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Prostate cancer screening: too early to say goodbye
First they try to take away our mammograms, and now this? Last week, the U.S. Preventive Services Task Force (USPSTF) followed up their October 2011 draft guidelines to recommend, definitively, that doctors not offer routine Prostate-Specific Antigen (PSA) screening for prostate cancer. They concluded from recent clinical trials that the harms from over-diagnosis (biopsies and surgeries complicated by infection, bleeding, and incontinence) outweighed the benefits of early detection and treatment. Not surprisingly, the move was not universally welcomed, in part because the notion of not doing everything in our power to hunt down cancer seems almost sacrilegious.
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But one key detail of the guidelines has been largely overlooked, the part that takes into account what individual patients want. "Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by the patients," the authors write. "Similarly, patients requesting PSA screening should be provided with the opportunity to make informed choices to be screened that reflect their values about specific benefits and harms."
To resuscitate or not to resuscitate: is that the right question?
In the standard patient interview, stuck somewhere between drug allergies and the review of symptoms, lies a question that’s a tad more existential: how do you want to die?
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I wrote recently about patients and their families making this difficult choice in the Intensive Care Unit. Now I’m back on a regular medical service, where there’s a more comfortable distance between life and death and the question is often hypothetical: if your heart were to stop, would you want chest compressions in an attempt to bring you back to life (ie. CPR, or cardiopulmonary resuscitation)? But it doesn’t make the conversation any easier.
There’s debate about the right time and setting for the end-of-life discussion: Most favor having it with a primary care doctor or another long-term provider that a patient knows and trusts. Some argue that a patient isn’t ready to have the conversation until a hospital stay throws his mortality into sharp relief. The reality is that it’s our job as doctors to know the answer to this question every time a patient arrives on the hospital floor, and the task often falls to an intern working in the middle of the night. Unfortunately, trainees and even full-fledged doctors don’t do a great job of having this discussion:
Death in the ICU
Until recently, I had known dying to be a chaotic endeavor. A patient’s passing required a noisy cluster of doctors and nurses pounding out chest compressions and barking orders to check for a pulse or deliver anti-arrythmia drugs - measures that delayed what was often inevitable. And then I worked in the Intensive Care Unit (ICU).
It was at once odd and fitting that my patients who passed away in the ICU did so calmly, deliberately, and - in that moment of transcendence - hidden from the gaze of medical personnel. It is a setting where doctors respiratory therapists, and nurses can control every detail of your breathing, finely titrate your blood pressure with the flow of liquid medicine that clamps down on your blood vessels, even act as your heart and lungs. When patients or their families decide (with our input) that these interventions are a bridge to nowhere, that they want to withdraw life-supporting care: it is a cruel-sounding term that nevertheless allows patients to exert some control over their fates.
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Heartburn or Heart Attack?
This year, about six million American adults will come to an Emergency Department (ED) with chest pain. Some of them will have full-blown heart attacks, a few will have life-threatening blood clots in their lungs. The vast majority will have acid reflux, muscle strain, or anxiety. It’s up to the ED doctor to separate the scary medical issues from the ones that require Tums.
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As an internist working in the ED, I was reminded frequently that my job there was to focus on the most dangerous medical problem rather than the most likely. In the effort to catch the “Don’t Miss” diagnosis, many patients who are unlikely to have a cardiac cause for their chest pain languish in the ED hallway or get admitted to a medical floor to rule out a heart attack: get a three-part series of blood tests and heart tracings every six to eight hours, maybe even undergo a cardiac stress test. Most of these patients turn out to have no heart damage.
Rethinking Readmissions
To my internist eyes, the Emergency Department (ED) is a wondrous and bewildering zoo of activity: muckety-mucks neighbor detox-ing alcoholics and surgeons comingle with psychiatrists in this microcosm of the hospital ecosystem. It is also a fork in the road for our regulatory target du jour, one that has come under recent scrutiny: The Hospital Readmission.
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For the past decade or so, hospital readmission rates - the percentages of patients admitted to the hospital who return within 30 (or 7, or 15) days of ending their previous stay - have been used to judge hospital quality. Under the Affordable Care Act, hospitals that have higher than “expected” 30-day readmission rates get a financial slap on the wrist from the Centers for Medicare and Medicaid Services. This metric is intended to address a few important gaps in health care quality by countering other financial incentives to reduce the time patients spend in the hospital and to encourage better planning for their departure and follow-up.
