It sounds like a nursery rhyme, but it's actually true.
Avery Johnson of the Wall Street Journal reported on an investor conference of Goldman Sachs in June of this year, in which major insurers discussed an unprecedented downward trend in medical spending. This has led to increased profits for insurance companies, but uneasiness in the many industries that live off of the abundance of excessive medical costs.
Specifically, hospital income is down 2-15%, costs associated with doctor visits are down 7%, and though patients are visiting quick care type providers more often, they are less likely to fill the prescriptions they receive at those visits. Simply put, people are going to the doctor less, they are spending less time and less money in the hospital and are taking less medications.
Humana reported and increase in profits of 30% and Aetna 42% since the patients they are insuring are costing them less money despite the fact that they raised premiums quite a bit last year. Eventually these profits will be limited by the provisions of the health care bill, so they will probably lead to reductions in health insurance premiums, but not this year.
The articles I read reported debate about whether the reduction in health care spending was just due to the economic downturn and was likely to end with a rebound as the economy recovers, but the magnitude of the decrease suggested something more permanent. Some data indicates that patients are considering costs more often when deciding on medical options and are looking at alternatives to standard medical care. Substantially more people have health plans that include very high deductible costs which fuels these considerations.
It will be very interesting to see if this voluntary reduction in health care spending can be correlated to a change in overall health. The patients who go to the minute clinics with their colds and flu and are prescribed antibiotics which they do not actually take may be well served by their "noncompliance". It seems to me that whenever a patient goes to a clinic like this with a cough or a sniffle they leave with an antibiotic, and if they take that antibiotic it is not uncommon for them to get some sort of side effect. Antibiotics are really only useful for a small subset of coughs, those due to pneumonia or to exacerbations of chronic lung disease, sometimes they help with sinus infections, and they are never useful in viral infections.
It seems most likely that this trend in health care spending is due to the fact that patients and doctors are starting to consider costs as part of what is relevant in making medical decisions. It seems like the fact of uncontrollable medical costs continuing to spiral upward is not a fact at all, but simply one of a number of possible futures. Decisions we make as providers and consumers are already having a significant impact on spending, and health care is in the process of reforming itself (though it definitely still needs lots of help.) Certainly widely publicized debate about the subject has influenced behavior. Although, or because, providers and consumers are still so confused about the provisions of the health care reform bill, they are changing their what they do in such a way that costs are already beginning to come down.
An article in the American Medical News reported on a few studies presented at the June meeting of the American Society of Clinical Oncology that looked at the financial impact on patients of treating their cancers. It is not uncommon for patients whose cancers do respond to chemotherapy to end of bankrupt due to costs. The first really effective drug to treat advanced melanoma, Yervoy, will cost $120,000 for 4 doses. Other common newish chemotherapy drugs are similarly expensive. Although insurance covers some of these costs, copays are significant. Many patients are simply not willing to bankrupt themselves or their families for the chance of a longer life. Studies such as these were not something I saw even a few years ago, and data like this certainly helps inform discussions of how to make medical decisions in a world where resources are limited.
Sunday, July 24, 2011
Tuesday, July 12, 2011
High blood pressure: who actually has it?
Hypertension is defined as the abnormal elevation of the pressure of blood within the arteries as measured most often by a blood pressure cuff. About 1 in 3 Americans has hypertension (which is the same thing as high blood pressure and has almost nothing to do with stress or anxiety.) When I finished medical school about 25 years ago, hypertension was diagnosed in an adult when the blood pressure was above 140/90 mm of mercury. In the last several years, since mortality pretty much just increases with increasing blood pressure, lower levels of blood pressure have been identified as being abnormal. Now a person has prehypertension if their systolic (top number) blood pressure is between 120 and 139 or if their diastolic (bottom number) blood pressure is between 80 and 89.
High blood pressure is a big deal because it increases a person's risk for stroke, heart attack and kidney failure. It is also mostly completely silent, causing no discomfort except at very high levels. The only way to identify hypertension is through having the blood pressure checked, usually at a doctor's office.
In the June 21 issue of the Annals of Internal Medicine, Dr. Benjamin Powers and colleagues from the VA medical center in Durham, North Carolina, compared blood pressure measurements in clinics, by researchers and by patients in their homes to see how we actually diagnose and treat that most common of diseases. What they found has major implications for most patients who have been told they have high blood pressure, and for all of us who are interested in providing rational and appropriate care.
All studies that look at the treatment of blood pressures are supposed to use a standard method of measuring it. The patient should be sitting down, not speaking, with back supported, feet flat on the floor, after 5 minutes of rest. If a person has a blood pressure over 139/89 when measured in this way, on more than one occasion, that person can be diagnosed with hypertension. Unfortunately blood pressure is seldom measured this way in actual practice. I think that most people who have ever had a blood pressure measurement done have experienced at least one if not many deviations from this protocol. We often measure blood pressure on the fly, right after a patient has sat down, while interviewing them, sometimes when they are sitting on the exam table with their feet dangling and back un-supported. We reassure ourselves that it doesn't really matter, but it actually does. The article shows that blood pressures taken by patients, by doctors' offices and by research personnel (who do it properly) do not agree. On average, clinic blood pressures are higher than home measurements and those are higher than research measurements. Measuring the blood pressure several times at the office can significantly help improve the accuracy of the diagnosis, and using 5 or 6 separate measurements provides the best results.
Another statistic that is interesting from this study is that, using doctor's office blood pressure measurements, only 28% of patients are found to have good blood pressure control. If we use the patient's own blood pressure measurements from their home machines, 47% have good blood pressure control, and if research personnel do the measurements, using proper technique, 68% of patients are in good control. To me this sounds like, because of shoddy blood pressure measurements 40% of our patients are mistakenly told that their blood pressure is too high, which would lead to expensive medication prescriptions and followup appointments.
Reviewing various sources on the subject, it appears that the condition hypertension costs the US nearly 80 billion dollars yearly of which maybe 25-30 billion dollars goes to actually treating hypertension (medications and office calls). The rest of this cost is presumably related to treating the conditions that high blood pressure causes. Appropriate allocation of resources to patients who actually have hypertension is supremely important. Repeated visits to treat uncontrolled hypertension, in my experience, leads to very high medication costs, higher incidence of medication side effects and, of course, frustration for both doctor and patient. If blood pressure control is being determined by significantly inaccurate technique, some simple changes could potentially make a significant impact both in dollars spent and quality of outcome.
