian.
He that outlives this day, and comes safe home,
Will rouse him at the name of Crispian.
He that shall live this day, and see old age,
Will yearly on the vigil feast his neighbors
And say “Tomorrow is St. Crispian.”
Then he will strip his sleeve and show his scars,
And say, “These wounds I had on Crispian’s Day.

I was reminded of this scene when I recently cared for a very elderly lady referred to the hospital by a hospice facility.  The hospice physician thought she was having problems that he could not control for her comfort and wanted us to do some hospital diagnostics to help clarify her condition.  He had no access to her past records because she had always been cared for via the Veterans Administration system.

She was the oldest female veteran of the second world war I have ever met, a 96 year old who, although her mind was not clear,  assured me the moment I met her that, “The War Department will take care of me.”  Since the U.S. Department of Defense has not been called the War Department since before I was born, her use of the term intrigued me and I asked her in which service she had served.  She told me that she served in the United States Army.  When I asked her where, she said “Tunis.”  She also said that she had served with bomb reconnaissance.  Her mind wandered and she began to tell me about a dog who was named Yorky Doodle Dandy and how the dog had done some things that were unintelligible to me, including being taken to Hollywood, and her mind drifted off.  I did not press her. (I do not expect to be alive at her age, let alone to be able to communicate coherently.)

I remember that when I was a boy my father told me about bombing the harbor at Tunis from his U.S. Army Air Corps base in Algeria.  It was held by the Germans, who were of course forced to surrender.  So I went to the Wiki and discovered that, indeed, shortly after the city of Tunis was in the hands of the Allies a large bomb reconnaissance group was sent to the city from Britain.  These people were women and men who for whatever reason—be they artists or archaeologists—were very good at looking at photographs of enemy territory taken from airplanes at high altitude and figuring out what the tiny images represented.  Since after the Germans left North Africa the Allies would begin to invade Italy, which involved a great amount of bombing, the reconnaissance work in Tunis went on for over a year.

And what of the dog?  It turns out that a Yorkshire terrier was acquired by a photo reconnaissance soldier in the Pacific theater and became famous for the tasks he could perform, sometimes under enemy fire,  to assist the soldiers.  That soldier, named Wynne, was from Cleveland and he named the dog “Smokey.”  He was also known as Yorky Doodle.  “Smokey” was allegedly a reference to the  then very much polluted skies of Cleveland. Wynne brought the dog back to Cleveland and wrote a popular book about the creature.  The dog was so famous that there is a memorial to it at the Cleveland Metroparks in Lakewood.

If you listen to the elderly patients, even through their dementia, at times they will connect you to a past that is still vivid in their memories, memories accurate in spite of loss of cognitive ability and the passage of three quarters of a century. These will often relate to the most vivid, perhaps horrid, perhaps exciting times of their youth.  They engender in me at times a respect—for bravery or diligence or the simple will to survive and be able to testify.  I have heard the stories of old African Americans who lived through the Jim Crow south, of soldiers who as mere boys stumbled on a German concentration camp and weep at what they saw, of steel workers who endured the strikes of the depression era and emerged bloodied but victorious.

This patient was soon discharged and I was left to wonder if she had gone from Tunis to the Pacific theater, if she had worked with the owner of Smokey.  What had she been trying to say?  Certainly the important roles that women played in the war have gone relatively untold compared to those of the men and I wish that I had been able to expand her story.

Certainly, and virtually on her deathbed, she was stripping her sleeve and showing her scars. Her military days must have been fraught with the dangers of war zones but also the excitement and wonder of a military and international experience.  She engaged in world travel in an era when that was virtually impossible for most Americans and included the exhilaration of transAtlantic crossings and air travel that probably in her most fantastic dreams she would not have contemplated as a girl before the war.

She had lived the day and seen old age.  Women from “The Great Generation” are dying off.  Few remain to tell us as living historians of their own St. Crispian’s Day.

