Saturday, November 30, 2013

Once Again, The Pound Of fat Comes From The Primary Care Physician

My dear medicare patients.  The government has just screwed you.  Did you know it?  Probably not, probably you have no idea about what the government is proposing to do.  But it is going to have profound effects on the quality of the care you are about to receive.  You are confused? You are surprised?  Let me explain.

The government is proposing to change the way it pays doctors for outpatients visits. According to modern healthcare, medicare intends to pay physicians a flat rate for each visit.  That's right, a healthy sixty five year old with a cold will lead to physician charges that are the same for a ninety five year old with congestive heart failure, emphysema, and out of control diabetes.

Accordingly, the complexity of the visit will no longer figure into the amount of reimbursement for the physicians.  What does this mean?  Physicians, fatigued and overwhelmed with patient care, will be much more likely to avoid sickly seniors.  It pays the same, why not select for the most healthy of the medicare population?

If you are old, sick, or have a complex medical problem, expect physicians to avoid you like the plague. You're care will cost us more, and lead to lower reimbursements.  For those of us in private practice, I expect that this will be the death knell.  You might as well sign up to a hospital based large medical group now, no one else will be able to afford to take care of you.

The reason why this is happening?  Apparently medicare believes that physicians are over coding.  The pound of fat for healthcare reform is going to be born by those who healthcare needs the most, primary care physicians.  It is the primary who handles the broadest, most complex, most multi system problems.  These problems take time, deep thought, and advanced planning.  These were things that medicare used to pay for.  Apparently no more.

This is a sentinel moment, a tipping point,

By the time I reach medicare age, will there be any physicians left?

Sunday, November 24, 2013

Do Mechanics Have More Freedom Than Doctors?

So a guy has his car towed to the mechanic. All four tires are slashed. He has a simple request.

Please replace the tires.

But this is one of those comprehensive care mechanics. He not only examines the tires, he does a full once over. He pops the hood and immediately knows that the engine is shot. It's fried. The cost of fixing the engine is more than the value of the car. It's a zero sum game. The owner shouldn't replace the tires, he shouldn't work on the engine, this car belongs in the scrap heap. He saunters out to the waiting room, and delivers the bad news to his eager customer. The mechanic is utterly stunned by what he hears next.

Please replace the tires.

The mechanic, being a kind and gentle sort, assumes that he has been misunderstood. He sits down quietly next to his fellow human being. He again explains, more slowly this time, how the cars value is minimal. He draws a diagram to demonstrate why the engine won't function. He reiterates the futility of changing the tires on such a car. It is not only a waste of money, it is a waste of precious time.

The customer turns his back to the mechanic, pulls out his mobile phone, and dials furtively. He hands the mechanic the phone. It's the customers insurance agent.

Please replace the tires. We will cover it.

The office is full, the cars are piling up in the lot, and yet the mechanic patiently tries to explain the situation again. Again he tells how the engine is nonfunctional. Again he outlines the price of possible fixes and how they are completely cost prohibitive. The tires are just the icing on the cake. They are not the problem, and fixing them will solve nothing.

The customer snatches the mobile out of his hand and dials yet another number. He pushes the phone back without saying a word. This time it is a lawyer. He demands that the mechanic fix the tires unless he wants to face a lawsuit.

So the mechanic bills the insurance company. He replaces all four tires. He drops the car in the lot and gives the customer the keys. The customer thanks him, walks out to the car, gets in, and puts the keys in the ignition. Nothing happens. He gives it another try. Nothing happens. He walks back into the shop and approaches the mechanic with one more question.

How much will you charge me to tow this thing to the junk yard?

In reality, no mechanic would have been expected to fix the tires. No insurance company would have paid the bill. And no lawyer would have taken a case they so clearly couldn't win.

Yet doctors are expected to put dying patients on dialysis, give fourth line chemotherapy when the first three lines (which actually have some clinical benefit) fail, and refuse to turn off the battery of defibrillators in bed bound, obtunded, dementia patients.

We don't do this because we want to.

