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On cabdrivers and patient empowerment
The cabdriver pulled up to take me to the community hospital where I work several weeks each year. Settling into the back seat, I made my request before he reached the intersection: "Could you please take 93 South?" He was quick to ask me why, and I hesitated. I had taken this route dozens of times and had usually found it to be faster than the alternative, I said, but what if there was something he understood, with his superior highway smarts and his advanced navigation technology, that eclipsed my knowledge? He nodded at my explanation and took the right onto the highway.
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A few minutes into our ride, I picked up my cell phone and my mother opened with her usual dramatic flourish. This time: "Ishani, you’re never going to fix your health care cost crisis." Earlier that day, she had gone to her annual physical with her primary care physician (PCP) of more than a decade. As in the previous year’s visit, her doctor ordered an electrocardiogram (EKG, or heart tracing) even though my mother has no history of heart disease. She gave my mother a lab slip to check her blood counts and electrolytes - tests that have limited value when performed routinely and not for a specific medical issue. She referred my mother to a gynecologist for a pap smear even though she is older than 65 (the guideline-recommended age to stop this screening for cervical cancer).
A week after the Boston bombings, a chance to reflect
I was sitting in the resident workroom at Massachusetts General Hospital (MGH) when my co-resident showed me the text from her sister: two explosions had shaken the finish line of the Boston marathon. Though news sites had not yet published the headline, it was immediately corroborated by the cacophonic wails of ambulances heading towards us and our shock was quickly replaced by the urge to learn more and to do something. We scrolled through the emergency department’s internal log and saw with horror as patient after patient entered with the chief complaint of "amputation." We made our way to the residency office to report our availability to pitch in, passing orthopedic residents called in to help and sharing the elevator with a case manager frantically wheeling one of several patients to another part of the hospital to make space in the Emergency Department (ED) for the expected deluge of injured runners and onlookers.
A few of us were recruited to help clear out the ED by expediting hospital admissions for patients with medical problems like pneumonia or heart failure. Other internal medicine residents continued their usual - now busier - work on the floors. Those, like me, on elective stayed close by in the off chance we were needed. We huddled in the resident lounge, checking in with our families and friends, scanning the ED log, and reading out loud Twitter updates filtered by source credibility. We bemoaned our internal medicine training - we could treat a heart attack but were useless when it came to mangled limbs - and shared our magnified respect for our colleagues in surgery and emergency medicine.
FULL ENTRYChronic care at Walgreens? Why (not)?
Walgreens, the country’s largest drugstore chain, announced on Thursday that its 330+ Take Care Clinics will be the first retail store clinics to both diagnose and manage chronic conditions like asthma, diabetes, high blood pressure, and high cholesterol. The Nurse Practitioners (NPs) and Physician Assistants (PAs) who staff these clinics will provide an entry point into treatment for some of these conditions, setting Walgreens apart from competitors like Target and CVS whose staff help manage already-established chronic illnesses or are limited to testing for and treating minor, short-lived ailments like strep throat.
A one-stop shop for toothpaste, prescription drugs, and a diabetes diagnosis? The retail clinic phenomenon has its appeal: it allows patients convenience and better access to care through longer hours and more locations than our health care system now provides. Walgreens leaders bill their latest offering as a complementary service to traditional medical care. They envision close collaboration with physicians and even inclusion in Accountable Care Organizations, according to reporting by Forbes' Bruce Japsen (though it's not clear how the retailer would share the financial risk or savings in such a model).
FULL ENTRYRevisiting non-urgent emergency department visits
Yesterday, I cared for one patient with chest pain, another with burning pain on urination, and a third with sharp belly pain. Two of the three came to see me in my primary care clinic, the third in the intensive care unit (via the emergency department (ED)). Who went where? You'd be surprised.
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In her most recent post, Pauline Chen writes about the unfairness of penalizing patients for visiting the ED for non-urgent problems - after all, it is often difficult for doctors, let alone patients, to define them as such until after they have passed. She cites a recent study of nearly 35,000 ED visits finding that the symptoms that brought patients in for what were ultimately primary care-treatable conditions were indistinguishable from the symptoms that brought in the sicker patients.
Tethered to a pole: the challenge of end of life decisions
When I attended the Association of Health Care Journalists (AHCJ) conference in Boston last weekend, discussion swirled on the topics of unsustainable costs of care, doctors’ incentives under traditional payment models to order more tests and treatments, and the struggles of patients’ family members to avoid unwanted care at the end of life. That Sunday night, I was back at my day job (so to speak) in the Cardiac Intensive Care Unit (CCU), a place synonymous with the utmost care and where I first grew accustomed to difficult conversations about such topics.