 

The Eyes Have It – Peter S. Kibbe, MD, FHM

When I shadow other physicians on their rounds I am sometimes struck by the variability of the social skills the physicians demonstrate.  The most skilled have a manner of speaking, a tone of voice, a rhetorical capacity and body language as well as facial expression—a demeanor, perhaps— that ingratiates the patient.  These skills invite the confidence of the patient and give the patient permission to reveal, often rapidly, the intimate details of their lives.  At times I wonder when I watch these excellent communicators work if what I am really observing is an actor or a con artist at work.  I have seen this  in all walks of life that require intense communication and relational skills. I am wondering if these skills can be learned or if they are attributable to some genetic sequence, already or soon to be discovered?  This leads me to recall the skills of my eldest daughter, Rachel.

When she was very young, around seven or eight years old, my wife and I noticed something a bit startling.  If we went out for an evening and hired a baby sitter, the following day she would be able to tell us in great detail all about who the baby sitter was.  The babysitters, almost exclusively teen age girls, would put her siblings, toddlers at the time, to bed early, then sit up for some hours with Rachel.  The curious thing that we noticed was that my daughter, even if she had never met the baby sitter before, appeared in an evening to come to know her well and could tell us about intimate details related to her life—school events, relationships with boyfriends, problems with her parents, her aspirations and fears.

This became something of a joke between my wife and me.  We knew that whenever we hired a babysitter for the evening the following day we would learn far more about her than we cared to hear.  Yet, looking backwards, this wisp of a daughter had been prematurely verbal, very garrulous and socially engaging. I do not think she learned these skills; her capacity to be disarming and charming, able to make a teenager feel that they were old friends and to quickly form a sort of intimacy and mutual confidence. It turns out that her talents probably were in her ability to read a stranger’s face.

I am reminded of the work of Oliver Sacks, a neurologist and writer who sadly died a couple of years ago, a physician who was fascinated by the brain but also by people.  He left us with volumes of insightful writing about neurological syndromes and the people who suffered from and dealt with them. One group of people he wrote about and videoed had Williams syndrome.

People with Williams syndrome have a rare genetic disorder that expresses itself with a mixture of physical tendencies, facial features, neurological defects and superior skills.  They tend to have elfin eyes and rounded noses.  They have a higher incidence of certain cardiac anomalies.  They are virtually anumeric, unable to sort numbers at all and they cannot comprehend simple spatial relationships.  If you draw a simple cross and ask them to reproduce it on paper they might draw an L-shaped figure and be perfectly convinced that they have succeeded.  Yet they are musically very adept, verbally highly skilled and socially they can make strangers think after a few minutes of conversation that they have been BFF’s.  In a typical video, Sacks walks hand in hand with a girl who has the syndrome, about ten years of age, into a sandwich shop she had never visited and within minutes the girl is sitting on the counter making friends with the waitresses and cooks, almost working the crowd as if she were the favorite neighborhood child come home from a long period of absence.

In my admittedly brief research on these Williams syndrome people I have discovered that they make eye contact with other persons much more intensely than the average.  Anecdotally I have almost always associated that behavior with the best physician communicators.  Looking someone in the eye implies the observer is reading the face of that person, and that is a quality or a capacity, an intelligence that can be measured and which some researchers link to social intelligence.  It appears to be inherited; identical twins share that capacity or lack of it more than non-identical twins, as do persons with Williams syndrome.

The question that arises for anyone who tries to teach communication skills is whether the ability of reading a human face for emotional content can be taught.  In other words, can the skill of one physician in reading anger or anxiety in a relatively subtle facial expression be taught to another whose visual cortex is relatively “blind” to facial expression?

It turns out the answer is affirmative and there is a huge area of scholarship surrounding this.  Darwin asserted about a century and a half ago that human facial expressions are universal and cross all cultures.  This has been widely accepted, and researchers have also  divided facial expressions into two groups, those that are maintained for a few seconds and those that are formed for as little as one thirtieth of a second.  These latter “microexpressions” appear to represent emotions that are difficult to suppress. Logic would suggest then that creating a favorable rapport with a patient would entail, in part, a keen eye for what are almost, perhaps, subconscious facial expressions and then molding communications to correspond to and deal with those emotions. That skill just might trump all others.