"The reason [this quality measure has] gotten so much traction is that it does seem on the surface to have such face validity. How could a readmission be good?,” asks Ashish Jha, Associate Professor of Health Policy and Management at Harvard and co-author of a recent commentary in the New England Journal of Medicine that argues that the answer is not so simple.
Nearly two weeks into my brief stint as an ED doctor, I’ve come to appreciate this sometimes frustrating reality.
The Managers We'll Be
Last Friday - Match Day - was an exciting time for medical school seniors who found out where they’ll spend the next three plus years of their trainee lives. For me and my intern colleagues, it was exciting in another way: we now have a list of people contractually obligated to take over our jobs in four months.
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For us, the excitement came hand in hand with trepidation over the responsibility of supervising our replacements.
Though interns do work one on one with medical students, managing teams is the purview of upperclassmen. On MGH’s Bigelow service, for example, a second year resident leads a team of four interns and a few medical students to care for 20-odd patients.
At this point in the year, internship’s daily grind of writing patient notes and ordering chest x-rays feels almost automated. Our next challenge is one for which we get little formal training. But we think about all the time.
When HIV privacy goes too far
The morning after she was raped, Sarah* went to her local emergency department (ED) to get herself checked out. Thankfully, she had suffered no physical injuries. She got the usual slew of tests and was sent home with a bottle of HIV pills and a recommendation to see her primary care doctor.
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Sarah came to her appointment with me three days later. We didn’t have access to her prior records, so Sarah had to call the ED and have them sent. In the meantime, I gave her a refill of the HIV medication – a standard safeguard against the small but devastating chance that her attacker had been infected with HIV and transmitted it to her. When her medical records finally arrived days later, one test result was conspicuously missing: the one for HIV.
The Medical Assistants
This entry is the fifth in a series on health professionals who work in the author’s primary care clinic.
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When Terri Egan graduated from high school in 1974, she was curious about health care so she jumped right into a job as a medical assistant. Thirty-six years later, she has made a career out of training young medical assistants to follow in her footsteps and to eventually outpace her.
For decades, medical assistants have managed many of the routine clinical and administrative tasks in outpatient clinics. Training programs take a few months to years and prepare students for tasks like scheduling appointments, measuring vital signs, performing EKGs, and drawing blood, but many of the estimated 523,260 MAs working as of 2010 take on more duties as their comfort level and colleagues allow.
For most, medical assisting is a transitional career - either a re-entry point into the working world after raising kids or a stepping stone to more training. Terri attended a year-long medical assistant training program at the Carnegie Institute in Boston, then stayed on to work at the Cambridge clinic where she’d done her internship. After a few years of work as an MA, she had picked up a few extra skills and started nursing school at Boston’s Laboure College. After six months, her mother’s illness and a budding relationship intervened, and Terri dropped out to return to work as an MA.
The Health Coach
This entry is the fourth in a series on health professionals who work in the author’s primary care clinic.
As a Health and Wellness Coach, Ryan Sherman takes his skills from bench (press) to bedside.
In grade school, he spent much of his free time either in the midst of football and basketball seasons or training for these sports at the gym. So it wasn’t a stretch for him to major in kinesiology - the study of human movement - while attending the University of New Hampshire. For his athletic training requirement, he spent a semester with the women’s field hockey team and found that he grew impatient “waiting till they [were] injured and then helping them.” Why not tackle the problem before it became one? His itch for prevention kept nagging at him as the years went on.
After graduation, Ryan spent a year as a YMCA wellness coordinator. Part of the job involved cardiac rehab for heart attack victims: he’d help them exercise, measuring their blood pressure and pulse before and after each workout. He found that he liked having clients who were patients and could use a little extra help.
The Registered Nurse
This entry is the third in a series on health professionals who work in the author’s primary care clinic.
As a Registered Nurse (RN), Mary Ann Marshall understands the enormous potential of good multidisciplinary health care and the hazards of hierarchy. It was the promise of collaboration that once drew her away from a career designing buildings and its fruition that has maintained her enthusiasm for nursing.
In the late 1970s, Mary Ann studied biochemistry at Merrimac College in North Andover, MA, then spent a few years at Saint Vincent Hospital’s chemistry department, testing blood samples and improving drug tests. She didn’t love the job – it offered little of the human interaction that she craved. She was close to leaving health care for architectural design when her friend, a nurse practitioner student, encouraged her to think seriously about nursing. Mary Ann saw an opportunity to apply her biomedical experience in a way that inspired her.
