The Fallacy Of Big Medicine

If you listen to the pundits, the future of medicine is big: big medicine, big data.  And indeed the healthcare policy of our nation is couched in the promise of what is to come.  Many dictates of the accountable care act focus on the ability to aggregate and consume a variety of inputs. ICD-10, EMRs, and meaningful use all tie nicely into a beautiful computational orgy. 

Big data, however, has it drawbacks.  One wonders if in usual fashion, politicians and pundits will do more harm then good.

Correlation and Causation

There is a hierarchy in medical data.  Every clinician knows that prospective, randomized, double blind studies are the gold standard.  The reason why, is that lesser models (retrospective and case study), often are only able to show correlation.  Time and time again, we find that clinical decisions based on correlation are faulty.  High homocysteine levels are associated with coronary artery disease but bringing them down with folic acid can be harmful.  Poor dental health may be related to cardiac disease, but good hygiene has little effect on the risk of heart attack.  In a world where the LDL and HDL hypotheses are quickly being disproven, one loses a taste for relying on such logic.

Yet, big data is clearly a correlational model.  One can only compare it to the weakest forms of evidence (case control, open label).  There is no ability to use it in a prospective randomized manner.

Poor studies lead to poor medicine. 

Period.

Garbage In, Garbage Out

I am not a big fan of meta-analysis.  The reason why, is often the bias of the investigator clouds the results.  If you want certain answers, you ask certain questions.  Inclusion criteria can be tricky and bend to the will of those crunching the numbers. 

Big data suffers from the same fundamental issues.  Who knows the political pressures that will be placed on scientists.  If you don't get the answer you want, maybe you have to ask the question differently, query the database more delicately. 

Anyone can produce results, but will they be meaningful.

Faulty Inputs

For years scientists have relied on death certificates to understand causes of death in America.  But as almost any signer of such documents knows, they are often completed in a hurried, haphazard way.  As a physician, I have no reason to care if the cause of death is correct.  Often, in fact, I don't even know the answer.  It's just another paper to fill out: cardiovascular collapse (whatever that means).  A grand majority of times when I review these documents as a medical expert, the cause of death on the certificate is inaccurate. 

Big data relies heavily on ICD-9 and CPT codes.  Providers often manipulate these codes, however, for a variety of reasons.  Want the venous doppler to be covered, say the patient has a DVT (of course you don't know yet because you haven't done the test).  Want the blood tests to be paid for by insurance, say the patient has fatigue.  The EMR doesn't have a code the suitably fits the situation, just use another, who cares if it's not accurate?

Most of the time these data inputs have no real meaning to the clinician and thus only receive a passing thought.  They are another hurdle to providing care, they are to be dispensed with as quickly as possible.

Keeping Our Eye On The Ball

The great task of big data is falling squarely on the shoulders of overburdened clinicians.

ICD-10, CPT, EMR, Meaningful Use, PQRI

Inputting all this data takes huge amounts of time, time that is being taken away from patient care.   Years of practice and training has formed clinicians who strive towards perfection.  These distractions destroy our attempts at mastery.

No one would think of asking the conductor of a symphony to also collect tickets at the front door in the middle of a performance. 

What is gained in knowledge with big data, is lost many times over in faulty, distracted, and poor face to face care.

In Conclusion

We are left with one basic question.

Do we want big medicine, or good medicine?

I'm not sure we can have both.

Do Not Pass Go

I'll give you three nights in the hospital for a a hundred days in skilled nursing. 

How bout a lung mass and a go directly to hospice minus room and board?

Oh... your stay was deemed an observation, do not pass go, do not collect a hundred dollars!

I sometimes don't know whether I'm doctoring or playing some insane nonsensical board game.  The complexities of sickness and healing have been eclipsed by the administrative nightmare of our payment system.  Providers no longer stress over diagnosis and treatment, we huddle with social workers and agonize over disposition.  Families no longer sit at their loved one's bedside and hunker down stubbornly in the face of the ravages of disease, instead they pace lonely hallways hoping to bypass the phone tree and speak to an actual person at the insurance company.

Try as we may to manage our patients pathophysiology and psychology, we now attempt to manage their checkbooks.  Not only the finances of our patients, but the economic well being of a nation is being placed at our doorstep. 

We are not accountants.  We are not economists. 

We neither created nor profited from the distorted system that we loosely call healthcare (to the extent that others have).  Most of the time, we slunk around the edges trying to squeeze the fat to create a few drops of precious water for the parched.

Let the doctors doctor.

For God's Sake, that's what we were trained for.

I Should Have

There's something strangely heart breaking in the You Should'ves:

You should've treated the infection sooner!
You should've made the diagnosis faster!
You should've done more!