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I was chatting with some of the nurses during a lull in our work and the conversation turned to a patient several of us had cared for in the past. He was an 80-something, emaciated man with an irreversible lung condition who seemed on the verge of passing on for much of his hospital course. The medical team had spent hours talking to him and his family about how aggressive to be with his care. Consistently, he and his family that he should have it all - even when that meant a tracheostomy tube through a surgical hole in his neck to help him breathe, accompanied (necessarily) by a feeding tube that would directly enter his stomach. One morning a few days after the procedures, the patient awoke and began cursing in a loud whisper at anyone within earshot - why was this object in his throat, and this other one in his belly? Who would do this to him?
US patients can choose better
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Would an ad influence your decision?
I came across this image on Facebook - part of a British campaign launched in late 2011 by the Leicester region of the National Health Service (NHS) in response to winter pressures on their Accident and Emergency units (A&Es, aka EDs). The campaign website lists the uses for various care options (Self-Care, Pharmacy, General Practitioner (aka PCP), Urgent Care Centre, Emergency Department & 999 (translation: 911)) and lets you download an iPhone or Android app to make the choice.
As it turns out, similar campaigns were launched in other regions of the United Kingdom, spurred by a national policy mandate to reduce A&E traffic and and to treat patients in the appropriate medical settings - after all, mismatches cost patients time and money in addition to placing a larger financial burden on the health care system. One such effort in London even involved planting an NHS employee in front of the A&E to redirect patients with minor issues to the on-site primary care clinic.
The bitter pill, chewable for doctors
When I read Steven Brill’s epic takedown of health care costs in Time, my first reactions were sticker shock and outrage at the capricious ChargeMaster that has pushed so many Americans into bankruptcy. This was followed by unease: Did I really need to use that second square of gauze (priced at $77 a box, according to Brill) after placing that central venous catheter the other week?
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As he dissects a series of medical bills and follows each line item to its source, Brill points the finger both at marked-up prices by manufacturers and hospital administrators stemming from our lack of price controls and at the quantity of line items (ie. the overuse of resources). Setting aside the critical need for payment reform and true price competition, doctors have a significant role to play in mitigating that second offense. To this end, we’re now meant to learn about medical costs as part of our medical training, though institutional norms and perverse incentives have made this challenging.
Over-testing on the medical boards
I just took step three of the national board exams - the final in a series that all U.S. physicians must pass to practice medicine unsupervised. The two day exam, composed of multiple choice questions and simulated patient cases requiring free-text answers, brought up subjects that we haven't thought about since medical school (Sick children? Terrifying.) The test also shed some light into how doctors think under pressure and why reigning in health care costs remains an uphill battle.
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I have to give credit to the test's authors. In the introduction to the simulated cases, they make a point of writing that over-testing and over-treating carry penalties (both on the test and for patients in real life). If a patient comes in with a headache and you order a brain biopsy straightaway, point deducted!
A doctor’s condolences
When a patient dies in the hospital, we go through a checklist that has become eerily mundane: Examine the patient to confirm the death. Notify the family, the senior doctor, the local organ bank, the admitting office, and (in some cases) the medical examiner. Fill out the report of death. Write a death note. Brace yourself against the emotional weight of the event and get on with your work. Nowhere in that process is a responsibility that should predate our medical training: the condolence letter.
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I'd never written one for a patient until last week in the Intensive Care Unit when our team's attending doctor brought up the idea. Instead of a fountain-penned, monogrammed note, ours was typed on hospital letterhead and signed with ballpoint pens. But it was a tribute all the same to what has become a dying tradition among doctors.
Quit (smoking) while you're ahead
I knew he was sick when he told me he'd thrown out his cigarettes on account of how badly he felt.
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Mr. P had gotten used to the breathlessness when he climbed stairs and the hacking, dry cough that followed him everywhere. What else could he expect after smoking three packs a day since he was six years old? But he had shown up in the emergency department earlier that afternoon, ended the decades-long standoff he'd held with the health care system, because whatever this was made him feel like he was about to die.
As it turned out, Mr. P had caught the flu on top of COPD, the chronic lung condition that is almost always caused by cigarette smoke. It was an all too common story.
Did your doctor get a flu shot?
