Saturday, October 31, 2009

Guest Blog: Advice to the Young Physician

Richard Colgan, MD, is a practicing family physician, Associate Professor and Director of Undergraduate Education in the Department of Family and Community Medicine at the University of Maryland School of Medicine. He is a Past President of the Maryland Academy of Family Physicians and serves as editor-in-chief of the Maryland Family Doctor. This guest post is excerpted from the conclusion to his recently published book, Advice to the Young Physician, which he describes as a book "for those who believe that there is an art to medicine, but are not sure where to turn to learn where to find it, beyond the role modeling which their exemplary teachers display. By looking through the history of medicine, the author identifies some of the recurring themes of the art of medicine, as taught or displayed by some of history's greatest physicians." You can preview the book's cover on my Shelfari bookshelf.



God, let me begin each clinical encounter by always putting my patient's needs first. Grant me the strength to not be seduced by the allure of worldly pleasures, so as to be the best healer I can be, as I look to be thorough and careful in practicing my art. Guide me as I practice this sacred vocation. May I have the wisdom to learn from the lessons of my teachers, as I contemplate how to best serve each person who seeks my counsel. Help me to use all of my senses as I strive for excellence in caring for my patients, and to understand that if I cannot help someone, then at a minimum I will do no harm.

Strengthen me to have an inner and outer calmness when faced with the inevitable difficulties that lie before me. Show me how to best educate my patients on how to live longer and healthier lives, while being open to learning from those whom I serve. Show me how to be temperate and modest as I look to assist nature by incorporating proper diet, exercise and my patient's own resources in their overall care. Never let me forget that I am caring for someone who is suffering from a disease, and not taking care of a disease.

May I never forget my duty to practice medicine based upon a conviction of pursuing altruistic beneficence, marked by showing compassion for others as I commit myself to a life of service. May I not abandon, but look to serve the poor and advocate for those who suffer because of disparities in our health care system. Remind me to keep matters between physician and patient confidential and that I am accountable for my actions. May I always show respect and care for myself and my family, while being kind in my everyday interactions with others.

I ask you for humility in knowing the limitations of my art. May I always end each encounter with my patient knowing that I have done my best in assisting you by applying the bandages, while taking comfort in the fact that only power greater than I heals.

- Richard Colgan

Thursday, October 29, 2009

Doctors' conflicts of interest can harm your health - Part 2 of 3

For the uninitiated (which aptly described me when I attended my first conference, the American Academy of Family Physicians Scientific Assembly in Orlando in October 2004), medical conferences can be truly awe-inspiring things. I'm not talking about the quality of the lectures, procedural workshops, or other officially sanctioned learning activities. I'm talking about the mammoth Exhibition Hall filled with wall-to-wall twelve-foot tall displays marketing the latest blockbuster drugs, medical devices, and electronic gizmos to physicians. Impeccably attired, physically attractive (and in some cases, stunning) salesmen and saleswomen beckoning conference attendees toward their wares - I remember that the Exhibition Hall that year included several high-end massage chairs, an operational 3-dimensional pregnancy ultrasound, and countless smaller "goodies" such as free pharmaceutical company-emblazoned bags, flash drives, cellular phone headsets, prescription pads, and penlights.

The supposed rationale for providing a separate "exhibit hall" is to cordon off commercial activities from genuine medical education. Conference speakers are generally required to disclose affiliations with industry that might represent conflicts of interest (COI); for example, a speaker who works for Pfizer (maker of the popular cholesterol-lowering drug Lipitor) could hardly be expected to give unbiased recommendations regarding threshold levels for cholesterol treatment. Cynics note that because conference organizers rarely make an effort to verify the accuracy of such disclosures, many speakers fail to disclose disqualifying affiliations. Judging from a recent study published in the New England Journal of Medicine, the cynics are right.

