Monday, November 24, 2014

Coming Up Empty. Does The Government Look Before It Leaps?

A few months ago I assessed a patient with dementia.  I dutifully ordered the appropriate blood testing and MRI.  As I delved further into the history, I was concerned that there may be a component of depression.  Pseudodementia (memory disturbance and dementia like symptoms caused by depression) can often mimic classic Alzheimer’s disease, but resolves with proper treatment.  The best way to differentiate these two syndromes is neuropsychological testing.  I decided to send my patient to a colleague whom I had been working with for years.  He had recently joined a large multi-specialty group owned by the major hospital system in our area.

The patient returned to my office a few weeks later.  Not only did he get the consult, he also was sent directly to the neurologist next door (who worked for the same medical group/hospital), and had all his blood work and MRI repeated.  He was placed on a dementia medication called Aricept.  Now most primary care physicians can manage run of the mill dementia without a neurologist’s input, and many agree with The American Geriatrics Society’s Choosing Wisely campaign that Aricept should be used sparingly.  So it seems my innocent and appropriate neuropsychology consult turned into a very expensive episode fraught with repetitive and unnecessary care. 

What gives?

A recent study in JAMA by James C. Robinson and Kelly Miller examined per patient expenditures for hospital-based practices in comparison to those that are physician owned.  They found that hospital practices were 10.3% more expensive and multi-hospital system owned practices were 19.8% more expensive then private physician practices in the period from 2009-2012.  The goal of the study was to examine the effects of work force consolidation among providers that was occurring at a breakneck pace as a result of Obamacare (for a good discussion of consolidation and Obamacare see Scott Gottlieb's article in Forbes).

Whether intended or not, this is just another example of how governmental policy is both failing to bend the cost curve, and having a neutral if not negative effect on healthcare quality.   In fact Washington has been dead wrong more times than not.  There is no better example than the Medicare demonstration projects.  Lauded as government innovation, these projects were set up to test the most "prescient" beltway policies.  In January 2012 the Congressional Budget Office produced a memo titled: Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment.  They concluded that of the ten projects to date,  the improvements in cost and quality had been negligible.  

More recently there has been a much hype about pay for performance.  Aaron Carroll does a nice run down of how it has failed to show benefits in his New York Times piece.   The promise of electronic medical records and meaningful use was just another disappointment as documented by the RAND Corporation's most recent analysis.  The Bundled Payments For Care Improvement initiative is now well under way and is the next in a long line of "innovations" which is expected to fail.

Looking into the future,  I am strongly in favor of the governments ability to form and test hypotheses.  Demonstration projects can help us predict which policies may actually lead to improved healthcare.  The problem is the government tends to look before it leaps.  Healthcare consolidation,  pay for performance, PQRS, and meaningful use are already prime time even as the studies to prove their effectiveness are coming up empty.


Tuesday, November 18, 2014

The Not So Humorous Unintended Consequence of Healthcare Reform is Monopoly

Check

The administrator's voice wavered as I picked up the phone.  He was calling about the nursing home patient that I admitted the day before.  While normally forthright, I could feel the discomfort in his tone as he danced around the issue.  The patient's insurer had called.  Apparently they made an "arrangement" with the Mega ACO owned by the latest consolidation of Goliath health systems.  They wanted my patient transferred to another doctor.  Apparently the insurer now required all it's patients to be seen by only medical group physicians.

The administrator was almost whispering now.

The truth is, if it was up to me, I would have you see all our patient's!

The medical group doctor hardly ever rounded.  She was almost never available for urgent calls.  Her patients were transferred out to the hospital at the drop of a hat.  Yet, incredibly, she was managing three quarters of the nursing home population.   But the medical group physician had one advantage that trumped clinical quality or even cost of care.  She was measurable.  Her every move was recorded in an electronic medical system that could be beamed into the greedy hands of administrators, case managers, and insurers at whim.  This data could be analyzed and assessed, and spit back at her with ultimatums and extracted promises.

We sat silently on the phone at a loss for words.  The nursing home could not dare damage the fickle relationship with the ACO.  Otherwise the growing stream of patients coming from the local hospital would diminish.  It had been that way for some time now.  The threat was implicit to the arrangement.  The not so humorous unintended consequence of healthcare reform is monopoly.  And there is a power grab by huge expansive hospital systems for the billions of dollars, I mean patients, ripe for the picking. Physicians and nursing homes, doctors and nurses have all become pawns.  They are fodder for a game playing out around the country.

The administrator was the first to speak.

You know that the ACO will be merging with your other hospital systems soon.

He was right.  It was only a matter of time before they would be kicking me out of the nursing home business and replacing me with some no named company man.  As I began to hang up I sensed a ring of optimism bouncing over the phone line into my unwilling ear.