So should medical schools be employing psychologists who specialize in evaluating and teaching people to read emotions in facial expressions?  Should they be screening us in our competencies?

 

Hospital Intolerance – Peter S. Kibbe, MD, FHM

Recently I was called by an emergency department physician regarding a patient of about ninety years who presented with shortness of breath.  His shortness of breath improved with inhaled bronchodilators but he then developed atrial flutter and due to changes in his ST segments a “code STEMI” was called.  There was a slight elevation of his troponin and the cardiologist arrived.  He wisely demurred, opining that this was not a STEMI but demand ischemia.  His ventricular rate slowed with no particular intervention to about one hundred.  A faint, ground glass pneumonia was apparent in the left upper lobe on x-ray.  He “required” admission for treatment.

He arrived at his room with his wife and son and I arrived shortly thereafter, to find a man who was afebrile, did not appear ill, was mildly cachectic but smiled and made the occasional witty remark.  He was not able to answer questions and deferred to his wife.  He had been short of breath for a day or two, had no serious history of chronic lung or heart disease but was suffering from advanced dementia which included a failure to recognize his wife of over fifty years as his wife and a hallucinatory component in which he asserted that there was another woman in the house. Several months previous to this he had been in the hospital with pneumonia.  She said that she and her son were “trying to care for him at home” but that it was difficult because he wandered and could not sit still and his gait was shaky—they were concerned about falls.

I examined him, reviewed his laboratory data which was benign, looked at his chest x-ray and began to explain what would be done for his conditions when I sensed that something was not right.  His wife was in tears and his son stoically silent with a somewhat pained expression on his face. So I asked, “Tell me what you think of him being in the hospital.  How does he do when he is in the hospital?”

Ask and ye shall receive. His wife told me that the last time he was in the hospital for pneumonia he suffered severely from agitation and required restraints, sedation and the nocturnal presence of family.  The severity of his dementia advanced rapidly and, following discharge, he could no longer recognize her as his wife.  He had been discharged to a nursing facility where the delirium/agitation persisted and she gave me to believe that the experience of hospitalization had caused a rapid deterioration of his primary problem, dementia.

So we broadened the discussion to the family’s goals of care and expectations of medical interventions.  It became apparent that she and her son understood that in caring for him they were in an end game; they wanted to keep him out of the hospital due to its previous negative consequences.  This led to a discussion of palliative care and limiting medical interventions to those measures that preserved his sense of well-being, his comfort and his dignity.  They were in agreement and were happy to discuss what hospice services might offer them.  The hospice nurse arrived shortly thereafter.  I discharged him on an oral antibiotic for what was probably a viral pneumonia.

This is a cautionary tale, in a sense, in that it illustrates how we have evolved a medical practice that processes patients not as individual humans but as potential diagnoses, with our protocols, alerts, codes and order sets.  We do this outside the boundaries of our patients’ larger realities—their frailties, their capacity to consent, their ability to tolerate or comprehend interventions.  We are judged by our algorithmic capacity rather than our capacity to sort out a diagnosis, propose therapeutics and query our patients and families regarding their own capacities to fulfill what is directed by the algorithm.

This man was hospital intolerant and in the end stages of dementia.   How might this 90 year old man  benefit from a real “code STEMI” intervention with catheterizations, stents and subsequent delirium?  We might preserve a myocardium, for good “door to cath lab” time metrics, but offer no benefit to the patient at all.  We must listen.   We must ask.

In Dubious Battle – by Peter S. Kibbe MD FHM

To look upon medicine with a literary eye is something of a burden.  If you have studied poetry, fiction and drama, no matter how much you have forgotten, you find yourself on the wards at times with literary phrases popping into your head that you cannot erase or make silent.  Regarding sitting with a dying patient, “They also serve who only stand and wait,” from a poem by John Milton pops into mind.  Recently, after a grueling day of caring for patients who almost to a person had fatal pathology, the phrase “in dubious battle” came to mind, and the often oxymoronic culture of “health” care as it “brands” itself in America vexed me.