In this study, investigators compared the COI disclosure statements of speakers at the 2008 meeting of the American Academy of Orthopaedic Surgeons with publicly reported information from manufacturers of orthopedic devices. They found that more than 20% of speakers failed to disclose payments related directly to the topic of their presentation, and fewer than half of speakers disclosed payments that were judged to be less related to the presentation topic. More than 80 percent of these payments were greater than $10,000; more than 40 percent were for more than $100,000. (By comparison, before I become a federal employee, the largest honorarium I ever received for giving a talk was $800.) Speakers were statistically more likely to disclose payments greater than $10,000 - but it's not as if $9,999 is exactly chump change!

So what do I conclude from this study? That I should never again trust an orthopedic surgeon who tries to teach me something? That I clearly chose the wrong medical specialty, if financial success was my measuring stick? I prefer to look on the bright side: at least these conflicts of interest, and the myriad ways that unscrupulous physicians and commercial interests try to game the disclosure system, are finally seeing the light of day. As President Reagan said about his policy toward arms control during the waning days of the Cold War, "Trust, but verify." That maxim should be medical education's policy, too.

Tuesday, October 27, 2009

Public option or no public option: that is not the question

I'm interrupting a series of posts on conflicts of interest in medicine in order to say something about health care reform, which is approaching a critical point as Senate and House negotiators try to combine the various bills that have emerged from different committees. One widely reported point of contention is whether or not the final bill should include a so-called "public option," a government-sponsored insurance product that its supporters feel would provide needed competition with private insurers and make the cost of insurance more affordable. Opponents believe that the public option would end up driving private insurers out of business and end up being the only option. While I think that this idea is hardly revolutionary - Medicare, after all, is a "public option" for senior citizens that's been around for 45 years - I also believe that it's a distracting side issue to what our health care system really needs: comprehensive cost control.

Public option or no public option, health care premiums are on a course to consume the entire average income of an American household by 2025 - a mere 16 years from now, when my oldest child will be entering college. While you might think it's okay in an abstract sense to spend a million or more dollars to save one life (especially if it's your life or that of someone you love), even the wealthiest nation on the planet can't afford to pay for every possible intervention that promises a tiny bit of improved health or longer life for somebody. We need to make choices, as a society, about our collective health priorities.

Other measures that have the potential to address skyrocketing costs (but are being underemphasized or completely ignored in the focus on the "public option") include:

1) Flat-fee primary care combined with insurance for catastrophic medical events. Your car insurance doesn't pay for oil changes, your home or rental insurance doesn't pay for furniture, and your health insurance shouldn't pay for basic primary care visits.

2) No-fault compensation programs for all but the most egregious medical errors (e.g., if your surgeon cuts off the wrong leg, or your internist prescribes toxic drugs for conditions you don't have, you would still have the right to sue).

3) Reforming medical education and continuing medical education to provide safeguards against conflicting interests (e.g. pharmaceutical and medical device companies) that lead to inappropriate or potentially unsafe prescribing practices. More on this in future posts, but I think we have a long way to go.

4) Let the insurance "bureaucrats" make informed decisions based on cost-effectiveness of medical interventions. I know that this is an unpopular position. I'm not talking about setting up death panels, or even dialysis panels, which actually existed in the past. And I'm not saying that insurance shouldn't cover every medication or surgery with a high price tag. What I'm advocating is that we take a hard look at what we're getting for the billions we spend on health care, the way you make decisions about how to spend your own limited budget. After all, drug companies still do business with the United Kingdom, even though their National Institute for Health and Clinical Excellence (NICE) applies strict cost-effectiveness criteria to determine whether drugs are worth paying for. If a drug doesn't meet NICE's standard, the company will often lower the cost of the drug so that it does. Not so in the U.S. - which is why we generally pay the highest prices.

Saturday, October 24, 2009

Guest Blog: Medicine in Translation

Since I started this blog a few months ago, I've supplied nearly all of the content myself, occasionally quoting others in posts but also adding reflections of my own. However, I always planned to eventually invite guest bloggers with other "common sense" perspectives on health and health care to add to the variety and breadth of content that you will find on this blog, and this is the first of (hopefully) many guest postings.