So, you may ask, why not just do it right, all the time? A valid question. Not a year passes without some concentrated attempt by organizations such as the American Heart Association to re-educate us in the proper measurement of blood pressure. Still, the constraints of being in a hurry (I think that trumps ignorance in its importance) continues to result in blood pressure measurements being done badly. The consequences of this are moderately important to each individual diagnosed with hypertension, and have a profound effect at the level of our whole population.
High blood pressure is a big deal because it increases a person's risk for stroke, heart attack and kidney failure. It is also mostly completely silent, causing no discomfort except at very high levels. The only way to identify hypertension is through having the blood pressure checked, usually at a doctor's office.
In the June 21 issue of the Annals of Internal Medicine, Dr. Benjamin Powers and colleagues from the VA medical center in Durham, North Carolina, compared blood pressure measurements in clinics, by researchers and by patients in their homes to see how we actually diagnose and treat that most common of diseases. What they found has major implications for most patients who have been told they have high blood pressure, and for all of us who are interested in providing rational and appropriate care.
All studies that look at the treatment of blood pressures are supposed to use a standard method of measuring it. The patient should be sitting down, not speaking, with back supported, feet flat on the floor, after 5 minutes of rest. If a person has a blood pressure over 139/89 when measured in this way, on more than one occasion, that person can be diagnosed with hypertension. Unfortunately blood pressure is seldom measured this way in actual practice. I think that most people who have ever had a blood pressure measurement done have experienced at least one if not many deviations from this protocol. We often measure blood pressure on the fly, right after a patient has sat down, while interviewing them, sometimes when they are sitting on the exam table with their feet dangling and back un-supported. We reassure ourselves that it doesn't really matter, but it actually does. The article shows that blood pressures taken by patients, by doctors' offices and by research personnel (who do it properly) do not agree. On average, clinic blood pressures are higher than home measurements and those are higher than research measurements. Measuring the blood pressure several times at the office can significantly help improve the accuracy of the diagnosis, and using 5 or 6 separate measurements provides the best results.
Another statistic that is interesting from this study is that, using doctor's office blood pressure measurements, only 28% of patients are found to have good blood pressure control. If we use the patient's own blood pressure measurements from their home machines, 47% have good blood pressure control, and if research personnel do the measurements, using proper technique, 68% of patients are in good control. To me this sounds like, because of shoddy blood pressure measurements 40% of our patients are mistakenly told that their blood pressure is too high, which would lead to expensive medication prescriptions and followup appointments.
Reviewing various sources on the subject, it appears that the condition hypertension costs the US nearly 80 billion dollars yearly of which maybe 25-30 billion dollars goes to actually treating hypertension (medications and office calls). The rest of this cost is presumably related to treating the conditions that high blood pressure causes. Appropriate allocation of resources to patients who actually have hypertension is supremely important. Repeated visits to treat uncontrolled hypertension, in my experience, leads to very high medication costs, higher incidence of medication side effects and, of course, frustration for both doctor and patient. If blood pressure control is being determined by significantly inaccurate technique, some simple changes could potentially make a significant impact both in dollars spent and quality of outcome.
So, you may ask, why not just do it right, all the time? A valid question. Not a year passes without some concentrated attempt by organizations such as the American Heart Association to re-educate us in the proper measurement of blood pressure. Still, the constraints of being in a hurry (I think that trumps ignorance in its importance) continues to result in blood pressure measurements being done badly. The consequences of this are moderately important to each individual diagnosed with hypertension, and have a profound effect at the level of our whole population.
Monday, June 27, 2011
Antibiotics for appendicitis, heparin for burns and other stories of wonder
In the recent batch of throw away journals, several articles reported on findings that are at least moderately exciting.
The first was from the annual meeting of the Central Surgical Association in Detroit. An analysis of several studies pointed out that many cases of CT scan proven appendicitis can be effectively treated with intravenous antibiotics. In the past, when I was trained in medicine and surgery, appendicitis was diagnosed entirely on clinical grounds. Exquisite tenderness in the right lower quadrant, fever, elevated white blood cell count and a story of diffuse abdominal pain gradually focusing on the lower abdomen were sufficient evidence to operate on a suspected acute appendicitis. Cases without all of these findings were also operated on, and removing a normal appendix was considered part of the cost of preventing a catastrophic appendix rupture with the associated spillage of fecal matter into the sterile abdominal space. Now classic cases of appendicitis as described here will usually be corroborated with an abdominal and pelvic CT scan which will show a characteristic swelling of the appendix. When appendicitis is treated with antibiotics, 20% of patients can avoid an appendectomy and will be able to walk home without an incision in their belly and without the risk of surgical and anesthesia complications.
The British Medical Journal online is said to have reported on a New Zealand study showing that in a randomized controlled trial of nearly 40,000 patients, women who took a somewhat low dose of calcium and vitamin D, 1 gram and 400 IU, had about 1.2 times the risk of women not taking calcium and vitamin D of having heart attacks and strokes. Other studies show similar findings for calcium alone. To truly evaluate the risks and benefits of calcium, one would need to know if calcium and vitamin D supplements in normal women actually prevent the condition they are prescribed for, that is osteoporotic fractures. When last I heard, proof of a positive effect of calcium on bone strength was lacking and vitamin D supplementation was only definitely good for fracture prevention in the frail elderly. I am not entirely sure what to do with this information, other than inform my patients of the depth of our ignorance regarding these supplements.
At the international conference of the American Thoracic Society, researchers reported that daily treatment with the antibiotic azithromycin could postpone exacerbations of chronic lung disease for nearly 100 days compared to patients not treated with the antibiotic. Azithromycin, because of how well tolerated it is and how it can be given in a very short course due to its persistence in the body, is one of the most overused antibiotics in my experience. It is pretty much good for what ails you: hang nails, mosquito bites, colds and flu. It is even generic. Using it daily on patients with chronic lung disease will undoubtedly cause an increased resistance of community bacteria to the drug, making it useless for others who might need it. Clearly this is an intervention that needs to be chosen after much consideration, and for patients who really have very little lung reserve.
A rheumatological meeting at New York University reported that treatment of gout with medications that reduce uric acid levels can decrease heart related mortality by nearly 50%. Patients with gout have elevated levels of uric acid in their blood streams, related to diet, genetics, kidney function and medications they take. Many patients have elevated uric acid levels without getting gout (a very painful inflammation of joints and soft tissues, especially in the legs.) These patients also will benefit from lowering the uric acid levels. The medication used most commonly to lower uric acid is allopurinol. It is very inexpensive and sometimes causes an allergic rash or hair loss. In general it is very well tolerated and very affordable. There are many medications that can control gout symptoms but only the medications that reduce uric acid levels are helpful to the heart. Allopurinol and it's new cousin Febuxostat work, as do the two ancient gout drugs probenicid and sulfinpyrazone which make a person eliminate uric acid in the urine. This study will help me counsel patients on what medicine to take to prevent gout.