In Dubious Battle is a novel by John Steinbeck.  Steinbeck purloined the title from a phrase in Paradise Lost, the epic poem regarding the biblical fall of man by John Milton.

Paradise Lost is considered by many scholars to be the great epic poem of the modern English Language.  The character of Satan plays a major role, of course, he being the character who will trick Adam and Eve into being ejected from the Garden.  “In dubious battle” is a phrase used by Satan to describe the conflict that he and his band of fallen angels have lost in their conflict with God “in dubious battle on the plains of heaven.”  The mythology is that Satan and co-conspirators in heaven, hating God and detesting his omnipotence, organize an armed uprising, lose and are thrown out of heaven by God.

In the poem, Milton employs oxymorons, a linkage of two ideas or words that are self-contradictory, such as “brilliant darkness.”  The use of the adjective “dubious” by Satan is a nod to the oxymoron, because the entire notion of winning a fight with God is oxymoronic—you cannot win a fight against an omnipotent opponent.

Who cannot, having walked the wards for decades, find the notion, implicit in what we do, of “curing” certain patients, or “rehabilitating” certain patients, as oxymoronic compared to the actual data we must point and click and type into the electronic medical records to describe our patients’ conditions.

We cannot promise health to those whose journey has already taken them beyond its prospect. The obesity epidemic seems to be swelling like a wave, crashing upon those of us who work in the medical field.  The changes of American culture, which I will call pathogenic, have brought us an opioid epidemic and an epidemic of obesity and they are causing our life expectancy to fall. They  germinated during the youth of the baby boomers, coming to full fruition through their lifetimes.  Now these massively obese souls have stumbled into the ranks of the aged and their multiple pathologies and physical impairments tethered to the expected impairments of aging itself kindle storms of acute disease.

I start a morning staring at the chart of a woman with a body mass index of 51. She presents with not one, but several potentially fatal events: her arm is infected; she has acute influenza and an acute exacerbation of her COPD with marked hypoxia.  The patient’s age is seventy-something.  She has had coronary stenting, lived for years with the metabolic syndrome of diabetes, hypertension and hyperlipidemia; she has had breast cancer bilaterally with infectious complications due to lymphedema, cellulitis and secondary bone infection of the spine, requiring months of intravenous antibiotics.  She has suffered from diastolic heart failure and atrial fibrillation as well as chronic obstructive pulmonary disease; and she has chronic kidney disease.

This poor person is in dubious battle.  We know she cannot win and we know that probably many medical adventures await her—those coronary arteries will get gummed up, the kidneys will fail completely and she will need dialysis. Chart review shows that she has been in and out of the hospital frequently over the past couple of years and the gravity of her morbidities appears on an upward curve.

Her aggressive consultants, her family informs me, are contemplating a biopsy of her vertebrae to make sure her bone infection is “under control.” I am fearful that procedure will not go well.

We are not caring for her health but attempting to react therapeutically to her multiple predictable disease states and the pathologies that are not random but rather the complications of a physiological illness for which we have little to offer.  Severe obesity, mixed with aging, is a poisonous cocktail.

I have argued that one of our cardinal failures as physicians is to not honestly give a prognosis. There is a delicate dance in communicating with patients who have multiple smoldering and flaring morbidities and who have a very high likelihood of suffering severe complications and organ failures.  On the one hand, it is not fair for us to maintain a pretense that patients such as the one whose clinical picture I sketched are going to be “cured.”  On the other is the fact that professionally she deserves our empathy and in our communications, verbal and non-verbal, we must attempt to be of benefit. This is, of course, our duty to all patients but we must not forget it in our care of the severely obese or the addicted.