These words uttered accusingly from a patient's mouth can cut to the core of a physician.  We've all been there.  No matter how rigorous your skills and training, there will be many bad outcomes.  Unfortunately, from time to time, a patient or family will point the finger directly at you.

I don't blame them.  How else to deal with death, destruction, and illness.  Some turn inward.  Some point to the heavens and ask why.  And some look you in the eye and spit venom in your direction.

I always try to step back and appraise the situation as objectively as possible.  I am not infallible.  Humans make human mistakes.  But often, I find, that bad things happen without adequate explanation.  We are both wondrous machines with infinite intricacy and ticking time bombs all at the same time.  If I thought accepting the burden of blame would ease the suffering, I would throw myself under the bus without question. 

We all know this won't undue that which has already been done.

Yet, there is a menace, even more devastating to the psyche of those who have taken such sacred oaths.  I am referring to none other then the havoc wreaked by the I should'ves.  Every physician I know is haunted by the times when their skill fell just a little short, their insight was lacking, or their timing was imperfect.

These are the cases that make you toss and turn through sleepless nights.  These are the faces you carry year after year.

So you walk into the room of the grieving patient or family.  You look these people who love and trust you in the eye, and you tell them of your shortcomings.  Mostly they shake their heads and forgive you quickly.  It's of little consequence that you shamefully accept the comfort they bestow on you.  You will not escape unscathed.

Over the coming months and years,

the wounds you inflict on yourself will do nothing but fester.

In Memoriam: Letting People In

They found you in death much as you had been in life.

Alone.

You once told my office manager that I saved you.  I shrugged.  I couldn't help but feel that I was watching you die day by day.  It's not that I didn't try.  I fought with you tooth and nail.  Begged you to go to the hospital, for anything: a pneumonia, vomiting, I would have been willing to make up a diagnosis.  But you told me that hospitals were places that people go to die.

I watched and waited.  I scolded that one day I would get a call from the police telling me you were gone. You lived up to that prophecy.  I wondered back then how I would feel.  I suspected some version of relief.  After struggling for months and years, I couldn't help but suffer a certain amount of battle fatigue.  I now know more accurately what resides in my heart

Emptiness.

Something strange happens when people let you into their lives.  You struggle through their peaks and valleys.  You become soldiers in a common battle.  In many ways they become a little part of you.  The hazard in this profession is letting too many people in.

Because they all die eventually. 

And tragically, predictably, a special piece of you goes with them. 

Embrace The Joy

It's not exactly Dr. Jekyll and Mr. Hyde, but everybody knows my level of patience varies from time to time.  So I was surprised to find myself happily telling the emergency room that I would assess the patient shortly.  The kids were horsing around on the playground, and I knew I would have to call my wife and ask her to come home.  It would be my second forty five minute trip to the hospital on an otherwise busy Saturday afternoon.

For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama.  I slowed down, listened to the patient calmly, and reassuringly put a plan into place.  Driving home, I felt both relieved and saddened by the joy that overcame me.  Why didn't my life's work make me feel this way all the time?

I guess it starts with one simple fact.  I blame myself: every heart attack, stroke, or new diagnosis of advanced cancer.  As disturbing as it sounds, how could I not?  It takes a certain type of personality to want to be a doctor.  A kind of hyper conscientiousness pervades our wounded souls.  What else would drive us to study while our cohorts play, or slave away in gross anatomy while our peers receive their first pay checks?  And how does one wake up in residency after an hour of sleep with a foreboding sense of nausea and fatigue, and face an overwhelming twelve hour day of patient care?

You learn to believe that your actions matter, that your struggles draw the line between life and death.  If you only work harder, stay up later, study more, bad things will cease to happen.  This is the promise that drives us through these PTSD inducing situations.  And, of course, the joy.

The joy in those fleeting moments where you hold a hand, sigh gently, and become one with the great swath of murky humanity.  Those moments are what sustains us through the everyday torture that many of us signed up for eons in advance of the knowledge of what we would be doing.

Half of today's practicing physicians have been irreparably damaged by the experience, and huddle behind walls so impenetrable that patients can't break through their stone faced facade.  The other half are trying so desperately to once again feel deeply, and yet not suffocate under the immense pressure of their daily lives.

If your are a patient, I suggest you avoid the former and seek out the latter.

If you are a medical student, you may want to learn how to embrace the joy now,

before it's too late.

In Which I Respond To A Faithful Reader

Below find excerpts of an email sent by a faithful reader.  I have included the whole text, but broken it down to respond to each point accordingly.