The proceedings of the National Academy of Science apparently reported on a slight reduction of the effectiveness of SSRI antidepressants such as Prozac (fluoxetine) in patients (and mice) treated with certain medications for pain, specifically NSAIDs such as ibuprofen and naproxen. The effect is small, but certainly worth thinking about if a patient doesn't respond to antidepressant medications. Of course, if they give up their effective pain medication, which may reduce their exercise, depression may rear its head in another way.
The British Medical Journal reported in May that using beta blocker medications along with asthma inhaler medications for chronic obstructive lung disease actually improves survival. I had always been convinced that use of a beta blocker in a patient who wheezed was a very bad idea and would reduce the effectiveness of a drug that stimulated beta receptors, such as albuterol. In fact I would often scoff at the silliness of doctors who would have their patients on both beta blockers and beta stimulators. I'm thinking now that I was probably wrong.
The last and most fascinating drug story came to me in the form of a high school friend whose father, a family practitioner, I knew from childhood. She visited me unexpectedly last weekend and told me his story and showed me his website. He, Michael Saliba MD, worked in La Jolla and did some research early on at UC San Diego medical school on treatment of burns. He found that a common and inexpensive medication that we use for treating blood clots, heparin, was a very powerful stimulator of skin healing in burned or otherwise denuded skin. He was able to try this on humans and over the years has successfully treated people with quite severe burns with heparin. He applies the solution by dripping it on a wound in the case of small wounds, and intravenously and as a subcutaneous injection of high doses in much more significant burns. He found that not only did it dramatically speed healing but it also nearly completely relieved pain, and patients often healed without much scarring. Most of the centers which use heparin are overseas, however, and the routine has never caught on in the US. Although there have been more studies reported, some showing dramatic successes and reductions in associated costs, there are none of the large multi-center studies that usually herald a major change in therapeutics. Some explanations include the fact that heparin has been a generic medication for so long that it doesn't financially benefit anyone to study it, that high doses of heparin worry physicians due to perceived risk of major bleeding (which actually only happens if there are bleeding injuries in the first place) and possibly due the fact that our standard treatments of very large burns is very big business, supporting all kinds of medical industry. Or he could just be making it up. Having known Dr. Saliba for as many years as I have, his overall kindness and trustworthiness are strong enough that I doubt that his claims are exaggerated. I think I will try it for the next burn wound I see. Besides being a very inexpensive treatment, what excites me most of all is the potential to treat burn pain which is so difficult to manage with oral medications.
The first was from the annual meeting of the Central Surgical Association in Detroit. An analysis of several studies pointed out that many cases of CT scan proven appendicitis can be effectively treated with intravenous antibiotics. In the past, when I was trained in medicine and surgery, appendicitis was diagnosed entirely on clinical grounds. Exquisite tenderness in the right lower quadrant, fever, elevated white blood cell count and a story of diffuse abdominal pain gradually focusing on the lower abdomen were sufficient evidence to operate on a suspected acute appendicitis. Cases without all of these findings were also operated on, and removing a normal appendix was considered part of the cost of preventing a catastrophic appendix rupture with the associated spillage of fecal matter into the sterile abdominal space. Now classic cases of appendicitis as described here will usually be corroborated with an abdominal and pelvic CT scan which will show a characteristic swelling of the appendix. When appendicitis is treated with antibiotics, 20% of patients can avoid an appendectomy and will be able to walk home without an incision in their belly and without the risk of surgical and anesthesia complications.
The British Medical Journal online is said to have reported on a New Zealand study showing that in a randomized controlled trial of nearly 40,000 patients, women who took a somewhat low dose of calcium and vitamin D, 1 gram and 400 IU, had about 1.2 times the risk of women not taking calcium and vitamin D of having heart attacks and strokes. Other studies show similar findings for calcium alone. To truly evaluate the risks and benefits of calcium, one would need to know if calcium and vitamin D supplements in normal women actually prevent the condition they are prescribed for, that is osteoporotic fractures. When last I heard, proof of a positive effect of calcium on bone strength was lacking and vitamin D supplementation was only definitely good for fracture prevention in the frail elderly. I am not entirely sure what to do with this information, other than inform my patients of the depth of our ignorance regarding these supplements.
At the international conference of the American Thoracic Society, researchers reported that daily treatment with the antibiotic azithromycin could postpone exacerbations of chronic lung disease for nearly 100 days compared to patients not treated with the antibiotic. Azithromycin, because of how well tolerated it is and how it can be given in a very short course due to its persistence in the body, is one of the most overused antibiotics in my experience. It is pretty much good for what ails you: hang nails, mosquito bites, colds and flu. It is even generic. Using it daily on patients with chronic lung disease will undoubtedly cause an increased resistance of community bacteria to the drug, making it useless for others who might need it. Clearly this is an intervention that needs to be chosen after much consideration, and for patients who really have very little lung reserve.
A rheumatological meeting at New York University reported that treatment of gout with medications that reduce uric acid levels can decrease heart related mortality by nearly 50%. Patients with gout have elevated levels of uric acid in their blood streams, related to diet, genetics, kidney function and medications they take. Many patients have elevated uric acid levels without getting gout (a very painful inflammation of joints and soft tissues, especially in the legs.) These patients also will benefit from lowering the uric acid levels. The medication used most commonly to lower uric acid is allopurinol. It is very inexpensive and sometimes causes an allergic rash or hair loss. In general it is very well tolerated and very affordable. There are many medications that can control gout symptoms but only the medications that reduce uric acid levels are helpful to the heart. Allopurinol and it's new cousin Febuxostat work, as do the two ancient gout drugs probenicid and sulfinpyrazone which make a person eliminate uric acid in the urine. This study will help me counsel patients on what medicine to take to prevent gout.
The proceedings of the National Academy of Science apparently reported on a slight reduction of the effectiveness of SSRI antidepressants such as Prozac (fluoxetine) in patients (and mice) treated with certain medications for pain, specifically NSAIDs such as ibuprofen and naproxen. The effect is small, but certainly worth thinking about if a patient doesn't respond to antidepressant medications. Of course, if they give up their effective pain medication, which may reduce their exercise, depression may rear its head in another way.