Taking a history from this patient was laborious and somewhat emotional.  She was assisted by her daughter (whose level of involvement in her mother’s medical picture was revealed when she showed me her mother’s X-ray images on her cell phone.)  I find it helpful, when trying to establish a relationship with a patient such as this one, to listen carefully to the story of her medical adventures and then acknowledge that she has had some really difficult encounters with disease over the past several years.  “It sounds as though you have had a really tough time over the past years with these medical problems.”  And then, of course, you have to listen to the response, which might give you a handle on what the patient and family have in terms of expectations.  One can further connect by inviting the patient/family to explain the situation in the context of exactly how she and the family are coping with it—how and where she lives, who helps her, her functional abilities and disabilities.  Being open to this information allows you to “go where the patient lives.”  Doing so makes further conversations (about CPR or other intensive measures if they need be discussed) more contextualized within a relationship you have established.

In explaining what the medical care will be for this person’s acute problems a physician does not need to offer a general prognosis for anything but the acute problems.  Should the medical situation deteriorate, giving as accurate a prognosis as possible may become necessary.  In order to make that easier, establishing a relationship is a crucial step in patient communication.

Listen. Acknowledge.  Listen more. Empathize. If we cast a cold eye on the numbers and ages of people with obesity in America, it is certain that our dubious battle has not yet reached its crescendo.

 

 

By 2020 it is estimated that 75% of Americans will be overweight or obese. 

To read more, see OECD(Organisation for Economic Co-Operation and Development) update from 2017: https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf 

 

 

Mismanagement by Metrics – Peter S. Kibbe, MD FHM

Some years ago when I practiced in a rural hospital I was asked to admit a man who had sustained fractures to both knees.  I balked because I knew that the only orthopedic surgeon at the hospital was out of town and the man needed surgery on both knees. Aside from the fractures, he had no medical issues preventing surgery.  Conventional medical wisdom teaches that the faster this sort of injury is fixed, the better the outcome for the patient.  The hospital administrators pressured me to keep the patient “for a few days” until the orthopedic surgeon returned.  Their incentive was clear.  They wanted to capture the operative/financial billing.  My incentive was to get the patient the care he required.  Discussions that ensued between the administrators and me were not pretty.

At times financial and outcomes metrics push in an opposite directions.

I recently came across an interesting article of investigative journalism by Pulitzer Prize writer David Phillips in the New York Times. Phillips describes the complaints of physicians at a small VA hospital in rural Roseburg Oregon. They claim that the hospital administrators frequently denied care to patients who were very ill, sending them home or off to other facilities, in order to make their overall medical care outcomes look better.  If the patients were not admitted, they were off the radar in terms of data analysis.  Any negative outcome of their illness would occur at home or at another hospital.

He describes a set of ‘metrics’ used throughout the VA system to grade hospitals and their associated clinics.  Patients who are very sick and die lower the grade as well as anyone requiring admission for congestive heart failure (the diagnosis implies poor system outpatient management).  Also bringing down the score are patients readmitted within thirty days, hospital acquired infections and so forth.  Phillips reports that there are about one hundred of these metrics that are used to grade facilities.

Curiously, Phillips finds, since the metrics grading system was implemented across the VA system, many facilities have improved their scores.  He interviews doctors who claim this has happened not because of improved medical care but due to the fact that administrators game the numbers by avoiding the treatment of patients who might have poor outcomes.  About half of the beds at the Roseburg VA, he reports, remain empty.

The community of Roseburg is rural and poor.  The unemployment rate is high.  The Roseburg VA Health System, he states, is understaffed and he reports that many of their primary care physician positions are empty, making ongoing care of patients in the system problematic.  The hospital itself has no intensive care unit.  But Phillips interviewed emergency and hospital physicians there who claim they are forced by administrators to turn patients away who could be cared for there in order to play the metrics game. They claim that the administrators want to keep patients with poor prognoses “off the books.” He describes a cachectic veteran in his eighties who presented with dehydration, falls and fractured ribs whom the doctors wanted to admit.  The administrators refused and sent him home.

Given the fact that the community is rural and poor one would expect the disease burden of the veteran population in Roseburg to be high.  So, given the poor staffing, the population, the location, and the demographics, why would distant administrators impose what sound like unattainable metrics on a group of health care workers struggling to provide veterans with care?