A practicing internist and Assistant Professor of Medicine at my alma mater (NYU School of Medicine), Danielle Ofri, MD, PhD is the author of three books about her medical experiences and also serves as editor-in-chief of the Bellevue Literary Review. The following piece is excerpted from a blog that was originally posted on the website of Psychology Today.



If asked what a doctor does, most people would probably come up with the standard description of diagnosing and treating disease, usually while wearing an ill-fitting white coat. Before I entered practice, even during my medical training, that probably would have been my answer too. But my years in the trenches of real medicine have altered that definition greatly. I do spend time doing the things I learned in medical school like diagnosing disease and writing prescriptions, but that turns out to be only a part of the job, often a very small part. ...

But when I think about what might be the overriding job description, the one that not only incorporates the above but also extends to the more existential aspects of medicine, I see the doctor as a translator. For most people, medicine is a foreign country, with its own language, customs, and mores. My patients are immigrants to this country, and many feel very disoriented. My job, as their physician, is to translate this alien world for them, to help them acclimatize and hopefully thrive. ...

Being a translator can often be burdensome. It is not enough, as a doctor, to assemble the clinical details, deduce a diagnosis, compose a treatment plan. You also have to be sure the patient understands it all—and that can be an infinitely harder and longer process. But there are also many joys to being a translator. I once had a new patient who suffered from both osteoporosis and osteoarthritis. Her previous doctor had worked out a meticulous treatment plan, including hand-written charts of how and when to take each pill. Yet the patient was entirely confused about her medications.

After a complicated conversation with many false starts, I finally realized that the patient thought that osteoporosis and osteoarthritis were one and the same thing. The pills for each condition were dumped into a communal pill bottle and taken in a random manner. My “diagnosis” was that this patient did not have a full understanding of the language of medicine and that these terms had never been fully translated for her. We spent a long time going over the difference between osteoporosis and osteoarthritis. It wasn’t easy, but by the end of our visit she had a basic comprehension that these were two different diseases and the medicines were treating entirely different things. This patient had many more serious medical conditions to contend with, but she seemed delighted at this small victory, that she finally understood these diseases, that she finally “owned” this aspect of her health.

There was, of course, no place on the insurance form for this sort of effort. The insurance company would never pay my hospital for the painstaking “translation” work that is so critical to good health. But that’s the reality. Luckily there is the patient’s happiness and hopefully improved health that is the real payback.

-Danielle Ofri

Tuesday, October 20, 2009

Doctors' conflicts of interest can harm your health - Part 1 of 3

As a government employee when I'm not blogging, I think that fears about a "government takeover" of health care have been greatly exaggerated by misunderstanding and persistent rumors (e.g. federal death panels) masquerading as facts. One often-stated fear in the reform debate is that personal medical decisions will be taken out of the hands of doctors. But even those who believe that our health system could use more evidence-based medicine (myself included) generally agree that individual care decisions should be left up to doctors and patients. Have you considered, though, how doctors continue to acquire knowledge to make good decisions after they complete their medical school and residency training? I finished medical school more than 8 years ago, and the aphorism "Half of what you learn in medical school will be out of date by the time you graduate" is more or less correct.

From my experience, most doctors rely on three primary sources of new information: scientific journals (such as the one I edit, American Family Physician), medical conferences, and information from pharmaceutical company representatives (or "drug reps"). You would probably expect information from the latter to be biased, since drug reps are trained to sell drugs, not to do what's best for patients. Organizations such as No Free Lunch have established that physicians who allow drug reps access to their practices to distribute free drug samples, meals, and other promotional products (such as pens, prescription pads, etc.) often end up prescribing expensive or second-line drugs to patients instead of the drugs recommended by national guidelines. Led by the American Medical Student Association, many medical schools have now established strict rules governing interactions between students, faculty, and drug companies.