Unlike the mechanic, we have been denied the basic logic of futility.

Monday, November 18, 2013

I Am Not A Mark

I am not a disease.

Although when I enter your hospital, or office, or outpatient center, you may refer to me as one. You may lump me together with an odd set of symptoms, or signs. You will define me with those antiquated terms. You will pretend that you will know how I, my body, will react when placed under certain stressors. You will prescribe treatments for my disease, and yet leave me out of the equation.

You know, me, the me that the rest of the world sees when I am outside the obtuse boarders you have created. Only a milifraction of my life occurs in your realm. The labels you give, the actions you take, have consequences. They may determine my physiologic or economic well being.

Are you listening?

I am not a checklist.

You may use one when deciding whether my treatments are covered. You may question my doctor, read him the riot act. You will say that I don't fit your algorithms. I do not adhere to your guidelines.

Diseases follow a pattern, unlike every other aspect of human behavior, they are quite predictable. Why should I be different from any other? Why should my pain and suffering be unique? Require unique solutions?

I am not a mark.

My suffering was not meant for your exploitation. I see your commercials on television. People with my disease run through angelic fields with smiles on their faces. I don not live here. I do not run when my body aches and my mind is numb.

You ride in like a saviour and ride out with my wallet strapped on your back. You offer false prophesies. Some of your drugs, injections, and sprays truly save lives. Others are crap.

Must you treat them as one and the same? Just to make money?

I am a human being.

My disease is part, not the whole of me.

Lift your eyes from your tired misconceptions, your white washed guidelines, and your market driven economies.

And look at me.

Thursday, November 14, 2013


Roger struggled with various maladies that came with growing older.  His blood was occasionally too sweet, his pressure stumbled upwards, at times perilously.  But it was the colon cancer that gave him pause.  It started rather innocently.  At first he noticed a little blood on the toilet paper, later, a touch of abdominal pain.  He put off the appointment for a few weeks, but eventually he showed up in my examining room.

We talked about the pros and cons of colonoscopy. Roger liked to think deeply about his medical problems.  A few days later, he underwent the procedure.  The cancer was localized. We picked a surgeon that seemed to fit his personality.  He scheduled a visit with me right after his consultation to talk over the options.  Would it surprise to you consider that he thought of doing nothing?

Roger eventually had the surgery.  His recovery was rocky.  I visited him in the hospital every day. When his temperature spiked, I put him on antibiotics for pneumonia.  There was a short nursing home stay.  To see Roger ambling through the hallways of the extended care facility was quite a sight.  A place he said he would never go, he seemed like a king sitting atop his thrown.

I discharged him home when he was strong enough to handle the apartment on his own.  There was quite a bit of discussion, he actually left a little earlier than I preferred.  What could I say?  He made some good points.

I bumped into Roger while walking down the street the other day.  He was chatting affably with an acquaintance.  He greeted me with a warm handshake, and we stood silent for a moment. Then he turned to the gentleman standing quietly next to him, and apologized for not introducing us.

"I almost forgot," He paused, and smiled broadly, "this is my colleague, Dr. Grumet."

Colleague.  I thought about Roger's words later that night while daydreaming in front of my computer. He was right.  The word patient didn't really make sense.  There was no paternalism.  A light went off in my head that day, and I haven't used the term patient since.

In the job of safeguarding Roger's well being, we were partners, workmates, collaborators.


Monday, November 11, 2013

Are We Waiting For Godot?

Ten reasons I feel pessimism about our current healthcare environment (in brief):

Process vs Product

Computers are just machines.  I repeat, they are just tools.  Health information technology is a shell which houses knowledge and human ability.  It is nothing more .  Electronic medical records may either streamline our thought processes or make them more cluttered.  They will not, however, lead to better or more perfect care.  They haven't yet, and they won't in the future. And they are prone to be adulterated by commercial intentions.  Looking for an answer to our complex healthcare problems here is like waiting for Godot.  You can wait and wait, but no one is coming.