I have really enjoyed your blog postings and the sensitivity you showed toward patients. But, your new venture is a real turn off, and makes it hard for me to want to read your posts anymore.

I have been waiting for this.  Expecting it.  I knew that when I changed my practice model there would be anger and disappointment.  For this reason, I have gone to the trouble of telling each patient face to face in the office when they come in for an appointment. 

This has been my decision.  I will own up to it.  I won't hide behind a formal letter or slink out of the room.  If patients are upset, I will soak in the anger and accept it.  I owe that much.

So far I have received mostly understanding with a smattering of joy and disappointment.  My patients know me very well, they don't believe I mean them harm.

My dear reader, sometimes you have to look eye to eye to see into some one's soul.  A blog, unfortunately, does not allow for that.

As a patient (not yours), it seems like you are abandoning patients who do not have the money to pay your new fees for which you will take no insurance. Instead of staying in the trenches and finding the insurance battle with them, you seem to be washing your hands of it and leaving them on their own. Onward to people with disposable incomes to pay for handholding.

On the contrary, I'm still taking insurance.  For fifty percent of my practice: nursing home, hospice, and palliative care there will be no extra charge.   These are some of the most difficult and high risk patients.  I will continue to stay in the trenches and battle for them.

I am changing, however, my outpatient primary care practice.  I will charge a yearly fee along with billing insurance.  The yearly fee pays for uncovered services like home care, cell phone access, and prolonged visits.  I believe this is a fair trade off.


My perception may well be wrong. Perhaps I did not listen carefully enough to your explanations. I want to believe that you are who you appeared to be, a great, caring physician. But, I thought that you might like to know that at least one of your loyal blog followers doubts that now. Take care.

I would like to think that I am still perceived as a great, caring physician.  I would also hope to be viewed as a strong patient advocate.  But the problem is, I can't protect my patients from the ridiculous, pervasive stupidity of medicare and our modern day insurance Goliath.

I can keep bending, and giving, and finding ways to work around the vicious beast.  Or, I can choose to step out of the lion's den.  I will not be an enabler of this broken system. 

Change will only come when doctors and patients alike are willing to stand up and say enough is enough. 

I am in the unique position to do just that.

Practicing At The Top Of Your License

My son and daughter play violin.  I accompany them to every class and stand over them in our living room as they practice.  From the very beginning, the teachers required parental involvement.  They often spent more time talking to me than my children.  They instructed on posture and fingering. Eventually, I learned to read music.  I even rented a violin of my own.

As the years have passed, I still play an active role.  I know when my son's elbow rides too high or my daughter's wrist curves upward like when carrying a pizza.  My ear can tell when a note is a touch too sharp or completely wrong.  But as an adult, I find I have little time to practice the same hours as my offspring. 

I returned the rented violin after months because it sat unused in the corner. 

My children have far surpassed my abilities.  Although I have knowledge of the appropriate technique and have learned the series of notes, I am a victim of insufficient practice.  And indeed, one can look down the line from less to more experienced and realize the difference repetition makes.  Although the notes are the same, the depth and quality of the sound that reverberates through the violin can be very different. 

Only when one practices hour after hour, year after year, can the shadowy mirage of mastery shimmer in the distance.

There are no shortcuts.

Not in violin,

and not in medicine.

Caring 2.0: #HCSM And The Rise Of The Empathic Physician

We have our rock stars.  Our members in the healthcare social media realm who have elevated the conversation to new heights.  Physicians are tweeting, blogging, and popping up on news shows across the country.  We are using our singular voices to educate on vaccines, heart disease, and the quantified self movement.  We are acting locally, but teaching globally.  The promise of social media has amplified our voices and carried our message to the unwashed masses. 

We once could affect the few thousand who passed through our office doors.  We now can touch the lives of millions.  This dichotomy, fulfilling our individual covenants as well as our debt to society as a whole, has proven a powerful draw.  One only has to look at the conversations on twitter to realize that our ranks are swelling.  Not only physicians, but nurses, pharmacists, patients and advocates are both teaching and learning.

We all win, patients and providers alike. 

Yet in our exuberance to transform, we continue to neglect certain self evident truths.  It's time to pivot.  It's time to not only tell people what we know, but who we are.  Knowledge has it's limits, but does caring?

I propose we move to a Caring 2.0 mindset.  The days of unidirectional emotion emanating from patient and bouncing off stoic expressionless physician are gone.  Like the Healthcare 2.0 movement, the elevation of caregiving requires a blurring of the line between teacher and student.  I can see no better way forward than social media.