But pens and drug samples are only the most visible ways that drug companies push their products. Recently, it has become obvious that an entire hidden industry of drug-company funded "ghostwriters" has been publishing articles in medical journals for years. A study by the editors of the Journal of the American Medical Assocation found that from 2-11 percent of articles published in 2008 in six major journals (including the New England Journal of Medicine) were actually written by people who were not named as authors. While the study could not establish that these particular ghostwriters had been directly financed by drug companies, the practice of writing up a scientific study and then recruiting a lead author (usually an academic physician under pressure to "publish or perish") has been well-documented in the case of previous "blockbuster" drugs that were taken by millions of patients for common conditions but later turned out to have dangerous or fatal side effects, including Wyeth's Prempro and Merck's Vioxx.

In an upcoming post, I'll discuss recent efforts by medical journals to save their scientific credibility from the "dirty little secret" of drug company influences.

Thursday, October 15, 2009

Post call: resident duty hour regs in perspective

"Post call" is shorthand for being at work the day after having spent the entire previous day and night working. While this sort of situation isn't unique to medicine (for example, attorneys in some specialities pull similar sleep-deprived work shifts early in their careers), it's probably the best known, thanks to medical-themed television shows such as "ER." In the days when medical interns lived at the hospital and were almost exclusively unmarried men, being post call every other day and regularly working more than 100 hours per week was not at all unusual.

Fortunately, by the time I did my family medicine residency (2001-04), matters had improved significantly. Although the Accreditation Council for Graduate Medical Education didn't mandate that programs limit residents to 30-hour shifts and an 80-hour work week until 2003, my program made the change in my second year. We all got more sleep, and I don't feel that quality of care suffered - what experiences I may have missed out on by not stumbling around the wards on a post call afternoon, I made up for by being awake to read more about the patients I was managing. So it strikes me as odd that serious physicians are still debating whether enacting the regulations was the right move - as if the benefits of more sleep to residents can be measured scientifically in any complete and objective way.

In 1997, Vancouver resident Rachel Rose, the author of two books of poetry (most recently, 2005's Notes on Arrival and Departure) published in JAMA what has long been my favorite evocative description of caring for a soul mate who's post call.



Postcall you come home diminished, wan, your hands
Faltering at the lock. You feel a need to tell me
Each patient’s history before you sleep,
The progress of each malignancy, the way the family
Spoke to you, the suffering that makes death a release.
I understand. But I wait for you, Isabelle,
Not your stories of the progress of the dying.
I lead you to bed like a child, almost crying
With fatigue and despair these anaemic mornings
When you have donated all your strength
And then come home to me, stricken, empty
And grateful for the smallest gesture of tenderness,
My easing your heel from your boot as you undress,
Holding you while you try to reclaim your membership
As one who sleeps. Your limbs twitch
Like a dog’s, hurrying into dreams, your lips
Part with sighs. I soothe you with my weight,
Whisper about the snow piling up outside.
Your eyes close, it’s late afternoon, slow repose
Beckons. But even in dreams your fingers pleat the quilt
As if gathering the flesh of an arm before a shot.
I understand. Accountability never leaves your hands.

– Rachel Rose

Saturday, October 10, 2009

Mental health care: a Bellevue success story

Although I trained in family medicine and have practiced in a variety of settings, I've never had the experience of being a small-town family doctor - the kind with an office adjoining his house and who runs into his patients regularly at the grocery store. In fact, the only time I can recall meeting a patient on the street was nearly a decade ago, in Manhattan, of all places, when I was fourth-year medical student who had recently finished a psychiatry rotation at Bellevue Hospital. The experience inspired me to write a poem that I share below. (There is a health care reform angle to this story as well, but I'll save that for another post.) "Sanders" is a pseudonym.