And, if you were the local administrator and the administrators above you would reward you if your scores improved and punish you if they did not, would you not manipulate everything you could to make your performance look better? Phillips reveals that administrator’s bonuses go upward with better scores.

This issue of avoidance of ill persons by medical professionals is not at all new.

The problem with evaluations at play in systems such as this is the failure of leadership (administrators) to embrace the reality of the workplace.  From what Phillips reports, Roseburg’s VA facility’s principal and overarching problem is lack of staffing. Until administrators attend to that it is hard to imagine the value of imposing grading systems on teams of workers which are skeletal.

It would appear that the grading system under which it struggles represents an administrative failure.  Expecting excellent medical outcomes in attempting to appropriately treat aging, rural veterans with multiple morbidities is a fool’s errand which fails the patients.  The doctors think it is actually diminishing the quality of their care by administrators who do not want physicians  to care for them in the hospital at all. The doctors he interviewed seemed to be saying, “Let us do our jobs and do what we can for these fragile and sick people without sending them many miles away from their families.  Some of them might die because some of them have fatal illnesses, but metrics should not be part of the decision to care for them here or transfer them out.”

In my experience I have found that physicians generally, in keeping a patient at their facility or seeking a transfer to a higher level of care, do so with the best interest of the patient in mind. The questions involved include whether the patient would benefit from care not available at his/her present facility, and whether the patient wishes to experience that higher level of care.  Hospital administrators can push and pull that decision in both directions depending upon their incentives.  I would argue that the decision should be medical.

Administrators, in most of these decisions, lack the license, the agency and the ultimate responsibility for these decisions.

We Are Not… -Peter S Kibbe, MD FHM

One often hears or participates in a political discussion about a problem we suffer in the United States which appears to have been improved or solved in another nation.  One side proposes that we adopt what country X has done to solve our problem.  The other side often counters with what is really not an argument but a non sequitur stating, “We are not country X.”  While true that we are not country X, the fact that we are not is an invalid argument within debate.  Embodied in that statement however, is the notion that:  a) we are unique and special, b) we are incapable or politically incompetent to confront the issue, or c) the problem is highly damaging to most of us but is producing great sums of money for a few individuals, and well… “We are not country X.”

I point this out as preface to a discussion of the success of the relatively poor country of Portugal in addressing its opiate abuse epidemic.  Their results in dealing with their own epidemic of opiate-related deaths has been only superficially exposed and virtually ignored by our corporate media. Yet from Portugal’s example we might learn striking and relatively simple lessons to put a halt to our opiate-related epidemic of death, and curb the associated medical pathology and social pathology.

During the 1990’s Portugal saw a rapid increase of opiate addiction and opiate-related deaths, mostly from intravenous heroin use, along with a striking increase in HIV and hepatitis transmission related to the same.  Their death rate climbed to twice the rate for European countries in general.  I have read estimates that one percent of their population suffered from addiction, perhaps more. From accounts, their problems with opiate addiction were almost a prelude or foreshadowing of what we are experiencing today in the United States.

In 2001 Portugal responded to their epidemic by decriminalizing the possession of relatively small amounts of illegal drugs. It has been reported that they consider possession of approximately ten days’ worth of drugs for a person to be a non-criminal offense, but they did not legalize the possession.  Possession of the small amounts of certain drugs remained an administrative offense and manufacturing or selling illegal drugs and trafficking remained criminal offenses.

The majority of addicts were thus removed from the criminal system of courts and prison sentences and therefore the society at large was spared these costs.  Persons found to have small amounts of illegal drugs were referred to administrative committees for evaluation.  These committees consisted of a representative of social services, a person from the legal system and a physician.  The committee retained punitive measures it could bring to bear against these persons, but these did not include prison sentences.  The committee is tasked with assessing the person and suggesting a treatment modality.  If the person does not comply, he/she could suffer various penalties such as forfeiture of licenses related to work.