Patients expect their doctors to espouse the same good habits that we foist upon you in the form of expert advice. We aren't always great at following through. But when the habit is getting a flu shot every year - and the repercussions clearly extend beyond our own health - I'd say we have a larger-than-usual responsibility to comply.
This year's Flupocalypse has hit harder than expected, prompting our mayor and others to declare states of emergency and journalists to beg Americans to get their flu shots (as of November, 65% hadn’t) with varying degrees of politeness. Of all people, those of us who have pledged to care for and protect vulnerable patients should get that message, so it still amazes me when I hear excuses to the contrary.
Christmas in the hospital
The hospital can be a strange place over the holidays. This year, it was work as usual, save the nurses' station festooned with tree lights, the occasional jolt of festivity from teen-aged Christmas carolers fulfilling their volunteer requirements, the frenzy of activity that came on the Friday before the holiday - arranging for patients to get procedures, speaking with consulting specialists, making follow-up appointments - and the unsettling quiet that dropped during it.
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I spent the past two weeks as the supervising resident for a team of five interns on a general medicine unit at Massachusetts General Hospital. One of my jobs was to oversee the admission, care, and discharge of the 20 patients on our team’s service, so I grew sensitive to trends.
Zen and the art of harm reduction
Between 7:30 and 10 a.m. on a glacial late November morning, a tall white van lingers at a street corner in Boston's South End. I consult my iPhone one more time to confirm that I'm in the right place and knock on the vehicle's glass-paned door. Ritchie, with his oversized Las Vegas baseball cap and faint smell of cigarettes, ushers me inside and I settle in across from him on one of the grey-upholstered seats to await the van's more typical visitors.
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Ritchie joined the Needle Exchange Van more than six years ago - after a midlife career change from furniture sales that was brought on by watching two friends and fellow Marine veterans start using, contract HIV, and die. My morning with Ritchie, part of a required residency rotation on addiction, offered a rare glimpse into patients' lives outside hospital walls and the important, if unsettling, work that complements our efforts as physicians.
The power of a nap
Protected naptime is a luxury usually reserved for the under-five-year-old set. Might it also be a tool to combat our country's astoundingly high rates of medical errors?
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Trainee fatigue has been a major focus of patient safety efforts since the mid 1980's, after 18-year-old Libby Zion died tragically from a drug interaction that may have been precipitated by residents working long hours. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) required all residents to work no more than 80 hours a week. In 2009, a congressionally-mandated report from the Institute of Medicine called for interns to work no more than 16 hours at a time and for all residents to take a five hour nap during longer shifts. By the time I started my intern year in 2011, the ACGME had enacted the IOM recommendations - on top of the intern work hour restrictions and a cap of 24 hours for more senior residents, we were encouraged to take "strategic naps" and offered online tutorials on staying alert.
Residency and the hidden curriculum
It’s that time of year: Amtrak is hiking up its travel fares. "All I Want for Christmas" is reclaiming its rightful place on mall playlists. And fourth year medical students are starting the interview process to match into a residency program - their next and potentially final stage of training.
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Over the next few months, these students will rank the programs they visit based on features such as geography, research funding, and hospital affiliations. But there's another factor to consider - one that gets little attention but that probably matters more for the kind of doctors they’ll become. You might call it the institution's culture or practice style. For trainees, it comprises the "hidden curriculum" - informal lessons about the delivery of health care that are learned through observation and cemented by repetition.
A recently published report from the Dartmouth Institute for Health Policy and Clinical Practice quantifies some of these cultural differences between hospitals and suggests that prestige and optimal care are not always aligned.
Younger doctor, bigger spender?
We know that physicians (and their pens/keyboards) are some of the main drivers in health care spending. But which ones are the biggest offenders?
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A recent study from the nonprofit RAND Corporation asked this question and found that newer doctors tend to run up higher health care bills for their patients than their more seasoned colleagues. The study, published in Health Affairs earlier this month, looked at insurance claims filed by more than 12,000 doctors in Massachusetts between 2004 and 2005. The researchers found that those with fewer than 10 years of experience generated 13.2 percent higher costs for comparable "episodes of care" (say, a series of appointments to diagnose and treat a breast lump) than doctors with 40 or more years of experience. Doctors between 10 and 40 years of experience fell somewhere in the middle. When they broke down the costs by types of care, the trend went in the opposite direction for preventative care (as opposed to care for acute or chronic illnesses): less experienced doctors spent less on prevention. Surprisingly, factors such as prior malpractice claims, practice group size, or whether or not the doctor was board certified had no significant impact on the cost profiles.