The British Medical Journal reported in May that using beta blocker medications along with asthma inhaler medications for chronic obstructive lung disease actually improves survival. I had always been convinced that use of a beta blocker in a patient who wheezed was a very bad idea and would reduce the effectiveness of a drug that stimulated beta receptors, such as albuterol. In fact I would often scoff at the silliness of doctors who would have their patients on both beta blockers and beta stimulators. I'm thinking now that I was probably wrong.
The last and most fascinating drug story came to me in the form of a high school friend whose father, a family practitioner, I knew from childhood. She visited me unexpectedly last weekend and told me his story and showed me his website. He, Michael Saliba MD, worked in La Jolla and did some research early on at UC San Diego medical school on treatment of burns. He found that a common and inexpensive medication that we use for treating blood clots, heparin, was a very powerful stimulator of skin healing in burned or otherwise denuded skin. He was able to try this on humans and over the years has successfully treated people with quite severe burns with heparin. He applies the solution by dripping it on a wound in the case of small wounds, and intravenously and as a subcutaneous injection of high doses in much more significant burns. He found that not only did it dramatically speed healing but it also nearly completely relieved pain, and patients often healed without much scarring. Most of the centers which use heparin are overseas, however, and the routine has never caught on in the US. Although there have been more studies reported, some showing dramatic successes and reductions in associated costs, there are none of the large multi-center studies that usually herald a major change in therapeutics. Some explanations include the fact that heparin has been a generic medication for so long that it doesn't financially benefit anyone to study it, that high doses of heparin worry physicians due to perceived risk of major bleeding (which actually only happens if there are bleeding injuries in the first place) and possibly due the fact that our standard treatments of very large burns is very big business, supporting all kinds of medical industry. Or he could just be making it up. Having known Dr. Saliba for as many years as I have, his overall kindness and trustworthiness are strong enough that I doubt that his claims are exaggerated. I think I will try it for the next burn wound I see. Besides being a very inexpensive treatment, what excites me most of all is the potential to treat burn pain which is so difficult to manage with oral medications.
Wednesday, June 8, 2011
Accountable Care Organizations--some perils and pitfalls
It is ever more widely accepted that fee for service medicine, that is payment for individual services that medical professionals provide, by patients or by insurers, is a bad idea. If a physician is paid to deliver a specific service, such as seeing a patient in the office, removing his or her gallbladder or doing a colonoscopy, the physician will perform more of these services, regardless of whether this improves the health of the patient. Ethically a doctor may make appropriate choices, but financially the reward will be for quantity of services not quality of care. If a health care provider is paid to take care of a patient, a flat fee per patient per year for instance, the incentive will be to keep that patient as healthy as possible with as little medical intervention as possible and to prevent costly disease. This is known as "capitation" (literally paying by the head.)
Capitation has been tried and used in many situations over many years in medicine. Staff model health care cooperatives such as Kaiser and Group Health operate this way. Many states pay flat fees to providers to serve their medicaid populations. Outcomes are often better because this system focuses on continuity of care with members assigned to specific doctors, and usually involves better coordination of aspects of care by the different providers involved. It sometimes irritates patients because choices of specialists and medications are often limited due to the staff model and to money saving drug formularies. In cooperatives, a governing board which includes patients help make decisions about what kinds of care are provided, which makes them somewhat more responsive to consumers' needs.
The present model (outlined in the Affordable Care Act) that attempts to get away from fee for service medicine is called the Accountable Care Organization (ACO). A group of physicians, often in cahoots with a hospital, can contract with medicare to provide service to at least 5000 medicare patients, and if they can provide that care for cheaper than benchmarks, while documenting good quality as measured by various things that organized medicine thinks is important such as lab test numbers and hospital admissions, they can have a share of the saved loot. There are various reasons why this is not a great solution. First of all, the creation of accountable care organizations is driving a big push by hospitals to employ physicians, which may make medicine more corporate, placing yet another entity between the patient and the provider. If a physician is employed, the rules of practice will likely be defined by the employer, and if that employer is interested entirely in saving money, convenience and the human touch may well be lost. Also, these much larger organizations may, by controlling more of the care that is delivered, have enough power to actually push costs up by monopolizing care.
Another problem with the present model of an ACO is that it would not end fee for service at all, and so the administrative hassles involved in making lists of diagnoses for each patient and matching them up with fees for units of service will continue to eat up our time. More non-patient time will be eaten by the documentation of quality. It is not entirely bad to be required to demonstrate that our care works, but the devil is in the details, and getting cholesterol numbers just right may not be the thing that my patients actually value.
Finally, in my personal world, ACOs are impractical because a community the size of mine, around 20,000 people, is too small to have 5000 medicare beneficiaries as is required by the Affordable Care Act. We could potentially hook up with other communities, but having meetings and communicating would be a nightmare, given the density of population around here.
I do think that physicians need to be more involved in providing care for patients that contributes to their actual health and happiness instead of simply providing units of service. I think that a system that rewards good care and encourages creative ways of delivering it are part of a successful future for medicine. It is vitally important in all of this that we continue to care for our patients and remain committed to the give and take relationship that allows us to share our knowledge while respecting what our patients value. Having a third party, an insurance company, pay for our services already negatively affects this intimate partnership. It is my hope that in reforming our present payment system we do not introduce yet another financially motivated entity into the exam room.
Capitation has been tried and used in many situations over many years in medicine. Staff model health care cooperatives such as Kaiser and Group Health operate this way. Many states pay flat fees to providers to serve their medicaid populations. Outcomes are often better because this system focuses on continuity of care with members assigned to specific doctors, and usually involves better coordination of aspects of care by the different providers involved. It sometimes irritates patients because choices of specialists and medications are often limited due to the staff model and to money saving drug formularies. In cooperatives, a governing board which includes patients help make decisions about what kinds of care are provided, which makes them somewhat more responsive to consumers' needs.
The present model (outlined in the Affordable Care Act) that attempts to get away from fee for service medicine is called the Accountable Care Organization (ACO). A group of physicians, often in cahoots with a hospital, can contract with medicare to provide service to at least 5000 medicare patients, and if they can provide that care for cheaper than benchmarks, while documenting good quality as measured by various things that organized medicine thinks is important such as lab test numbers and hospital admissions, they can have a share of the saved loot. There are various reasons why this is not a great solution. First of all, the creation of accountable care organizations is driving a big push by hospitals to employ physicians, which may make medicine more corporate, placing yet another entity between the patient and the provider. If a physician is employed, the rules of practice will likely be defined by the employer, and if that employer is interested entirely in saving money, convenience and the human touch may well be lost. Also, these much larger organizations may, by controlling more of the care that is delivered, have enough power to actually push costs up by monopolizing care.