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The Nurse Practitioner
This entry is the second in a series on health professionals who work in the author’s primary care clinic.
If Nurse Practitioner (NP) Jane Maffie-Lee had been born a few decades later, she would have become a doctor.
Instead, as an inquisitive Catholic school fourth grader in the early 1960s, she picked up a book series on Kathy Martin, nursing student and sleuth extraordinaire, and decided that she’d become a nurse who wouldn’t repeat Kathy’s mistakes.
It was around the same time that the first formal NP training program in the United States opened its doors to nurses interested in primary care. Today, the career has exploded: nurse practitioners are the most prevalent breed of so-called advanced practice nurses who have pursued a graduate degree and state-certification in areas outside the traditional nurse’s job description. In 2008, 36% of the estimated 158,348 NPs in the United States were working in primary care to manage common illnesses and prescribe drugs.
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Team players
Teamwork. It is the stuff of motivational posters (whether ironically or in earnest) and the long-leaked secret of successful industries. Health care has been relatively slow to catch on, but at forward-thinking medical practices like the primary care clinic where I work, teamwork has become a central tenet of how care is delivered. Our diversely trained staff members start the day with a team huddle to discuss the patients we’ll see and divvy up our work according to our unique skill sets.
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We know that effective multidisciplinary teams can provide safer, higher quality, and more efficient health care. By doctors sharing tasks with non-MD health care providers, we just may be able to put a dent in our presumed doctor shortage.
But we are up against a long history of tensions between disciplines and we continue to face disagreements over who should be called what and how much various providers should be allowed to do.
Community health and the ACO
How does a tertiary care hospital practice community medicine? We’ll find out soon enough.
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Last week, Partners HealthCare (co-founded by Mass General and Brigham and Women’s Hospital) joined four other state institutions and 31 others nationally in adopting the accountable care organization (ACO) model as a Medicare Pioneer ACO. The ACO model is designed to improve the quality and coordination of care while reining in costs. Its success rides on a group of providers working together to take care of a defined population - in other words, a community - of patients.
Doctors have long been trained to think at the level of individual patients rather than of populations. This is changing somewhat as we are asked to evaluate ourselves on how well we take care of our panels of patients. But the next step is to think outside the four walls of our clinics and hospitals and tailor our efforts to the individual needs of the populations we serve - this is the key to effective community health care.
Daughter or Doctor?
On Monday evening of last week, my mother found my father fallen and bleeding at the foot of the stairs in their Princeton, New Jersey home. She called 911, then me.
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I’ve heard that doctors shouldn’t treat their family members because it is so hard to think rationally about those we love. I quickly found this to be true.
My father was lucky, I learned through frequent phone calls and eventually in person. He had become dizzy while sitting in his second floor office, walked to the top of the staircase to call for help, and blacked out. In the emergency department, they found that the only injuries from his descent were a broken nose and some cuts on his face.
When he was hospitalized to investigate the cause of his fainting episode, the hospital setting was familiar to me but my role in it was not.
Where are all the doctors?
Clustered in the northeast United States, apparently.
Newly released 2010 data from the Association of American Medical Colleges (AAMC) reveal stark variation from state to state in the number of doctors per capita. Massachusetts had the most: 415.5 active doctors per 100,000 state residents, with 314.8 of those involved in patient care, compared to the national average of 258.7 active doctors and 219.5 involved in patient care. Mississippi, on the other end of the spectrum, had 176.4 active doctors and 159.4 in patient care. The stats didn’t look so different two years ago, but as the number of doctors rose across the board, the gap between Massachusetts and Mississippi widened. (To be fair, tertiary care centers in Massachusetts tend to see more out-of-state patients.)
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On a recent visit, my older brother challenged me to a dance-off. The forum was Wii’s Just Dance and the stakes (bragging rights) were high. Somewhere between Tik Tok and Walk Like An Egyptian* - my right hand gripping the controller, my arms and legs fighting against fatigue to hit each move with some semblance of precision - it occurred to me that these efforts were not unlike those of doctors and hospitals working toward quality standards.
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In the last decade, with the aim of narrowing the quality chasm between the health care we provide and the health care we ought to provide, policymakers have turned to performance metrics to define and motivate our success.