We are human.  We suffer, triumph, and struggle with our own inner demons.  As Louise Aronson said in her book A History of the Present Illness:

Doctors, you see, aren't so different from patients. Every day we hope someone will see past our elaborate and very impressive window display to the jumble of expired products weighing down the shelves and choking the aisles of our psyches.

It is in this imperfection that we realize our best version of ourselves,

that we become the doctors our patients really need.

CrisisMD Launched Today

CrisisMD.com launched today!

Our goal is to provide healthcare coaching, translational services, and advocacy to those in the midst of a crisis.  Below find the post that spurred this business venture.  It appeared recently on kevinmd.com.

If Only The Patient Had An Advocate

It had all been so easy when Jim was still around. Lisa’s ex-husband had many shortcomings, but being a critical care specialist sure came in handy. Any time her mom or dad had a health crisis, he was right there in the middle of it: advocating, interpreting, breaking down the complexities into easily digestible morsels of information. But then Lisa’s father died, and the emotional and physical stress brought the unstable union to a breaking point.


Years later, she sat in the ICU holding her mother’s hand and longing for the man that she had grown to despise. She felt a slight tenderness stir in her heart that was suddenly extinguished by picturing her previous husband with his new, almost teenage love interest.

Damn!

Lisa’s mother suffered another stroke. The ventilator had been removed but her mental state was dubious at best. She was not eating. And the hospitalist was suggesting a feeding tube. Lisa recoiled. Her memories of her agitated grandmother socked away in a nursing home pulling on the plastic protruding from her abdomen was too much a burden to be replayed a generation later.

If only Dr. Phillips would come to the hospital. As her mom’s primary care physician, Lisa trusted him. But he abandoned his privileges years ago. He once confided that he no longer knew how to take care of such sick patients. Lisa missed his optimism and his gentle hand on her shoulder resting tenderly. He understood her struggles. The hospitalist was nice enough, but young. He seemed overly concerned with protocol and rarely spent more than a minute in the room without leaving to answer a page. He certainly had no advanced knowledge of the woman lying in the bed in front of him.

The family meeting was pathetic. Instead of the hospitalist, a palliative care nurse joined the social worker and other supportive staff. Thirty minutes later, Lisa walked out more confused than ever. Most of the conversation resolved around disposition: nursing home, home with hospice, or rehabilitation center. Each member had their own checklist of salient decisions that often seemed far removed from her mother’s wants or needs. There was no question who each participant worked for. The hospital, the government, anyone except for the poor helpless struggling patient.

Lisa thought of Jim again. If only she had an advocate. Someone who answered to her and her mother instead of the litany of outside interested parties. If only her doctors would lift their heads from the computer screen for just a few moments. If only someone with medical knowledge took a moment to see the forest from the trees.

The mice keep running through the maze trying to find the elusive cheese.

Damn!



What the hell has happened to our medical system?

Poof!

It happened once before.  I logged onto the computer on a particularly challenging day to find that my blog was gone.  Just like that.  After countless  posts, telling stories, complaining and rejoicing...poof.  I was on WordPress at the time.  I called the help line and frantically explained the situation.  Weeks later I got the data back, unformatted and imported to a new web address. 

I was crushed.  Not just about the loss of all that writing, but more because the conversation had stopped.  The unidirectional talk that I had been having with myself and my readers came to a sudden unexpected end.  And when it finally came back, the connection had severed. 

For a long time there was silence.

My writing is now hosted on blogger.  Four hundred and seventy six posts later, the self expression dwarfs that of it's forebearer.  Yet, I have taken no actions to record or backup my posts.  Like a game of Russian Roulette, I keep hitting the publish button in complete denial.  I have no explanation why I am paralyzed in taking such precautionary measures.

Poof!

Many have told me to collate my posts into a book.  They say to self publish or get an agent.  I have contemplated many times.  But I could no more anthologize than I could backup my blog.  We don't record our conversations with our friends, our loved ones.  We remember them.

And this, my friend, is my conversation with you.  I spew forth the randomness and you sometimes respond.  You comment, email, or retweet.  We have a relationship, real or imagined, I can't always tell.

I guess it was never really about the specific words.

I was just trying to tell you things. 

Fatherhood And My Son's Kindle

It's kinda curious.  For all the technology I live and breath, put me in an empty room with an IPAD and after a few minutes of browsing, I'm bored.  I've tried to wile away the hours on the Internet, but I can't.  I'm just not built that way.  Even the games and downloads lose me fairly quickly. 

My son, on the other hand, is an altogether different creature.  He somehow wrangled us into allowing him to use his own (birthday) money to buy a Kindle.  And at the age of eight, he is already bumping heads with his fifteen minute daily allotment.  He carries the little device in it's dark blue case around the house like a trophy.  He may be limited in minutes, but no one can deny him the pleasure of feeling the weight underneath his wanting hands.