Role Confusion

Physicians, nurses, and therapists are some of the most educated, expensive cogs in the healthcare machine.  Forcing them to become secretaries, scribes, and box checkers is both inefficient and redundant.  Furthermore, it doesn't take a physician to make sure a patient has had a flu shot, colonoscopy, or pap smear.  These are roles for nonclinical, low payed employees.  Take them of the clinicians plate.  Let doctors be doctors, nurses be nurses, and physical (and occupational) therapists do what they are trained to do.

Call It Courage

Until physicians have the courage to practice sound medicine and are willing to deny inappropriate antibiotics, narcotics and futile care, we are lost.  Until politicians are willing to forgo the electoral advantage, and vote for what is sound, we are handicapped.  Until patients are willing to own up to their own unsavory habits and practice will and self control, our medicines are impotent.

In Data We Trust

Data is being collected on the backs of physicians and nurses who have no reason to insure its fidelity, and have almost every reason to fudge their answers to move on to the herculean task of treating their patients.  Garbage in, garbage out.  The medical decisions of a generation will be based on crappy, nonsensical, inaccurate information.

Right Or Privilege

Either healthcare is a right or it is a privilege.  If it is the former, tax the American people more (like we do for roads and such) and implement a single payer system.  If it is latter, then let the market have at it, and accept that the have nots will have not.  This is how we do it in America.  Somebody has got to choose.

In Government We Trust

Can anyone out there say Need I say more?

Anti Intellectualism

Few would call the care of the human body a simple matter.  Some would argue that it is remarkably harder than, oh let's say, setting up a web site for a healthcare marketplace.  So why ever would we consider shortening medical school, truncating residency, or replacing MDs with less trained practitioners?  Anyone?  Anyone?

The Sands Of The Hour Glass

My belief is that the number one determinant of quality healthcare is the amount of time your clinician spends thinking about you.  In other words, most practitioners are relatively smart and caring.  Mistakes are made when the amount of time relegated to the task is insufficient.  Yet we add more and more trivial chores to each encounter without expanding the allotted time.  Something has got to give.

It's Futile

We offer dialysis to centenarians, physical therapy to end stage lung cancer patients, and a bevy of harmful and costly treatments inappropriately.  The main reason, of course, is that there is no such thing as futility in American medicine.  We are so busy charging up the hill, that we fail to see that the apex is a ledge that we are about to fall right back off.

The Foxes Are Guarding The Hen House

Do we really think that pharmacy run clinics are going to be the saviour of our access problem?  Are we to trust expert opinions from specialists when their suggestions are both self serving and run counter to what our best data tells us?  Should politicians wield so much legislative power when they receive financial support from pharmaceutical companies, insurers, and the device industry?  Why do we have so much faith on those who have their hands in the cookie jar?

If we want to meaningfully reform our healthcare system we have to take a hard and difficult look at ourselves.

I'm willing to own up to my professions role in this horrible debacle, are you?

Thursday, November 7, 2013

Introducing The Palliative Care ICU

I think we are overly limited by our descriptive terms.  We throw around concepts like hospice and palliative care, but in reality the medicine I practice is much more a hybrid.  Many of my patients are elderly, demented, and plagued by metastatic disease.  Often when one of them becomes ill, it is unclear if they are merely treading water, or about to drown.  The problem with our modern definitions is that they leave little room to pivot.  Pivoting, it turns out, is critical to delivering humane, dignified, high quality care.  And our patients don't want  to be pigeonholed.  They want aggressive doctoring when it will be helpful, and hospice when chances are slim.  Unfortunately our crystal ball rarely provides the answers we are looking for.

With these ideas in mind, I would like to introduce the concept of the Palliative Care ICU (PCU).  Less an actual place than a state of mind, the PCU is a philosophy of doctoring that allows physicians to treat both aggressively and palliatively at the same time.  In other words, short term, intense, pain neutral interventions are carried out acutely with an eye on pivoting to hospice vs aggressive care depending on short term response.

In order to illustrate, lets consider Tom, an eighty five year old in a nursing home with metastatic lung cancer.  Although he is getting weaker, he still is able to ambulate and enjoy time with his wife and daughters.  One evening he develops fever and somnolence.