Doctors learn to share
As I near the six month mark of my internship year, it occurs to me that my experience has mirrored, in some ways, the evolution of American health care.
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I began the year working on the Ellison, a general medicine service with a traditional model of care. Among four interns, we split a list of 30-something patients and I was responsible for a cohort of up to ten of them. When I went home at the end of the day, I “signed out” my patients to the resident covering the floor that night. When I came back the next morning, that resident signed those patients right back out to me. I was intimately aware of every lab test and specialist consultation that had been ordered for the patient (at least, during the day) because I’d been the one to order them. As medical students, we’d been assigned individual patients and encouraged to take ownership of them, so this model felt familiar.
My next inpatient rotation was markedly different: The Bigelow is a team-based general medicine service that is unique to MGH. I became one of four interns sharing responsibility for up to 24 patients. We took turns playing different roles in their care - one day I was in charge of coming up with treatment plans for each of them, another day I scribed these plans onto daily progress notes, and a third day I admitted new patients to the floor.
What Dwight Schrute can teach us about patient safety
Thursday’s The Office hit close to home. In the episode, Dunder Mifflin CEO Robert California descends upon the Scranton branch and demands that regional manager Andy Bernard put an end to the staff’s sloppy errors. Dwight has a solution, carefully guarded in an accordion file: The Accountability Booster, an electronic device that registers mistakes - from late deliveries to accounting blunders. Five such strikes in a day is a home run, one home run and you’re out, Dwight explains with his trademark disregard for logic. The penalty for a strike-out is an automatic leak of incriminating emails to the boss and near-inevitable branch shutdown.
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Throughout the day, the red Xs accumulate as the social experiment unfolds: The accountants question Oscar’s mental math and distract Kevin, the weakest link, with a made-up assignment. The staff huddles around Jim as he attempts to hack into Dwight’s system and defuse the Doomsday device. When the error count hits five, chaos ensues and all hands are on deck to convince Dwight to stop his device and distract Mr. California from its potential consequences.
IMHO, this comedy of errors bears analogy to our relatively nascent patient safety movement.
Walking a mile: Why doctors should learn to feel your pain
Patient-centered care: Like most health policy wonk-speak, the term is both obvious and perplexing. (What kind of health care ISN’T patient-centered? Who else would doctors and nurses care for?, a reader recently asked me. It’s a fair point.)
In Sunday’s Boston
Globe magazine, I took a stab at understanding what it means to practice
patient-centered care through my story on
training doctors in this elusive art. A day later, Lisa Rosenbaum, M.D. wrote in The New York Times about the pitfalls of
training doctors to be nice to patients (more on this in a bit).
Here’s how I understand patient-centered medicine: it means keeping the individual patient at the forefront of, and actively involved in, decisions about his or her care. It is a principle that seems to help us take better care of patients and may even lower health care costs. Though it seems intuitive, many doctors aren’t good at doing this, and researchers find that bad habits start early in medical training.
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Perverse incentives in residency training
It was an hour into my overnight shift and three new patients had already hit the floor. One of the nurses on our medical unit pulled me aside and asked me to see another patient who had been with us for days: a 20-something man who’d come in for treatment of his blood disorder.
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The patient had just developed a cough and she asked if I wanted him to be tested for the flu. If we did test him, then we’d be obliged per hospital policy to put him in a private room, even before the results were in, to avoid infecting his roommate. And because our floor only has 24 beds in single and double rooms that are divvied out based on gender and the risk or presence of certain infections, this would mean one fewer patient for me to admit that night - four instead of five in a span of 12 hours. It was a very tempting proposition.
Making health care more productive
Never tell a medical resident that she doesn’t work hard. In a 16 hour night on my current inpatient service, I’ll care for up to 24 patients on the hospital floor and admit up to five new ones: examine them, order their medications and laboratory tests, dig up their prior medical records, write several page notes about them, maybe extract fluid from their bellies or stick needles in their arteries to measure their oxygen levels. I’m lucky if I have a ten minute break to gulp down some leftover cafeteria food for dinner.
It doesn’t seem fair, then, that the health care industry has had negative productivity growth for the past 20 years.
But it has, argue Bob Kocher and Nikhil R. Sahni (who is my fiancé, incidentally) in a Perspective published in this week’s New England Journal of Medicine. (Really, honey, if you think I should spend less time watching Gossip Girl, you don’t have to tell me via an internationally distributed journal.)