Stuck in the Emergency Room
The crowded emergency department (ED): It has become a symbol for our fragmented, inefficient health care system and for one presidential candidate, an acceptable alternative to expanding health insurance under Obamacare.
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In the wake of Hurricane Sandy, the visual has become more familiar than we'd like - the young and the old slumped forward on rigid plastic chairs in the waiting room, occupied stretchers lined up in tandem in the hallway. Some of these patients are sick enough to warrant a hospital admission but languish in the ED for hours to days until beds are available for them upstairs. This last group of patients - so-called ED boarders - has become a new focus of efforts to mitigate ED overcrowding. One way to address the issue? Assign a doctor whose only job is to take care of them.
Stuck on loop: why do patients have to repeat their stories?
The other night, a patient gave me a piece of his mind. Mr. Q was a middle-aged man debilitated by days of nausea, vomiting and intractable belly pain. That morning, his wife finally convinced him to get medical attention and drove him to our emergency department. On arrival, he sat in a cubicle in the waiting room and explained his story to a triage doctor: how he was doing well until he ate a particularly rich meal a few days ago. How he'd vomited five, maybe six times. How he hadn't noticed any fevers. How he'd tried Tums for his symptoms with little effect. After he was escorted to a bay in the emergency room, he repeated the unpleasant details for the resident who came in to evaluate him. This time, he added that he takes a statin for his high cholesterol, that penicillin gives him a rash, and that he doesn't smoke. Within the hour, he gave a repeat performance for the emergency room attending.
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Just as he was settling into his slightly-more-permanent bed on the medicine floor, here I was, poised before a laptop on wheels and demanding yet another re-hashing of a narrative that had grown both trite and physically exhausting: “So, Mr. Q. What brought you to the hospital?”
"Doesn’t anyone write this stuff down?" He followed with a few other choice phrases.
Patients and doctors benefit from shared notes
When I joined the Ambulatory Practice of the Future (APF) as a first-year resident, I learned that the primary care clinic had an open notes policy: whatever we wrote about our patients could be seen by our patients through a secure online portal. It was a startling departure from medicine's tradition of records shrouded in the secrecy of long, Latin-rooted words written in chicken scratch and kept out of patients' reach by mounds of paperwork.
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I liked the concept of open notes but wondered how it would play out. What would patients make of all the medical jargon? How could I be forthcoming in documenting, say, obesity or a personality disorder if I risked offending my unintended audience? The past year-and-a-half has convinced me that record transparency is worthwhile - even when balanced against the potential for discomfort. A recent article in the Annals of Internal Medicine shows how about one hundred primary care physicians (PCPs) and thousands of patients in Boston, Seattle, and Danville, PA came to the same conclusion.
Wheat from chaff: Making sense of the electronic health record
At 5am, Mr. A rolls onto the medicine floor: the fifth and final new patient to be admitted that night. The 70-year-old is well-known to our institution from his near-monthly hospitalizations and his primary care doctor, cardiologist, podiatrist, ophthalmologist, and both of his endocrinologists all work in-house. Unfortunately, for the intern admitting him (and for Mr. A), this translates into a few hours-worth of prior blood test results, MRI reports, visit notes, and discharge summaries to peruse. Where to begin? How to find the key details buried in this hoard of information?
Electronic health records (EHRs) have brought to health care both a much-needed modernity and an emerging challenge: how do doctors manage the rapidly growing quantities of health records that we are responsible for reviewing and that (theoretically) help us take better care of our patients, so that we can extract critical information while spending more time with patients and less in front of a computer?
Electronic health records in the classroom?
Outside a patient’s room in the cardiac intensive care unit (CICU), a senior doctor, a nurse, and several residents in various stages of wakefulness cluster for morning rounds. Each resident mans a computer-on-wheels (once called a C.O.W., the acronym was formally abandoned at MGH, legend has it, after a patient thought it was directed at her and took offense). One of the residents reads off laboratory test results from the patient’s electronic record. Another resident uses her mouse to toggle through the patient’s medications and share them with the group. The nurse reads aloud blood pressures and heart rates from a handwritten hourly log. As scribe for the day, I type these numbers to update a progress note that we’ll later print and place in the patient’s paper chart. Someday, these records will be completely digital, finally matching the wonderland of medical technology that is the CICU.