At the same time Portugal established a free system of treatment centers, some public and some private, that promoted harm reduction, some social services and conversion to medical replacement therapy. They included inpatient services but the bulk of their treatment facilities were for outpatients.

Their success in reducing drug-related death rates over a few years was stunning.  Portugal joined the three lowest death rate countries in Europe.  Rates of HIV and hepatitis transmission also declined dramatically.  The rates of opiate and other drug addictions do not appear to have changed, but this part of the epidemiology is difficult to assess due to the fact that their policy changes made it much easier to count the number of addicts out there once many of them were offered free treatment.

I am not able to comment on the financial costs of this change of policy in Portugal.  There was a savings, no doubt, from not having to support the cost of the courts and incarceration which we continue to sustain in this country.  There was a cost to establish medical facilities for treatment.  Were we to emulate Portugal I suspect we might actually see a net savings, given that within our prison-industrial complex we are currently spending tens of thousands of dollars a year to incarcerate addicts. It would be difficult to quantify the dollars saved by decreasing the social costs of our addiction epidemic—the costs of social services for the foster care of children with addicted parents, the medical costs of the complications of intravenous drug abuse, the EMS costs of dealing with overdoses and so forth.  Political push-back would, no doubt, be strong from the for-profit prison corporations in the United States and assuredly from other entities that directly or indirectly profit from the status quo.

What the Portuguese did was to take the problem out of the system of criminal justice and to treat it as a medical and social problem. There are many reports of entities such as local criminal courts attempting basically the same thing in the United States but clearly we need to change on a national level. For years now our “war on drugs” has failed and criminalization of addiction has failed.  Both have cost us phenomenal amounts in terms of social disruption and pathology, to say nothing of the fortunes sunk in failing policies and policing.  The profits related to these policies have gone to pharmaceutical giants, the private prison-industrial corporations and to cartels of traffickers in illegal substances.

 

Portugal, a much less wealthy nation than our own, has created solutions which we, with much more in the way of fortune and resources, should emulate.  The morgues here are bulging.  Death rates continue to rise.  “We are not Portugal” is an insufficient statement regarding our inertial present posture.

 

 

 

 

Clarity & Craftsmanship – Peter S Kibbe, MD FHM

As Director of Patient Experience in our group of physicians, my job is to promote better patient communication. However, it increasingly appears to me that physician to physician communication is generally deteriorating and in need of remediation as well. Perhaps as my years advance I am forgetting that poor communication has always existed. Please help me out: are a lot of medical people speaking gibberish today, or is it just my imagination? As a group of hospitalists, we care for patients in the hospital. We admit patients into hospital beds principally after they have been evaluated and treated in the emergency department of our hospitals, but we also receive them from other emergency medical facilities, clinics and doctors’ offices.

Historically when these transfers occur it is convention that the referring physician verbally “presents” the patient case to the accepting physician. This allows the accepting physician to establish the seriousness of the illness, to be sure that the hospital where we practice has the capacity to care for the patient’s illness and to establish what kind of medical floor the patient will re-quire(intensive care, regular medical floor, monitored bed) and so forth.

And, time out of mind, this presentation of the case by the referring physician has been an important expression of the craftsmanship of the referring doctor. What he or she says proves that she knows why the patient has been brought to a doctor, who the patient is in terms of age, chronic and past medical problems, what the patient exhibits on physician examination, and what, if any, laboratory studies and imaging studies show. This usually includes a description of what treatment has been rendered.

Just last week I received a call from a physician at a clinical location outside the hospital, to accept a transfer to our hospital of a man this physician was evaluating. The physician was clearly a native English speaker but after several minutes of listening to him I had no notion of who the patient was or why he was being transferred to me. I knew I was in trouble when the referring physician began with an introduction, “Well, I have a guy here who, I don’t know, had a fever and, well, maybe there is a pneumonia….his white count is 24 thousand…He played eighteen rounds of golf yesterday and then felt bad…”

This frustrating, unorganized “hand-off” conversation degenerated into a sort of game of twenty questions. I had to ask the patient’s age, race, current medical problems and whether he was diabetic (the physician did not know). The physician gave me the laboratory and imaging data before telling me about the findings on physical examination. There was talk of fever and a pos-sible pneumonia. I concluded by simply accepting the patient after determining he could go to a regular medical floor.

