Ideal Medical Practices

Clinical gist and what we measure

Interesting commentary:  Lloyd FJ, Reyna VF. Clinical Gist and Medical Education JAMA Vol 302 No 12, 1332-1333

The authors describe two types of memory: verbatim and gist.

As you'd expect, verbatim is about remembering specific things & lists of things, gist is about remembering the underlying concept.

It seems that these memory types are independent - strength in one does not predict strength or weakness in the other.

From studies of these two memory types they point out three implications:

1:  "...gist memories endure over time and are more robust to interference from distractions such as stress or interference."
2: Learning environments assess for verbatim learning "List the three things..."  "What are the top ten diagnoses..." but are not as good at assessing gist.  Good clinicians rely on gist and can for the most part look up facts on the internet.
The authors give an example of a medical trainee presented with a 4 year old child with fever, runny nose, sore throat & family members sick with the same thing.  A verbatim assessment leads the trainee to assess for sepsis with blood cultures, to use imaging to evaluate sinusitis, strep test, etc.  A gist assessment would lead a trainee to diagnose a viral upper respiratory infection and prescribe acetaminophen rest & observation.
3: Medical training is typically aimed at lists and facts that can be easily gleaned from on line medical resources, yet evaluations of medical facts (that deteriorate in memory over time) imply that older clinicians are at risk of providing substandard care.

"The upshot of this distinction between verbatim and gist memory failure is that verbatim memory failure can be remedied easily with cognitive assistance from online information tools and is fundamentally different from not understanding the clinical gist..."

What I find most fascinating in this commentary is the degree to which medical quality is assessed based on the verbatim model and how little we measure based on the gist.  In Milstein's Health Affairs piece we see that the critical elements leading to improved care and reduced costs is the gist of effective primary care, yet we find the laudable principles of Patient Centered Medical Home bastardized into a verbatim list that more accurately reflects Doctor Centric Technology Marvel.

We really need a national conversation about how we measure quality.  The Cartesian verbatim approach is missing the forest for the trees.

Real patient-centered care: where more spending results in net savings

Four primary care sites in the United States constitute “medical home runs” because their patients incur 15–20 percent less (risk-adjusted) total health care spending per year than patients treated by regional peers, without evidence of reduced quality.  Milstein & Gilbertson Health Affairs article

An interesting article and worth reading.  Of particular note is what the practices do that results in the equal-or-better-outcomes and the lower-net-cost:

(1) an exceptional form of individualized caring tailored to preventing ED use and unplanned hospitalization for chronic illness
(2) efficient service provision
(3) careful selection of, and coordination with, medical specialists

Note the intersection between these observed qualities and the attributes of effective primary care:

1. "I can get care when and how I need it" - access
   
2. "I have a PCP/nurse who know me as a person" - relationship
   
3. "My PCP takes care of the bulk of my health care needs" - comprehensiveness
   
4. "My PCP coordinates any care I need in the health system" - care coordination
   

(adapted from Barbara Starfield's/IOM/WHO definition of primary care).

Milstein & Gilbertson call these "exceptional caring characteristics:"

1. we will take enough time during office visits to fully understand your illness and self-management capability and fine-tune your treatment plan
2. between office visits, we will directly provide or mobilize the help you need to succeed in implementing your self-management plan, with special emphasis on medication management
3. we will respond promptly 24/7 when you ask for urgent help between visits
4. we will link you with a small group of carefully selected specialists with whom we actively coordinate
5. we care personally about protecting you from health crises.

Also notable is the lack of correlation between Milstein & Gilbertson's qualities and the tens upon tens of arcane electronic minutia demanded by the NCQA for "medical home" recognition (180+ metrics).

The Ideal Medical Practices project demonstrated that even independent solo and small practices were willing and able to deliver truly patient-centered care if:

1. They were provided a teaching vehicle at reasonable opportunity cost (conference calls & webinar versus time away from patients and travel to meetings)
2. They had real time feedback on their own patient data
3. The results were actionable - they could understand them and do something to make them better
   

Is technology the answer (as implied by the 97% emphasis on technology in the current recognition system for medical homes)?