Another problem with the present model of an ACO is that it would not end fee for service at all, and so the administrative hassles involved in making lists of diagnoses for each patient and matching them up with fees for units of service will continue to eat up our time. More non-patient time will be eaten by the documentation of quality. It is not entirely bad to be required to demonstrate that our care works, but the devil is in the details, and getting cholesterol numbers just right may not be the thing that my patients actually value.
Finally, in my personal world, ACOs are impractical because a community the size of mine, around 20,000 people, is too small to have 5000 medicare beneficiaries as is required by the Affordable Care Act. We could potentially hook up with other communities, but having meetings and communicating would be a nightmare, given the density of population around here.
I do think that physicians need to be more involved in providing care for patients that contributes to their actual health and happiness instead of simply providing units of service. I think that a system that rewards good care and encourages creative ways of delivering it are part of a successful future for medicine. It is vitally important in all of this that we continue to care for our patients and remain committed to the give and take relationship that allows us to share our knowledge while respecting what our patients value. Having a third party, an insurance company, pay for our services already negatively affects this intimate partnership. It is my hope that in reforming our present payment system we do not introduce yet another financially motivated entity into the exam room.
Thursday, June 2, 2011
How to get more gifted physicians to practice primary care
It is entirely clear that too few medical graduates go into primary care. Although the number of family physicians is increasing modestly, there are very few internal medicine residents becoming primary care doctors. This year there will be only about 200 new internal medicine doctors entering the workforce from training programs, which will not even begin to cover the attrition of older and more efficient physicians, and due to improvements in access with the affordable care act, demand will be increasing significantly. The main reason that very few physicians are choosing primary care is that specialty fields are just about as rewarding personally and way more rewarding financially.
Insurance companies in our present, primarily fee for service, payment system, pay generously for operations and procedures, but much less for complex interactions such as counseling patients on their multiple medical problems, medications, and managing their many diseases. A cataract operation is reimbursed at around $1500 or more, and an ophthalmologist can perform one of these in less than an hour. A similar hour of seeing patients will net a physician a small fraction of that amount of money, and will require many more decisions and neuron firings. Many other procedures have similar high reimbursement for very low amounts of work. If a physician specializes in a field that involves many procedures, he or she can make truly absurd amounts of money if there are sufficient numbers of patients who need that procedure.
Because of the shortage of primary care doctors, more and more people are getting their primary care from nurse practitioners and physician's assistants, who have many fewer years of education than a physician. These providers are paid less than physicians and are more plentiful. Many of them are very competent, but patients often prefer an MD over a PA because the MD has a greater depth of knowledge. A primary care visit is often a combination of counseling about psychological issues, medications and interactions, review of tests, recommendations about prevention and careful examination (at its best). MDs can be very good at this. Midlevel practitioners are often quicker, having been trained to treat urgent problems more than chronic ones.
Training to be a primary care physician requires at least 7 years after completing a bachelors or higher level college degree. The first year is spent learning basic science and physiology, the second involves absorbing huge amounts of information about human beings in health and disease. The third and fourth years bring the student in direct contact with patients, providing supervised clinical care along with classes and individual teaching by practicing physicians and academics. After these 4 years we have an MD degree, and must pass a licensing exam that assures a certain level of competence in all fields of medicine. At this point we can still choose to become surgeons, radiologists, pathologists or go on to academic medicine or research. Those of us who intend to be primary care docs then spend at least 3 years in residency, taking care of patients under the supervision of more experienced physicians, with an increasing level of independence. When we finish these residency years we are broadly competent in taking care of most of what can go wrong with a human, with fresh and extensive knowledge of psychiatry, critical care, well patient care and the vast variety of other illnesses we have been exposed to. After those residency years we have the opportunity to take another year or more of specialty training in fields such as cardiology, oncology, infections disease or rheumatology. Most physicians who specialize limit their practices to specific diseases and no longer do general medicine.
Nurse practitioners and physicians assistants must complete 2-3 years of training after getting their undergraduate degrees and in most states are then certified to practice independently. Although they are often gifted and become increasingly capable with years of practice, they do start out with considerably less training than physicians and the programs that train them are significantly less competitive.
So what would a midlevel practitioner be really excellent at doing? In what kind of a situation would a provider with less extensive experience and education really shine? Procedures. A midlevel such as a nurse practitioner or physicians assistant could learn to do an excellent cataract extraction or colonoscopy. Advanced level nurses already act as surgical assistants and have been providing anesthesia services at a high level for longer than MDs have done. In developing countries with less medical regulations, it is often the janitors or former patients who learn to do operations and act as surgeons when the foreign trained doctors are not available. I have read that some of the most skillful surgeons for vaginal fistulas, a very delicate and specialized condition of women who have had disastrous labors, are lay people.
What else would midlevels really excel at? Already much of diabetes care is delivered by nurse practitioners who limit themselves to issues related to that disease. They do an excellent job, often better than MDs. Specific disease states, as are now managed by subspecialists, would be perfect for nurse practitioners and PAs. In fact, this is already starting to gain momentum.
How would shifting procedural work to midlevel providers affect the health care equation? If less well paid providers did this work market forces would drive down costs, which would make procedure rich specialties less desirable. Health care costs would also go down, and if cognitive specialties such as primary care were even somewhat better reimbursed it would increase the number of talented folks choosing those careers.
A recent article in the New England Journal of Medicine obliquely addressed this question. Here is the link:
http://www.nejm.org/doi/full/10.1056/NEJMoa1009370
In this article authors looked at the success of treatment of hepatitis C by specialists vs primary care doctors after an online course in treating this common and deadly disease. Primary care providers were slightly more successful than the gastroenterology clinic which trained them in curing the disease. This does, of course, involve MD providers in both cases, but gives very strong support for the idea that specialization can be taught effectively and quickly.
A move in this direction will be very unpopular among just those who are most needed to make it work, the MDs who make their livings doing procedures. These folks have years of practical experience and have skills that are not available in books or videos. Excellent surgeons will always be necessary and appreciated. A supremely skilled surgeon is an artist and deserves money and acclaim. Wise subspecialists will always be needed and appreciated in taking care of patients with diseases that are rare or so complicated that primary care physicians are just not enough. But we are now grossly out of balance, with a truly inadequate number of primary care physicians to take care our our growing needs, and appropriate use of midlevels could be a solution to the problem.