When I went to see him and asked him what was troubling him his wife told me he had a recurrent soft tissue infection in his leg. He was a morbidly obese, insulin resistant diabetic with hypertension and obstructive sleep apnea and a body mass index of forty five. He was hospitalized two years ago for cellulitis of the right leg. And, indeed, he had a swollen and erythematous right leg.

This sort of communication failure seems to be happening to me more frequently. The following day I was called to accept a patient from an emergency facility because she used heroin and needed to have an observation admission to rule out bacterial endocarditis. Not only did she have no complaints to suggest bacterial infection, she had never used intravenous heroin. She had a long history of ingesting heroin via the nasal route, but never had used a vein. I could imagine sinusitis secondary to heroin inhalation, but endocarditis?

These frustrating hand-off encounters suggest that the basics of practice are being ignored. The basics, of course, include the step by step process of evaluating a patient—the reckoning of who the patient is, what chronic and past medical conditions exist, what the complaints are, what the physical findings are, then what the laboratory findings tell.

This process is then articulated by verbal presentation of the patient to another physician. That presentation is effective only if the information within it is accurate and also has coherence. So the first patient I mentioned above can be medically described well in a couple of sentences: “This is a 68 year old, very morbidly obese, white, male, hypertensive diabetic with a complaint of malaise and fever.” When one hears that last sentence one has an immediate picture of the “who” of the patient, at least in the medical sense.

I would also urge colleagues to consider including in that first sentence any information that medically defines the patient. If a patient suffers from a severe cardiomyopathy, or is being treated for a malignancy, or has a major ongoing series of morbidities, those should appear in the opening first or second sentence. “This is an 85 year old with advanced dementia, DNRCCA status and an ejection fraction of 25 percent who was brought to the hospital due to fever from the nursing facility where she is a resident.” I find that more typically when an ED clinician calls regarding that same person, I am told about an 85 year old patient with fever and a urinary tract infection and a high white blood count. Verbally expressing the “who” of the patient is critical to better communication. It is essential to treating people rather than processing patients.

The issue of the heroin addict implies poor patient communication but also implies that she was evaluated without the craftsmanship demanded by competent practice. If you are practicing in an emergency facility, particularly one in a state and nation known for its huge epidemic of deaths from opiate abuse, you have to be able to have a competent conversation with people who use opiates. That includes finding out their method of ingestion—prescriptions, intravenous ingestion or nasal ingestion; one of the oldest methods of ingestion is to smoke it. You need to know how often they need to take it to avoid withdrawal. Then you can employ “harm reduction” strategies which include questions about needle exchanges, Narcan availability, instruction about the safest ways to injectand also question the patient about previous rehab attempts, street Fentanyl issues and ask for a social service consult regarding treatment venues for the patient. (see SHM’s website:
http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/Radeo/radeo_home.aspx  

This particular patient who regularly used opiates was fully employed, demonstrated insight into her addiction, recognized that at this point she was  using heroin pretty much to avoid withdrawal symptoms and had been thinking of finding some treatment options to “get clean.” She “used” several times a day. Since she had spent about twelve hours within the other hospital and our own it was pretty clear that she was dosing herself while in the hospital and she had no withdrawal symptoms.

As I listened to her describe the symptoms that had brought her to an emergency department in the first place(which were fairly trivial) and heard what she had to say about her life it struck me that subconsciously she was most likely looking for some help with the primary problem of her life, opiate dependence. Sadly our society has this problem in spades and our medical /social system seems flummoxed about what to do with it. We are unable to employ models successfully employed in other countries, but that is the subject of another of my screeds and tirades. In any event, her “who” was much more in need of some counseling and support than blood cultures and antibiotics.