However, all four sites had achieved their distinguished results without the benefit of such IT. This suggests that recovering the first 15 percent of the 35 percent estimated waste in U.S. health care spending may not hinge on use of health IT or the larger organizational scale required for nuanced, IT-enabled continuous reengineering of clinical processes.

In their conclusions:

The signal to public policymakers is that to attain more health with less health care spending, health plan enrollment must be tilted toward those plans that vigorously reward PCPs and physician groups that excel in low total annual per capita health care spending and clinical outcomes.

What it's like in the front lines of health care

From a colleague in a rural practice:

1)  I saw a new patient with no insurance a week ago Friday on Sept 4.  I told him the yeast infection he had in his throat was not usual at his age and that we needed to do further workup. He rejected it and would not let me do anything but give him a swish and swallow because of no money.  He died this last Saturday after an ER visit and an emergency laparotomy for an acute abdomen.  He had a perforated rectum from a stage 4 stomach cancer that had spread from his Barretts Esophagus.....a completely treatable issue if caught early.  He was 55 years old.  Today I treated his wife for anxiety and irreconcilable grief.

2)   For those who are following my patients as I mention them dying of health care neglect....the bed ridden 79 year old guy who would not see another MD and wouldn't accept any treatment because he was afraid the costs would leave his wife with no home, as he had no Medicare secondary.   He neglected his congestive heart failure that caused liver and kidney failure.  He passed last Wednesday;  at least he only worked up a several thousand dollar bill (his ear was scratched and started to bleed two days before he died and the family had to send him to hospital as the bleeding could not be stopped. The ear bled because he had another fall, just after the last week fall and the last month fall when he decided to get up and shoot the damn deer that was eating his wife's petunias)  The hospital said he had "cirrhosis" but I had been doing his blood tests, and had an ultrasound from a year ago....not very primary, the cirrhosis..  Probably directly because he would not see an MD for three months when he got CHF for fear of costs...

[congestive heart failure (CHF) can lead to blood backing up into the liver and produce signs that look like but are not cirrhosis of the liver]

I had to pretend to be buying his home picked blue berries and pretend to accidentally find him sick to get him on to diuretic treatment this last June... He was bedridden with 19 century medicine the last three months.

3)     Also for those who know about my previously mentioned patients:  the homeless man who was living under the covered bridge is now dead as well as of two weeks ago.  He had been employed until November 06 and should have been on SSDI because we helped him apply in 2008 before the 2 year deadline, but they rejected him because of inadequate documentation of his disability...schizophrenia and organic brain damage with seizures secondary to a beating by teenagers which resulted in blood coming out of his ear.  He couldn't get to an ER, and couldn't see to drive anywhere, had no family.  There is no outreach here, so he could not get to the city for a workup by the federally funded clinic.  My report and the report of the monthly visiting nurse practitioner from the clinic was not enough for SSI.  So he lived under the bridge until he died of some blow to the head that left a lot of blood all over the ground and that gave him a flight in a coma to the tertiary care center in [major city] where thay spent, I am sure, more than he ever made in his life in the last four days of his life.  If he had had SSDI he would have been in a local apartment (preventing the attack by another teen if that is what happened) and been on medication (that prevented the seizure and fall if that what was happened).  The county police called him a transient and have closed the case..  He wasn't transient, he was just an unemployed mill worker. Probably a quarter of this community is about 3 months away from possibly living the life he led in the last two years. People are not happy.  I will report if there is any vigilante activity.

     .  Welcome to 21 century American medicine;  at this point all I can do is document.

Why does it cost doctors $68,000/year to deal with the insurance industry? Reed it and weep.

This is from EC, an MD in CA

1. insurance company sends me back an EOB stating 'we can't pay you because this pt may have another insurance policy in addition to ours. we need to clarify.'  I have seen this pt and his family before, have been paid by same insurance for him for other visits. when I call the insurance company, they say 'will need written letter from family stating they have no other insurance before we can reconsider. No guarantees'