Insurance companies in our present, primarily fee for service, payment system, pay generously for operations and procedures, but much less for complex interactions such as counseling patients on their multiple medical problems, medications, and managing their many diseases. A cataract operation is reimbursed at around $1500 or more, and an ophthalmologist can perform one of these in less than an hour. A similar hour of seeing patients will net a physician a small fraction of that amount of money, and will require many more decisions and neuron firings. Many other procedures have similar high reimbursement for very low amounts of work. If a physician specializes in a field that involves many procedures, he or she can make truly absurd amounts of money if there are sufficient numbers of patients who need that procedure.
Because of the shortage of primary care doctors, more and more people are getting their primary care from nurse practitioners and physician's assistants, who have many fewer years of education than a physician. These providers are paid less than physicians and are more plentiful. Many of them are very competent, but patients often prefer an MD over a PA because the MD has a greater depth of knowledge. A primary care visit is often a combination of counseling about psychological issues, medications and interactions, review of tests, recommendations about prevention and careful examination (at its best). MDs can be very good at this. Midlevel practitioners are often quicker, having been trained to treat urgent problems more than chronic ones.
Training to be a primary care physician requires at least 7 years after completing a bachelors or higher level college degree. The first year is spent learning basic science and physiology, the second involves absorbing huge amounts of information about human beings in health and disease. The third and fourth years bring the student in direct contact with patients, providing supervised clinical care along with classes and individual teaching by practicing physicians and academics. After these 4 years we have an MD degree, and must pass a licensing exam that assures a certain level of competence in all fields of medicine. At this point we can still choose to become surgeons, radiologists, pathologists or go on to academic medicine or research. Those of us who intend to be primary care docs then spend at least 3 years in residency, taking care of patients under the supervision of more experienced physicians, with an increasing level of independence. When we finish these residency years we are broadly competent in taking care of most of what can go wrong with a human, with fresh and extensive knowledge of psychiatry, critical care, well patient care and the vast variety of other illnesses we have been exposed to. After those residency years we have the opportunity to take another year or more of specialty training in fields such as cardiology, oncology, infections disease or rheumatology. Most physicians who specialize limit their practices to specific diseases and no longer do general medicine.
Nurse practitioners and physicians assistants must complete 2-3 years of training after getting their undergraduate degrees and in most states are then certified to practice independently. Although they are often gifted and become increasingly capable with years of practice, they do start out with considerably less training than physicians and the programs that train them are significantly less competitive.
So what would a midlevel practitioner be really excellent at doing? In what kind of a situation would a provider with less extensive experience and education really shine? Procedures. A midlevel such as a nurse practitioner or physicians assistant could learn to do an excellent cataract extraction or colonoscopy. Advanced level nurses already act as surgical assistants and have been providing anesthesia services at a high level for longer than MDs have done. In developing countries with less medical regulations, it is often the janitors or former patients who learn to do operations and act as surgeons when the foreign trained doctors are not available. I have read that some of the most skillful surgeons for vaginal fistulas, a very delicate and specialized condition of women who have had disastrous labors, are lay people.
What else would midlevels really excel at? Already much of diabetes care is delivered by nurse practitioners who limit themselves to issues related to that disease. They do an excellent job, often better than MDs. Specific disease states, as are now managed by subspecialists, would be perfect for nurse practitioners and PAs. In fact, this is already starting to gain momentum.
How would shifting procedural work to midlevel providers affect the health care equation? If less well paid providers did this work market forces would drive down costs, which would make procedure rich specialties less desirable. Health care costs would also go down, and if cognitive specialties such as primary care were even somewhat better reimbursed it would increase the number of talented folks choosing those careers.
A recent article in the New England Journal of Medicine obliquely addressed this question. Here is the link:
http://www.nejm.org/doi/full/10.1056/NEJMoa1009370
In this article authors looked at the success of treatment of hepatitis C by specialists vs primary care doctors after an online course in treating this common and deadly disease. Primary care providers were slightly more successful than the gastroenterology clinic which trained them in curing the disease. This does, of course, involve MD providers in both cases, but gives very strong support for the idea that specialization can be taught effectively and quickly.
A move in this direction will be very unpopular among just those who are most needed to make it work, the MDs who make their livings doing procedures. These folks have years of practical experience and have skills that are not available in books or videos. Excellent surgeons will always be necessary and appreciated. A supremely skilled surgeon is an artist and deserves money and acclaim. Wise subspecialists will always be needed and appreciated in taking care of patients with diseases that are rare or so complicated that primary care physicians are just not enough. But we are now grossly out of balance, with a truly inadequate number of primary care physicians to take care our our growing needs, and appropriate use of midlevels could be a solution to the problem.
Wednesday, May 25, 2011
How I Spent My Day, most of it good, some of it stupid (E and M codes)
Today started early because I was being the hospitalist as well as the stress test doctor as well as my usual identity as primary care physician. A hospitalist is a doctor who takes care of all of the patients in a hospital who have no other doctor or whose doctor doesn't take care of patients in a hospital. It is a fine job, as it is practiced in many larger communities, though it limits the doctor's ability to make long term connections with patients, who usually see someone else when they are not confined to a hospital. People who take hospitalist jobs work shifts, make a fixed salary and get lots of time off. In our small town, the hospitalist is my long suffering partner, nearly all of the time, but I and my other internal medicine colleagues spell her evenings and weekends and occasional vacations. We all squeeze our hospital work into a day that also includes outpatient primary care medicine.
As the hospitalist I had 6 patients to see before clinic started at 10, only 2 of them really critically ill, and because this is my week for doing stress tests, I had two other people to supervise while we used various methods to stress their hearts to see if they had coronary artery disease. The stress tests are a great joy because I get to meet new people and hear their stories and give them health advice while they are open to it. While they are walking or being injected there is nothing else I need to be doing, no computers to interact with, at least not in a distracting way, and no distractions. There is plenty of time to find out who they are and maybe help them make a slight detour if their lifestyle and habits are heading them in a deadly direction.
After nearly 25 years of medical practice, most things I do are rewarding. There are exceptions, however. Most exceptions fall into the category of things I can't do well. If there is something I don't know about or physically am not skilled enough to do, I can find a colleague to help. The most difficult situation, though, is when it is necessary to be in two places at the same time, or do two (or three) things in an inadequate amount of time. When situations like this arise, I begin to be annoyed by inefficient processes.