For him, the tiny screen frames a world of wonder and technology.  It's not just the games, but Google Earth, Wikipedia, and a vast marketplace for all those lovely objects his rambuctious boy mind desires.  It's a destination unto itself filled with both learning and shiny sparkling objects. 

It is what his heart desires above all else.

He takes the Kindle everywhere.  He lugs it to the grocery store, paws it at Home Depot, and cradles it before violin practice.  It's always by his side.

The other night after a long shopping trip, we gathered the kids together for an evening bath.  My son ran into the room frantic.

Mommy, Daddy...where's my Kindle?

An exhaustive search of the house lead to a startling conclusion.  We must've left it in the shopping cart at Target.  My son twisted his hands in knots waiting for me to connect to the lost and found.  Nothing!

As I lay awake that night, I listened to him toss and turn in the adjacent room.  Occasionally he would jump out of bed and search an odd drawer or basket.  The next morning he crawled into bed between my wife and I.  His eyes full of tears, he nestled into my arms.

As silly as it sounds, I hurt for him.  I hurt for his little boy hopes and dreams.  I mourned for the exquisite suppleness of inexperience.  Of course I could buy him another kindle (which would have taught him nothing), but I can't protect him from the hardships of growing up.  I couldn't protect myself.

There will be fights, both physical and mental.  There will be disappointments and broken promises.  There will be somatic and emotional pain.  And like the heart extirpated wildly from my chest, I will have little control over his destiny, yet will feel each horrible prick.  

I am like my son, and he is like my Kindle.

I am starting to lose him already. 

The Power Of The Pen?

I almost fell off my chair.  It was bad enough that he showed up to the ER.  But what happened next really blew my mind.  He fell and bruised a rib.  The pain in his left chest had obvious enough origins.  But triage had put in for an electrocardiogram and the interpretation apparently scared the resident.  The attending took a look, and shook his head.

Left bundle branch block.  Better call the Mecca.

A few minutes later a cardiologist and nurse manager were videoconferencing in and interviewing the patient.  Next came an order for thrombolytics and transfer to the big medical center ninety minutes away by ambulance (the same medical center that owned the emergency department as well as the local hospital the ambulance bypassed).

Rules are rules.  And the bylaws state that all patients given thrombolytics have to be transferred to the brand new multi billion dollar cardiovascular institute no matter how far a distance.  It didn't hurt that said institute was having trouble filling it's beds and apparently the administrative folks were starting to lean on the clinical staff.

The cardiac cath was mostly clean.  Was it an over call, or did the medicine really just do a great job? He was never given a clear answer.  He left the hospital with more questions then answers, and a prescription for a baby aspirin and a statin. He came to my office to try to figure out what had just happened to him. 

This sort of thing seems to be occurring more and more often.  The business aspects of medicine are starting to trump appropriate care.  While no one is saying that more is better, aggressive management has become the rule and not the exception.

Healthcare reformers, politicians, and policy wonks wag their fingers at physicians and place the blame squarely on our shoulders.  They say that only the doctor has the power of the pen.  They completely ignore the bullying, administrative pressure, and the automatic rules and regulations forced on clinicians by the nonclinical (or no longer clinical) C-Suite. 

A recent article in The American Medical News brings to light a radically different view point.

When the federal government sorted through the first round of clinical information it was using to reward hospitals for providing higher-quality care in December 2012, the No. 1 hospital on the list was physician-owned Treasure Valley Hospital in Boise, Idaho. Nine of the top 10 performing hospitals were physician-owned, as were 48 of the top 100.

This news comes three years after the Affordable Care Act effectively prohibited the expansion of such existing facilities and severely limited the creation of new ones.

As Obamacare pushes more and more physicians out of decision making positions and herds them into large academic and nonacademic hospital systems, one would expect one thing and one thing only: spiraling costs.  Business exists in order to make money.  Businessman go to school to learn about profit.  Physicians who leave clinical practice to become administrators aspire to similar ends. 

Physicians are the only ones who have made a covenant.  We are the only ones who have taken an oath.  We are smart, well educated, and innovative.  And we have to look each and every patient in the eye before making decisions.

Yet time and time again, we are asked to move out of the way so the smart guys with the business degrees can come in, and make the tough decisions. 

(Disclaimer.  This story is an amalgam of a number of experiences gleaned over years of practice in a number of different hospital systems.  The details of the actual medical story are fiction.  Neither the patient mentioned or the medical center are meant to be reflective of any specific patient or hospital.)