2. Aetna phone line is impossible. BCBS better. I call here from CA at 3:10 pm. You go thru all this garbage pushing codes you don't need, no option to speak to human, then 20 mins later they tell you their office hrs are 8-5pm then it hangs up. I figured it must be the time change, so i call next morning at 7 am before work...go thru the same 20min of garbage then they tell me they are closed until 8 am. They must close eastern or central time and open pacific time.
Incredible.
So fist call- machine says a check for $57 has been issued for that date of service. great- I wait no check comes.  I call back 1 mos later, clerk says I can't get paid because I did a procedure for pt the same day or some one did, and can't get paid for both. Of course I did not do any procedure. They check their computers and say 'you are right she did not have any procedure for 30d before or after date of service, Aetna can make mistakes too.
They ask me to be understanding. So now I get a letter stating I can't bill for this office visit because I am a radiologist!!! So again after 3 trials to get thru on the impossible phone line, I tell the woman I have a letter from them stating I am primary care dated jun 09. She says they will need to look into it. It will take another 10 business days to clarify.
Do you believe this? Anyway, for this same pt, I am likely going to get paid about $50-60, half to overhead, so I am trying to get $25-30 for 5 hrs of my time wasted on telephone, plus the visit! I have basically taken a loss on this.
Anyone else heard of better excuses not to pay out for honest work done? Should be illegal. Should be in next health care bill, if insurance treats people like this, they should incur a fine or penalty of some sort. They need to pay claims in a timely manner.

 I had no money at all come in  last week
 Well that was a first  
 Makes for a great story 
 I made NO money at all last week.
 I am frustrated  in the hell of primary care 

 Today I see a sweet person who needs her Mirena IUD  replaced . I can do that. I have the skills. But money and the System may stand in my way. So I take time out. She  calls Blue Cross on her blackberry-- oh yes you have   full coverage    they tell her.
Mirena costs 468.00 plus insertion charge. Hmm- I get on the  blackberry -what will you reimburse ?
 OH we cannot tell you that, they say- you have to call her local , we are  in Illinois. I say you are the number on  her  card.
 We cannot say what you will be reimbursed but she is covered , they say

Apparenlty "covered" and what they will pay  have nothing to do with  each other

 Covered for  less than it costs me wouldn't be coverage. I try to explain this and the Blue Cross woman  says "Well  just because you don't like the answer..." !!!

So I   take more  time  and have my biller find out , and  she tells me- after the patient has left, which means I have to take more time and contact the patient-she tells me that blue cross will pay 171.00 for that 468.00 iud
  So I sent the  patient to family planning .which  is  of course subsidized by tax dollars. The patient is delighted. I am screaming with injustices rudeness and  insanity
  Will it ever end?
The part I  hate is that I end up always complaining  and always spending my free time to find a work around .The patient  ends up getting what they need .But her care is fragmented ,I do not get to use my skills, be paid for a procedure I can do, and the broken system continues looking only like doctors are whiners.
That is one brilliant plot  someone  has cooked up

And no money at all came in last week.
Sigh.
I love my  job

The tortured logic of tort reform

Being a doctor means my pulse races when I think of malpractice suits.  The response seems to have become hard-wired to my nervous system and at the first mention of tort reform parts of my brain that I don’t even seem to control jump to the fore shouting “You lie!”  (Oh, wait…. that was Wrong Way Wilson).

See what I mean?  It’s like a knee-jerk emotional response.  But when my heart stops palpitating I start to think about the logic:

We need tort reform so we can reduce unnecessary testing so that we can reduce costs.

Seems logical, right?  Let’s put aside for a minute the non partisan studies that deflate the premise:

The problem is, there’s little evidence that medical malpractice suits actually have much effect on the cost of health care. We first wrote about this back in 2004, when President Bush was making the claim. Although one 1996 study did find that so-called “defensive medicine” added between $60 billion and $108 billion per year to the cost of health care, more recent studies have disputed that assessment. In both 2004 and 2006, the nonpartisan Congressional Budget Office concluded that limiting medical malpractice claims would have little effect on the overall costs of health care. FactCheck.org

Let’s put the facts aside and follow the logic of ‘defensive medicine:’