The New England Journal of Medicine published an article this week about one of the stupid processes upon which we physicians, those of us involved in fee for service medicine, waste our time.
here is the link:
http://healthpolicyandreform.nejm.org/?p=14489#more-14489
When I see my patients in the hospital, I just estimate the time and complexity of my services and bill accordingly. When I do stress tests, I am paid by the hour. When I see patients in the office I must calculate their bill based on Evaluation and Management Codes, introduced for the first time in 1991. These codes are an attempt to calculate the value of a medical service based on various pieces of information that can be documented in a patient's chart. If I document a very complete history and include a physical exam of several parts of the patient's body that is exhaustive, I can bill a 99214, which will pay me substantially more than a 99213 which still requires quite a bit of documentation. If I do everything imaginable in the appointment and document that, I can bill a 99215. This is the king of the outpatient bills and pays the most money. If I document that I spent an hour talking to the patient, I can legally bill a 99215, but if I work really fast and ask a whole bunch of questions and poke and prod every part of my patient and that patient is pretty complicated, I could potentially get 2, 3 or even 4 99215's in an hour. But by law if I bill a 99215 and I don't document that I did all of the little things I was supposed to to qualify for a 99215, I can be heavily fined or even arrested. (Legal sanctions apply only to Medicare and Medicaid billing, but E and M coding is used pretty much universally by all insurers.)
So today, like every day, despite the fact that today was plenty crowded with people who needed my attention, I spent a significant amount of precious time making sure that I documented (typed up, clicked on) enough elements for my outpatients that my billing would stand up to scrutiny should I be audited. My electronic medical record is built to help me with my E and M coding, but because it is so geared to coding, it is not nearly as good at concisely expressing what I did with my patient. I can review the patient's family history and social situation, but if I don't include the verbiage, which may be identical to the verbiage I documented last week, my documentation will be inadequate to bill for the complex and time consuming interaction and I will need to charge less than the appointment was worth. The time I spend polishing my documentation is time that I can't see sick patients. It also, more insidiously, affects the way in which I care for my patients and what my brain is doing when I am with them. It is vital for the survival of my office that I make enough money to support my nurses and receptionists, pay my rent and eventually support my family. So I, like all other fee for service physicians, play the E and M game. I am mostly unable to get payment for any of the rest of the work that I do, such as telephone management or written communications, so E and M coding of my face to face patient interactions pays for everything else I do.
When the various codes were introduced in the early 90s, many of us objected to the changes, but now we are so accustomed to spending our time and brain cells to categorize our work in this way that very few people even realize what an impact this has on our quality of service. Robert Berenson MD, Peter Basch MD and Amanda Sussex MPH who wrote the New England Journal article are the first to publicly complain about this system for years. Improvements in billing including streamlining the coding has been suggested, but instead it will soon be getting even more complex. Truly the best solution to the foul and tangled web of medical billing will be significant payment reform. Calls for the end of fee for service medicine have been increasingly common, and as far as I'm concerned, it can't happen soon enough.
As the hospitalist I had 6 patients to see before clinic started at 10, only 2 of them really critically ill, and because this is my week for doing stress tests, I had two other people to supervise while we used various methods to stress their hearts to see if they had coronary artery disease. The stress tests are a great joy because I get to meet new people and hear their stories and give them health advice while they are open to it. While they are walking or being injected there is nothing else I need to be doing, no computers to interact with, at least not in a distracting way, and no distractions. There is plenty of time to find out who they are and maybe help them make a slight detour if their lifestyle and habits are heading them in a deadly direction.
After nearly 25 years of medical practice, most things I do are rewarding. There are exceptions, however. Most exceptions fall into the category of things I can't do well. If there is something I don't know about or physically am not skilled enough to do, I can find a colleague to help. The most difficult situation, though, is when it is necessary to be in two places at the same time, or do two (or three) things in an inadequate amount of time. When situations like this arise, I begin to be annoyed by inefficient processes.
The New England Journal of Medicine published an article this week about one of the stupid processes upon which we physicians, those of us involved in fee for service medicine, waste our time.
here is the link:
http://healthpolicyandreform.nejm.org/?p=14489#more-14489
When I see my patients in the hospital, I just estimate the time and complexity of my services and bill accordingly. When I do stress tests, I am paid by the hour. When I see patients in the office I must calculate their bill based on Evaluation and Management Codes, introduced for the first time in 1991. These codes are an attempt to calculate the value of a medical service based on various pieces of information that can be documented in a patient's chart. If I document a very complete history and include a physical exam of several parts of the patient's body that is exhaustive, I can bill a 99214, which will pay me substantially more than a 99213 which still requires quite a bit of documentation. If I do everything imaginable in the appointment and document that, I can bill a 99215. This is the king of the outpatient bills and pays the most money. If I document that I spent an hour talking to the patient, I can legally bill a 99215, but if I work really fast and ask a whole bunch of questions and poke and prod every part of my patient and that patient is pretty complicated, I could potentially get 2, 3 or even 4 99215's in an hour. But by law if I bill a 99215 and I don't document that I did all of the little things I was supposed to to qualify for a 99215, I can be heavily fined or even arrested. (Legal sanctions apply only to Medicare and Medicaid billing, but E and M coding is used pretty much universally by all insurers.)
So today, like every day, despite the fact that today was plenty crowded with people who needed my attention, I spent a significant amount of precious time making sure that I documented (typed up, clicked on) enough elements for my outpatients that my billing would stand up to scrutiny should I be audited. My electronic medical record is built to help me with my E and M coding, but because it is so geared to coding, it is not nearly as good at concisely expressing what I did with my patient. I can review the patient's family history and social situation, but if I don't include the verbiage, which may be identical to the verbiage I documented last week, my documentation will be inadequate to bill for the complex and time consuming interaction and I will need to charge less than the appointment was worth. The time I spend polishing my documentation is time that I can't see sick patients. It also, more insidiously, affects the way in which I care for my patients and what my brain is doing when I am with them. It is vital for the survival of my office that I make enough money to support my nurses and receptionists, pay my rent and eventually support my family. So I, like all other fee for service physicians, play the E and M game. I am mostly unable to get payment for any of the rest of the work that I do, such as telephone management or written communications, so E and M coding of my face to face patient interactions pays for everything else I do.
When the various codes were introduced in the early 90s, many of us objected to the changes, but now we are so accustomed to spending our time and brain cells to categorize our work in this way that very few people even realize what an impact this has on our quality of service. Robert Berenson MD, Peter Basch MD and Amanda Sussex MPH who wrote the New England Journal article are the first to publicly complain about this system for years. Improvements in billing including streamlining the coding has been suggested, but instead it will soon be getting even more complex. Truly the best solution to the foul and tangled web of medical billing will be significant payment reform. Calls for the end of fee for service medicine have been increasingly common, and as far as I'm concerned, it can't happen soon enough.