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Extreme couponing for medical residents?
The Accreditation Council for Graduate Medical Education (ACGME) holds residency programs accountable for six competencies—knowledge, skills, and attitudes that it believes are necessary to make good doctors. These competencies reflect our evolving views of quality in health care (the two newest ones are systems based practice and practice-based learning and improvement). The list does not include, as one of my co-residents suggested on a recent quiz, smelling good and wearing shoes.
In keeping with the times, what about a seventh competency: cost-conscious care that maintains or improves on the quality of this care? Steven Weinberger of the American College of Physicians made this argument in a recent article.
It would certainly be timely, even overdue: Our health care costs continue to escalate. According to one estimate from the Institute of Medicine, 30% of these costs (more than $700 billion per year) may be wasteful.
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The Patient Safety Report
Ordinarily, I would have griped about the incident with my co-interns and moved on with my day: While I was on call, a patient arrived from the Emergency Department (ED) to our floor without verbal pass-off (read: phone call) from the ED. This pass-off is standard protocol meant to let us know that the patient is en route and to communicate key information - Is he in stable condition? What drugs did he receive in the ED?
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So I called the ED and talked to the responsible provider, who was apologetic - she had spoken to the patient’s primary care doctor who had arranged for the admission and hadn’t realized that she should contact me as well. No harm done, I thought. Now to get on with my work.
During rounds, I mentioned the incident in passing and an attending involved in patient safety at MGH encouraged me to file a safety report. I’d heard of these from friends but had never submitted one, and I added the task to my To Do list.
Van Gogh on the Wards
It was a break from the usual slog. On those precious mornings, instead of talking about the oxygen saturation of our patients’ blood, we opined on the color saturation of paintings projected onto a screen. We took turns describing the sights, sounds, and smells of our commute to work. After class was dismissed, I carried a sketchbook with me on the T like I was some sort of artist, inhaling the nostalgic scent of my number 2 pencil as I sketched my converse sneaker for an assignment.
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Art Med Insight is an elective course offered several times a year to medical students and residents at MGH and elsewhere. It's meant to sharpen our powers of observation in medicine by practicing this skill with sculpture, paintings, and photographs. Some might call it hokey, but the approach has caught on with a large handful of medical schools and residency programs and there's growing evidence that courses in art observation and critique can improve the trainee's ability to articulate clinical observations and analyze complex information.
Habits
At the beginning of internship year, even the simplest tasks take forever.
A dismaying chunk of our more limited time and brain space is occupied with logistical quandaries: What tabs do I click on to order an EKG for my patient? Where on earth are the consent forms for a blood transfusion? Who do I have to call to get a cast boot around here?
And then, we have to make clinical decisions. Sobered by the new-found power of our prescription pads and ordering privileges, we deliberate and chew over everything from “laxative or stool softener?” to “what are the chances this patient is having a heart attack and how aggressively should I evaluate it?”
Of course, such decisions are shaped (and sped up) by experience and by our deepening knowledge of the clinical literature, as I’ve seen even in my few weeks working in inpatient medicine.
As our habits develop, I’ve also come to appreciate the less celebrated influences on them -- the incredibly varied habits of the senior doctors we work with, the so-called "cultural" practices specific to institutions (MGH carries one sort of blood thinner, the Brigham and Women’s Hospital another; or certain Doctors Who Don’t Do Weekends). We act in the interest of saving time, of catering to our patients’ preferences (though not often enough), and of saving health care dollars.
There are a few studies that suggest that residency training is incredibly influential in physicians’ practice habits. One cited by Shannon Brownlee in her book Overtreated examined internists’ training sites and their scores on board exams. They found that doctors from residency programs at hospitals known to overtest and overtreat did more poorly than their counterparts on questions in which the correct clinical decision was to do nothing.
It’s hard to see the impact with any one click of a mouse or signing of a prescription, but accrued over years and across states, these varied habits create the practice variations that Jack Wennberg and others have found to have an enormous impact on American health and health care spending.
Of course, habits serve an important purpose -- they are adaptive shortcuts that let me get on with my job and take care of patients efficiently. But as they form in the coming months and years, I can at least be aware of their influences and try to separate out the good ones from the bad.
About the author
Ishani Ganguli, MD, is a journalist and a first-year resident physician in internal medicine/primary care at Massachusetts General Hospital. She studied biochemistry and Spanish at Harvard College and received her More »Recent blog posts
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