1. I’m a physician worried that I might get sued.
2. I order unnecessary tests so that I’m less likely to get sued.
3. The tests are unnecessary by definition - the patient doesn’t need them.  I’m doing them to defend against a possible lawsuit.
4. Unnecessary tests come at the risk of unmasking spurious results (1/20 tests are ‘false positive’ - Take a simple blood test: a complete blood count (CBC) and blood chemistry.  These are made up of more than 20 separate tests, leading to ~64% probability of a false positive).
5. Unnecessary tests come with some (sometimes nominal) risk to the patient.
6. Spurious results require more testing and more intensive testing.
7. Sometimes this more intensive testing leads to procedures and other interventions based on spurious results.
8. These interventions come with some (not so nominal) risk to the patient.
9. Because of my fear of lawsuits I have subjected my patient to unnecessary testing that can lead to spurious results that lead to unnecessary interventions that sometimes harm my patients.
10. The patient didn’t need the testing in the first place, I only did the testing because I was afeared of lawsuits.
11. I sometimes harm my patients based on stuff they didn’t need done.

That to me sounds like grounds for a lawsuit.

The very thing I try to prevent with ‘defensive medicine’ increases my risk of harming my patients and lawsuits.

I’m not trying to make light of a topic so emotionally laden for me and other physicians, but when we step back from the emotional front there certainly does appear to be a lack of logic at work.

Why not just start with doing the right stuff for people?

Primary care is about so much more than treating disease.

Primary care is so much more than treating disease.  Treating disease is part of what we do but does not define what we do.

I’m fascinated by the studies that delve into what helps people do better with managing their conditions - be it diabetes or heart disease, exercise, or consistency in taking pills.

What fascinates me is what you find when you read studies that demonstrate an improvement in populations of patients with - for instance - diabetes.  Often we find that the intervention was some person or persons charged with doing extra stuff.

Some studies use diabetes educators to help teach diabetics more about their disease.  Good results lead the logical conclusion that we must all have diabetes educators if we hope to do a good job for people with diabetes.

Some studies show that telephone calls from health coaches lead to improvement in management of chronic pain.  Hey - let’s get health coaches!

Others demonstrate the value of cool technology:  “Look!  We put a registry in place to track patients with diabetes so we could remind them to get the care they need and we got good results!”

At the core of all of these is the basic premise that if we do a little more for people - remind them that we care and want to help, work with them to improve their understanding, provide consistent follow up and follow-through.

Good primary care is based on doing well for all of our patients not just those with diabetes, heart disease or a few other conditions.  Sequestering our resources in one or a few conditions makes us quasi-specialists.  Specialists have their place but it is not that of primary care.

If we want to effect the greatest change for the greatest possible population we serve we would do well to invest in improvement that accrues to our entire population and not just the lucky few.

Good primary care benefits society with improved population health outcomes at lower cost.  This is in part due to the role of primary care in understanding the importance of taking care of the whole person, not just an organ system.

This leads me to question why have we accepted a quality measurement paradigm that is specialty based and has almost no reflection of the systemic work we do in primary care?

Health Care: Right or Privilege?

 

The main reason there is so much confusion over health care reform is that our society has yet to decide whether we believe health care should be a right or a privilege. Instead of answering this fundamental question, we have leaped into the details of fixing our broken system. Of course, proceding with reform without coming to a consensus on whether health care is a right or a privilege is equivalent to building a house without paying attention to the foundation. It can look beautiful initially, but is likely to collapse over time. 

If our society deems health care a privilege, then we need to decide who is not worthy to receive it. A privilege is defined as “a special right, advantage, or immunity granted or available only to a particular person or group of people.” So if we believe only a particular group of people should have health care, then who does not deserve it and who do we entrust with this decision? I believe most people in society have been taught that health care is a privilege—something we should work toward and strive to achieve. But when we watch the elderly or poor die because they cannot afford basic care, our hearts take over and we develop programs like Medicare and Medicaid to help. If indeed health care is a privilege, then our society needs to stop thinking with our hearts, decide who should be denied health care and be completely unapologetic about it. We should base this decision solely on sound financial data and determine whose perceived worth to society is less than their benefit to society and let them die. By doing this, we could get rid of Medicare and Medicaid, and there would be no need for "free" clinics or community health centers.  Heck, over time, we could save trillions of dollars and potentially even pay off the national debt.