As the Electronic Health Record (EHR) slowly but inexorably assumes its rightful place in modern health care, obviating the ridiculous cultural norm of physicians with illegible handwriting, reducing medical errors, and making care (usually) more efficient, educators are asking the question: are we teaching this in medical school? Not consistently, it turns out.
FULL ENTRYWho are the costliest patients?
We’ve known for decades that a small fraction of Americans incurs the bulk of health care costs. A report released last month by the National Institute for Health Care Management (NIHCM) analyzes 2009 data to shed light on the patients we should worry about most. Their findings take on special relevance in the wake of Massachusetts lawmakers passing an ambitious health care cost control bill on Tuesday.
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As health care spending increases across the board, the cost distribution is becoming a bit less skewed – probably because more Americans are developing risk factors like obesity that lead to chronic and costly conditions like diabetes and heart disease, according to the NIHCM report. Still, in 2009, 1% of the U.S. civilian patient population ran up more than 20% of the nation’s health care bill at a cost of $90,000 per patient while 5% of the population accounted for nearly 50% of spending at a cost of $41,000. In contrast, the lowest spending 50% of the population spent an average of $236 that year, they found.
Disagreeing with your doctor: It’s harder than it seems
While our dad was in the hospital last winter, my brother shared with me his strategy for talking to the doctors we encountered - an approach honed over ten years of marriage to an internist and dozens of pediatrician visits for his two little boys.
He asked smart questions that used medical terms to earn their respect, he told me. He was appropriately deferential, admitting his lack of clinical experience. If he disagreed, he gently offered empirical evidence to support his argument and then hoped that the doctor listened and didn’t get defensive.
I’ve written before about shared decision making: the idea that for medical decisions in which there is no clear right or wrong answer, doctors and patients should collaborate on choosing a path that best fits the patient's preferences. The success of this approach rests on the ability of patient and doctor to have a frank conversation. But this has been historically difficult and a study that was published last week in the Archives of Internal Medicine helps explain why.
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That’s a tall order, even for the savviest of patients.
The Affordable Care Act and me
When I learned about the Supreme Court’s decision on Thursday to uphold (most of) the Affordable Care Act (ACA) I was lying in bed with a trash can at arm’s length, feeling horribly sick to my stomach. So I received the news with muted relief and dropped back to sleep.
Later in the day, I pulled myself out of bed and walked to the clinic where I work to ask for some help with my dehydration. My supervising doctor, nurse, and medical assistant escorted me to our corner room and into a rich brown leather recliner. They alcohol-swabbed my right arm, stuck a catheter in me, and then a liter of rejuvenating normal saline began its swift descent into my vein.
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Later in the day, I pulled myself out of bed and walked to the clinic where I work to ask for some help with my dehydration. My supervising doctor, nurse, and medical assistant escorted me to our corner room and into a rich brown leather recliner. They alcohol-swabbed my right arm, stuck a catheter in me, and then a liter of rejuvenating normal saline began its swift descent into my vein.
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How do you choose a doctor?
My friend Matt and his wife recently settled in Boston and were looking for primary care doctors. They had joined Blue Cross Blue Shield and had been invited to choose from thousands of providers (because who doesn’t love choice?). Overwhelmed, Matt emailed me for a recommendation, so I did what many residents had done before me: emailed the MGH internal medicine resident list-serve with a plea to take on the couple as patients. They went to the first bidder, one of three interns who responded within 20 minutes. He also happened to be a friend and someone whose clinical judgment I respect.
When I moved to Manhattan right out of college, I chose a doctor solely based on proximity (the cut-off was two street blocks) and name brand credentials. Since then, my growing foothold in the medical profession has afforded me the privilege of co-workers' recommendations. On the most recent go-around, I picked a female doctor billed as smart, thorough, and (still importantly) close by, though this time I liberalized my radius to a ten minute walk.
The process of picking a primary care physician (PCP) – the person who sees you undressed, grills you on your smoking habits, and prevents or treats what ails you – is a critical one, particularly as we move closer to models of health care (ACO, PCMH, you name it) that center around the PCP - patient relationship. Yet there’s little information out there to help us make the decision, especially for those of us without Friends-With-Doctor-Friends-Who-Are-Accepting-New-Patients. As any physician who self-googles can tell you, the now plentiful Yelp-like online doctor review sites that use anonymous comments and star ratings offer only random, often emotionally driven glimpses into a doctor’s merits and faults.
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About the author
Ishani Ganguli, MD, is a journalist and a second-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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