I hardly recognized him. How changed
He appeared from that combative, demanding
Patient I knew on those 90-degree days in July!
Then he had been overflowing with suggestions
For his treatment – use this painkiller, not that one –
Living up to the secondhand stories of his terrorizing
Orderlies at Beth Israel. “Can’t anybody see a doctor here?”
Loitering at the nurses’ station, demanding his methadone
On the clock. At war with Sanders over the morality of the unit.
We groaned. Later, dominating therapy groups, he puffed up
With pride at his “progress.” I shied away, leaving him
In the spotlight one last time for others to examine.
Antisocial personality disorder, the attending pronounced.
Sense of entitlement. Which made me wince.
The man just needed a stage. Those final days,
I watched him play spades with the pretty volunteer,
A new man. Praising me to the skies, his Good Doctor.
I saw him on the sidewalk this morning, with headphones
And shiny Giants jacket, inhaling the crisp autumn air.
He shook my hand, wished me the best.

Thursday, October 8, 2009

Medication errors and patient safety

When physicians and health care administrators talk about about "improving patient safety," they're usually referring to preventable events that occur in hospitals: blood transfusion mismatches, or infections in intensive care units, to give examples. But the vast majority of health care takes place in communities, in outpatient or ambulatory care settings ("ambulatory" being something of a misnomer, since wheelchair-bound patients can and do seek treatment in offices). In this setting, errors in dosing prescription and over-the-counter medications are an important safety issue.

Taking doses that are too large, or taking correct doses too frequently, can cause serious and even fatal side effects. An advisory committee to the Food and Drug Administration recently voted to lower the maximum daily dose of Tylenol due to evidence that many adults sustain liver damage by inadvertently taking too much. On the other hand, inadequate dosing of medications can result in conditions such as epilepsy, diabetes, and high blood pressure being poorly controlled.

Patients may take medicines improperly because their doctor gives inadequate oral or written instructions. More prescription medications also may make errors more likely. In a 2006 study published in the Annals of Internal Medicine, Dr. Terry Davis and colleagues examined the relationship between literacy levels and a patient's understanding of common prescription drug labels.

In this study, 395 English-speaking adults were recruited from 3 primary care clinics' waiting rooms. They were shown 5 labeled prescription medicine bottles and asked to describe how they would take each medication, including the number of pills to be taken in a day. The interview concluded with a health literacy assessment to determine the patient's literacy level: low (sixth grade and lower), marginal (seventh to eighth grade), or adequate (ninth grade and higher).

Out of 1,975 responses, 374 were incorrect. Most incorrect responses were dosage errors (51.8 percent) and dose frequency errors (28.2 percent). A few patients were unable to find the instructions on the label (5.8 percent) or admitted to being unable to read (3.2 percent). Incorrect responses were strongly associated with low and marginal literacy levels, and the risk of an incorrect response increased with more medications used. Surprisingly, many patients who read the instructions correctly still counted out an incorrect number of pills.

This study reinforced my longstanding (but unfortunately time-consuming) practice of asking all of my patients who take regular medications to bring in their pill bottles at every visit so we can go over how to take each one properly. Quite often, I'd find that another doctor had added or changed a prescription without telling me about it, often leading the patient to take two different medicines for the same condition. Without a single physician coordinating care, medication errors become almost inevitable. So how might health reform address this problem? Stay tuned.

Monday, October 5, 2009

Why "patient centered" health care isn't the norm

If you aren't very familiar with medicine or have had few encounters with the U.S. health system, you may think that the concept of health care being "patient centered" is so incredibly obvious that it shouldn't need to be stated. After all, we wouldn't need health care if people didn't get sick, and the ultimate role of doctors, nurses, hospitals, clinics, and medical technologies is to either prevent patients from getting sick or to help them get well. Yet the term "patient centered" is actually a surprisingly new idea in a complex health care system that has long focused on treating discrete diseases and organ systems (e.g. the heart, the lungs, the kidneys, etc.) rather than whole patients.

When I did my medical training a decade ago, it often seemed to me that medical students were encouraged to depersonalize patients and not listen to their concerns. During my surgical and medical rotations, a patient with stomach pain became "the abdomen in room 6," and the patient with a rare or difficult-to-diagnose illness became a "great case." There was a distinct pecking order within the prestigious academic hospitals where I did my clinical rotations - attending physicians at the top, followed by fellows, residents, nurses, students and other trainees, and finally, at the very bottom, the patients themselves. We took for granted that on the basis of years of studying medicine, we knew what was best for patients, and the few who questioned whether our care was actually making their health better were quickly labeled as "difficult" or "non-compliant."