Tom has a fairly limited prognosis based on his aggressive malignancy.  On the other hand, his family has been enjoying visiting with him, and would hate for him to die prematurely from a treatable infection.  The patient himself has resisted hospice because he wants to continue getting chemotherapy.

If this is Tom's time to die, all parties agree to make him comfortable, and let him go.  On the other hand, if medical intervention could prolong his life and maintain a semblance of quality, no one would argue with intervening.

What is Tom's physician to do?

PCU Concept 1: Shelter In Place

Tom will die soon from his cancer regardless of the outcome of the current infection.  The last thing his family wants is for him to spend his last moments in an ICU being poked and prodded by strangers wearing isolation gowns.  Thankfully, there really is no reason to move him out of the comfort of his nursing home bed.  Given today's current medical climate, high level care can be delivered not only in extended care facilities but also in people's homes.  IV's can be placed, antibiotics given, and pain levels monitored.  If Tom were at home he could be attended to by an home health company or palliative care program.

Maintaining Tom's location is critical to the PCU concept.  It allows humane, dignified medicine without the trauma of escalating the place of care.  When possible, home patients stay at home, nursing home residents remain in the nursing home, and floor patients remain on the floor and avoid the ICU.

Tom's family and doctor decided to sign a do not hospitalize form and manage the current crisis in the comfort of his own room.

PCU Concept 2: Pain Neutral Interventions

Because Tom's quality of life was still reasonable, his physician and family felt that drawing blood tests, placing an IV, and beginning intravenous antibiotics was reasonable.

Each intervention was discussed amongst all parties and decided that the amount of discomfort was minimal compared to the possible benefit.  CPR and artificial ventilation and feeding, however, would clearly be painful and therefore were forbidden.

Although Tom continued to decompensate, he appeared comfortable and no worse for the wear given the current levels of treatment.

PCU Concept 3: Pivot, Pivot, Pivot 

Tom's physician reviewed the lab results with the family the next morning.  The kidneys were shutting down, the liver tests were abnormal, and Tom hadn't shown any signs of waking up.  He started to moan occasionally during the night and morphine was started.  The nurse carefully placed a few milliliters of medicine under his tongue every few hours, and he quickly became peaceful.

During a family meeting, Tom's wife and daughters understood clearly that recovery was unlikely and that little benefit would come from hospitalization.  Hospice was consulted.

Tom died quietly, surrounded by his family and friends, a few days later.


Conversely, if Tom had a limited infection like a UTI, he may have responded quickly to antibiotics and recovered uneventfully in the nursing home.  Either way, he was given high quality, judicious care that allowed nature to declare itself.

The future of healthcare is here.

We have to learn to drop our preconceived labels and adapt more hybridized models.

With this intention,

I introduce the Palliative Care ICU.

Sunday, November 3, 2013

The Return Of The Prodigal Daughter

When I was in training, I had the mistaken belief that disease was treatable. I felt human weakness resided in the inability of the physician. If a patient deteriorated, if a battle was lost, it was because we weren't skilled enough. I studied with every extra moment. I followed the gurus and hung on each word of wisdom that flowed from their eloquent lips. I embraced the wonderful naivete, hoping against hope, that illness was curable and human fallibility could be scrubbed from our pristine souls.

There was a time after residency when I lost faith in medicine.  I kneeled at the steps of a broken shrine. In the great war against nature, we physicians waged an imperfect and often losing battle.  We flung our minuscule pebbles against the three headed dragon of cancer, cerebrovascular disease, and infection.  The darkness of night was set afire by noncompliance, resistance, and futility.

Many wars were lost, few were won.

Yet battle warn and beleaguered, humility, the prodigal daughter, returned to re stake her claim.  And I learned that being engaged is a gift that each physician can give.  When we listen, when we care, we provide a salve more precious than our impotent pills.  Our hands can be more adept than scalpels.

I've ended at the beginning.

The science of the novice has been tempered by the wisdom of humility.

I continually strive to use both.