Wednesday, May 18, 2011
How death panels can save your life and other stories
The Annals of Internal Medicine occasionally reviews the articles and studies of note in a particular field of internal medicine for those of us who don't read all of the specialty journals. This month there was an update in pulmonary and critical care medicine, the internal medicine specialty that is most intimately involved with caring for the very ill and those people who are at the ends of their lives. Nestled among articles on diagnosis of tuberculosis and novel treatments for non-small cell lung cancer is one about palliative care, that is medical interventions intended to make people more comfortable as they die.
This article, published in the New England Journal of Medicine by Dr. J.S. Temel and colleagues from the Massachusetts General Hospital in Boston, looks at quality and length of life in patients with recently diagnosed incurable lung cancer, cancers that have spread metastatically beyond the lung tissue. These patients cannot expect to be cured of their cancers, but will be offered many treatments intended to lengthen their lives and shrink their tumors. About half of the patients were offered visits early in their treatment with the palliative care team, to discuss what kind of treatment they wanted at the end of their life, including resuscitation and life support, but also pain and other symptom control. The other group received standard treatment, which might include palliative care, but usually not until life prolonging therapy was found to be ineffective. The patients assigned to early palliative care consultation received less intensive treatments as they were dying, but they also had a significantly better quality of life and they lived longer.
An article like this doesn't explore the individual stories of the people who were involved, but I'm thinking those stories would be pretty interesting. Without those stories, one can only speculate what made the early palliative care group happier and healthier. My speculations would include that it was comforting to patients to know that they would be well taken care of and their suffering would be relieved when it was their time to die. Other factors might include family members being reassured by open conversations about the end of life, leading to better care at home and more contact with doctors who are good listeners and take the time to really discuss the patient's and family's concerns.
It is also interesting to note that the group with early palliative care, though receiving less intensive medical interventions at the end of life, lived longer than those with more intensive interventions. Intensive care was not "rationed" as frightened legislators might think, but rather used appropriately for the individual.
The whole discussion of death panels sort of escaped me when it came around the first time and when it has recurrently resurfaced. End of life discussions have always been a part of practicing good medicine, and it would be nice to be paid for them specifically so that more physicians would take the time to do them properly. A panel of physicians would not be particularly good at talking to people about death and so a death panel, even if it weren't just a figment of a paranoid imagination, would be terribly inefficient. One of my patients, a 90 year old woman, expressed fear of death panels several months ago, and after explaining that I wasn't sure where that idea had sprung from, we had a good, simple and productive talk about what kind of therapy was available to her should her heart stop or her other functions cease to be, and we were able to document exactly what she would want should she not be able to express her wishes.
As doctors who frequently admit patients who normally see other doctors to the hospital, my partner and I are often on the receiving end of the problem of inadequate discussions of end of life wishes. Very ill or dying patients will be admitted to the hospital, with one of us as their doctor, and have never discussed with anyone what kind of care they would want. They are often too sick by that time to talk about it or think about it, and even if they were capable, they don't know me or my partner from Adam, and reasonably don't have the level of trust necessary to allow us to help them make a good decision. This leads to heartache and wasted effort.
So what I see as the take home message of this New England Journal article is that discussions of end of life preferences including life support but also ways to receive comfort do not need to be depressing, but can be affirmations of life's value and our own self determination. When a doctor opens up this area for a person and his or her family to talk about, fears can be allayed and options can be explored. Death is just about always difficult in some way or another, but there are many ways to handle it that help to maintain our love and humanity.
This article, published in the New England Journal of Medicine by Dr. J.S. Temel and colleagues from the Massachusetts General Hospital in Boston, looks at quality and length of life in patients with recently diagnosed incurable lung cancer, cancers that have spread metastatically beyond the lung tissue. These patients cannot expect to be cured of their cancers, but will be offered many treatments intended to lengthen their lives and shrink their tumors. About half of the patients were offered visits early in their treatment with the palliative care team, to discuss what kind of treatment they wanted at the end of their life, including resuscitation and life support, but also pain and other symptom control. The other group received standard treatment, which might include palliative care, but usually not until life prolonging therapy was found to be ineffective. The patients assigned to early palliative care consultation received less intensive treatments as they were dying, but they also had a significantly better quality of life and they lived longer.
An article like this doesn't explore the individual stories of the people who were involved, but I'm thinking those stories would be pretty interesting. Without those stories, one can only speculate what made the early palliative care group happier and healthier. My speculations would include that it was comforting to patients to know that they would be well taken care of and their suffering would be relieved when it was their time to die. Other factors might include family members being reassured by open conversations about the end of life, leading to better care at home and more contact with doctors who are good listeners and take the time to really discuss the patient's and family's concerns.
It is also interesting to note that the group with early palliative care, though receiving less intensive medical interventions at the end of life, lived longer than those with more intensive interventions. Intensive care was not "rationed" as frightened legislators might think, but rather used appropriately for the individual.
The whole discussion of death panels sort of escaped me when it came around the first time and when it has recurrently resurfaced. End of life discussions have always been a part of practicing good medicine, and it would be nice to be paid for them specifically so that more physicians would take the time to do them properly. A panel of physicians would not be particularly good at talking to people about death and so a death panel, even if it weren't just a figment of a paranoid imagination, would be terribly inefficient. One of my patients, a 90 year old woman, expressed fear of death panels several months ago, and after explaining that I wasn't sure where that idea had sprung from, we had a good, simple and productive talk about what kind of therapy was available to her should her heart stop or her other functions cease to be, and we were able to document exactly what she would want should she not be able to express her wishes.
As doctors who frequently admit patients who normally see other doctors to the hospital, my partner and I are often on the receiving end of the problem of inadequate discussions of end of life wishes. Very ill or dying patients will be admitted to the hospital, with one of us as their doctor, and have never discussed with anyone what kind of care they would want. They are often too sick by that time to talk about it or think about it, and even if they were capable, they don't know me or my partner from Adam, and reasonably don't have the level of trust necessary to allow us to help them make a good decision. This leads to heartache and wasted effort.
So what I see as the take home message of this New England Journal article is that discussions of end of life preferences including life support but also ways to receive comfort do not need to be depressing, but can be affirmations of life's value and our own self determination. When a doctor opens up this area for a person and his or her family to talk about, fears can be allayed and options can be explored. Death is just about always difficult in some way or another, but there are many ways to handle it that help to maintain our love and humanity.
Subscribe to:
Posts (Atom)