But if putting money ahead of people's lives sounds unsettling and we cannot determine a particular group of people who should be denied care, then we really believe health care is a right. If health care is a right, then, by definition, it needs to be universal. If health care is universal, then why are we quibbling about a “public option?” It should be a “public necessity” and our system needs to be completely revamped to make sure no one falls through its net. This could be approached as an onerous task of keeping the status quo and adding even more services for more people leading to untold amounts of bureaucratic paperwork and cost, or it could be seen as the challenge of our generation and we can face it with the vigor and sense of unity we have not seen since the NASA moon landing project of the 1960s. We could take the thoughts of Bodenheimer, Starfield, Emanuel, and all the great minds at the Institute for Health Care Improvement, and merge them into a system which uniquely American, cost effective, and the envy of the rest of the world.

But first we must take sides. Is health care a right or a privilege? Answer that question and we can then proceed with filling in the details.

John

Primary care must reject flawed p4p: Organ system management is the wrong approach

My fundamental beef with CMS's PQRI and NCQA's PCMH is the flawed premise that primary care quality should be measured by the sum of organ system management.

Reject pay for performance (P4P) in primary care unless it is tied to generic improvements in patient health that are attainable and directly measurable. Support disease-oriented P4P when applied in specialty care, where it is more appropriate.  B Starfield 5/09

The essential value of primary care is not the sum of organ part management but the comprehensive care we give to people.

1:   People are much more complex than their organs. 
It is possible to maximize adherence to an organ system guideline and create an overall decline in health & well being.  The feedback from patients is along the lines of "yes, doctor, but my quality of life is terrible."

2:  Excellence in organ system management does not translate to excellence in primary care.
A decade of teaching the Chronic Care Model all over the US demonstrate the lack of 'spread' from excellent condition management to excellence overall.  The recent study of the massive p4p program in the UK's NHS demonstrates the same.

3:  Excellence in primary care is linked to overall population health improvement and reduced costs, organ system management is not.
What's the ultimate goal - every diabetic person gets great guideline adherent-care or we serve all our patients well?

Ultimately we want both, but the premise that we can do both by starting with a paradigm based in organ system management flies in the face of years of experience observing this approach fail across the US (with very rare exception) and the evidence in numerous studies.

Because it is a fundamentally flawed paradigm that impedes our ability to deliver on the true quality of care we offer as primary care, we must reject PQRI and other flawed p4p approaches.

L Gordon Moore

Losing Faith in Society or Individuals or Both?

As information and misinformation surrounding health care legislation continues to be front and center in American politics, many of my patients have begun to tell me what they think. Lately, I have had a string of patients tell me things like, "It is all about individual responsibility. If people weren't so fat, health care would be cheaper," but then they go on "those people always eat at McDonald's, never exercise, and use their food stamps to buy junk food and not fruits and vegetables. The government has enabled them to behave this way through continued subsidies and now we have to bail them out again."

It is an attractive argument. After all, we all know that not enough Americans exercise regularly and there certainly is a higher rate of obesity and major diseases (and therefore health costs) in poorer populations. But I have an uneasiness about accepting the rest of the argument because I have never been there. Through luck of birth, I grew up in a stable family which valued education. I was always safe and never had to worry about whether I would be shot while walking in my neighborhood. I always had food on the table (even though my mother admitted some months were harder than others). I have never had to work more than one job, and I never had to worry about losing that job if the city bus was late or never showed up. Compared to many, my life has been easy. So how can I possibly know what "they" are going through or understand why "they" make different decisions than I would.

The attractiveness of the "us" vs. "them" argument is that "we" are always in the right. The problem is that it quickly falls apart when challenged. Who are "we?" Or alternatively who are "they?" Are they just the poor, the sick, or the elderly? Are they just the ones who have made bad decisions? Perhaps they are just people who think and act differently than we do. Not surprisingly, we are all a "we" or a "they" depending on the perspective of the individual rendering the opinion.

Encouraging healthy behavior is great and it would likely save money, but moving the argument to an emotional one hinged on the deeper issues of society is a slippery slope. Such arguments cease to see individual people struggling to do their best in the midst of huge challenges and instead focus on bad outcomes--essentially throwing the baby out with the bathwater. I realize much of this emanates from the difficult balancing act any society faces between helping its most vulnerable citizens and maintaining the status quo. But I also know if I ever become one of "them," I hope there is some safety net in place to help me out in my time of need.

John