National patient safety advocate Sorrel King, whose one-year old daughter died in Johns Hopkins Children's Center due to preventable medical errors, writes in her poignant 2009 memoir Josie's Story that being in awe of the technical skills of her daughter's physicians made her reluctant to challenge questionable medical decisions until it was too late. One of the reforms that she and her foundation have encouraged hospitals to adopt is the development of rapid response teams that could be triggered by anyone in the medical hierarchy who had concerns about a patient's condition, including - and especially - patients and family members.

But you don't have to set foot inside a hospital to know that we have a long way to go to get to patient centered care. It's typical in most parts of the U.S. to have to wait months to consult a family doctor about a non-acute problem. When you finally arrive at the office, you often aren't ushered back to an examining room until half an hour or more after your scheduled appointment time, then have to wait some more to actually see the doctor, who may spend five minutes or less with you before he or she is racing off to the next patient. (I'm happy to say that not every practice I've worked at fits this description - for an example of how electronic medical records and "advanced access" scheduling can greatly reduce such inconveniences, see the website of the one of the premier primary care practices in the DC Metro area.)

In future posts, I'll write more about a few important topics that I've only touched on here: improving patient safety, shared decision making, and practice transformation, including the patient centered (there's that term again!) medical home.

Thursday, October 1, 2009

Taking the Pulse of primary care medicine

Previous posts may have implied that restoring an adequate supply of U.S. primary care physicians is all about money - that is, less student loan debt and reducing the salary disparity between "front-line" clinicians and subspecialists. If only it were that simple! Alas, even if student loans were forgiven and salaries were doubled, it is unlikely that students would immediately flock to family medicine, pediatrics, and general internal medicine. The reason: time - or more precisely, a lack of it.

Paul Gross, MD, an academic family physician at Montefiore Medical Center in New York and editor of the online magazine Pulse: voices from the heart of medicine, recently wrote a poignant piece about the challenges of family doctoring in the context of 15-minute (or shorter) appointment slots. In "Late Again," Dr. Gross observes:

"The joy of primary care is also its curse. With each patient, I have to keep track of everything--the trivial and life-threatening, the physical and mental, the acute, the chronic and the preventive. And try as I might, I simply don't have enough time. ... My colleagues and I are often still seeing our morning patients at 1:00, when our afternoon session is supposed to begin. Lunch hour? Wouldn't it be nice. And I have it easy. One hears of offices scheduling patients every ten minutes--every ten minutes!--and doctors "seeing" fifty patients a day.

Doctors talk of running on a hamster wheel. Patients complain that their doctors seem distracted, don't take the time to listen, and run late--as I routinely do. Am I a bad doctor--disorganized and inefficient? Or maybe I'm doomed to fall short as I bump up against powerful economic forces--the 'do-more-with-less' pressures that make medical administrators everywhere create schedules like mine, designed to bring in enough money to keep health centers afloat but which end up hustling me and my patients along at an impossible pace. As a nation, we are now trying to fix our foundering healthcare system. Before we set new rules in place, shouldn't we first ask this basic question: how much time is actually required to see a patient?"

As all physicians know, time spent with patients doesn't include time spent documenting visits, reviewing test results, making referrals, filling out administrative paperwork, et cetera. A 2007 study in the Annals of Internal Medicine estimated that doctors in an academic geriatric practice who saw only 14 patients per day (most docs in private practice see 30 to 40) spent nearly 8 hours per week on these non-reimbursed tasks. This reality has led some solo family physicians to adopt a no-frills practice model that relies on few (or no) staff, leading to lower overhead costs and more time to see patients. Unfortunately, more time per patient means fewer patients per day, so such a model applied nationwide would require training even more family physicians, in addition to the ones we already don't have.