You might want to join the medical group, we really need you to see more patients here.

I hung up.

Check...mate.

Monday, November 17, 2014

You Are Not Your Data

A few weeks ago, @drmikesevilla (Mike Sevilla) live tweeted a slide from Eric Topol’s (@EricTopol) talk at the American Academy of Physicians' 2014 annual meeting. The slide, a picture of a young man with transparent numbers and data points outlining his face, is silhouetted by words in bold black print: YOU ARE YOUR DATA. This sentiment was a throwback to Dave deBronkart’s (e-Patient Dave’s) 2009 keynote address for the Medicine 2.0 Congress in Toronto titled “Gimme my damn data, because you guys can’t be trusted.”
The idea is that a person’s ability to understand and control their medical records, previous lab results, and even biometric data will lead to more engaged patients and better outcomes. While enticing to blindly follow this logic, there remains a fallacy to such arguments...

Please read the rest of my post at The Medical Bag.

Tuesday, November 11, 2014

My First Patient Was A Mouse

I didn't think much of it at the time.

Most physicians can trace back and recall their first patient.  For some, it is a clinical encounter the third or fourth year of medical school.  The more creative may point to their cadaver during first year anatomy and nod knowingly.  My first patient was a mouse.   Or shall I say a group of them?

My freshman year of college, I volunteered in the lab of a prominent endocrinologist and studied a new drug to reverse the course of type 1 diabetes.  We monitored genetically bred, non obese, diabetic mice.  Every day we would reach into their cage and grab them as they scurried about.  Then we would rub their bellies inducing urination, swab the urine, and test for glucose. The unlucky creatures with a positive urine test needed to have blood drawn.  The thing about mice is that they don't have obvious vessels like you and I.  In order to get a drop of blood, we had two choices: either cut a portion of the tail or tap the choroidal plexus behind the eye.  The latter approach, while more brutal, was less maiming.

I would take a swab and dip it in ether.  The swab would be applied to the mouses nose inducing anesthesia.  The tough part, while applying pressure to the orbit causing the globe to pop out of the socket, I would slip a pipette behind the eye and turn until blood shot up the tube.  Then, if we were lucky, the mouse would wake up.  If not, we used our fingers to compress the chest performing mouse CPR.  Those mice proven to have diabetes would be randomized to two separate groups.  One would get the experimental injection while the other would get placebo.

I passed many days and weekends alone in the lab.  One sleepy Saturday,  I approached a mouse in preparation for a blood draw.  Mice can be slippery creatures.  The technique most favored was to grab them by the scruff of the neck with the thumb and forefinger, and hold the back tightly with the base of the hand.   So I thrust forward like I had done dozens of times.  I got a good hold, and flipped the mouse around to face me.  But something went terribly wrong.  I must have grabbed too high, or maybe too roughly.  The mouse's body quivered and then shuddered in such and odd and frightening manner.  I reflexively released as the mouse fell to the table.  Dead.  With horror, I realized that I accidentally snapped it's neck.   I will never forget the feeling of life passing so quickly and unexpectedly in my hands.

I occasionally think about this as I watch family members cradle their loved ones in those passing moments before death.  Do they feel the shudder?  Do they experience revulsion or relief?

And I sometimes have fevered dreams about that mouse.  When I toss and turn, unable to sleep because of the crushing pressure of some clinical decision or another.  That poor creature.

That poor creature who succumbed under the weight of my thick, clumsy hands.


Tuesday, November 4, 2014

Sadness On The Side

The calls came simultaneously.  One from the hospital and the other from a nursing home.  Two deaths separated by fractions of a second.  My heart swelled.  For a moment.  The pile of papers on the desk softly whispered.  My mobile howled jealously vying for my fragile attention.   I could feel the emotion drain as I turned back to the task at hand.  Unexpectedly, my mind wandered back to the wedding in California.

It was a spectacle.  Pre-ceremony hors d'oeuvres with sushi stations and Kabobs.  An open bar long before the utterance of the first I do.  The wedding party bespectacled in gowns and tuxedos danced down the isle as the gala began.  I felt the joy, in every corner of the room, soak the participants in a  humid haze.  It was heavy but far from suffocating.

I held my wife's hand as first the groom and then the bride sauntered down the isle.  The groom paced the full length but then circled back as his bride reached the middle section.  They walked together to meet the Rabbi.  My wife glanced in my direction and saw the tears welling in my eyes.  She looked quizzically before turning back to the ceremony.  I was far from surprised.  

I have been crying a lot lately.  At weddings, during movies, or while watching television  It's something that has grown exponentially over the years.  The barriers of my heart have become weak and the tide crashes into the breakers and spills shockingly on the barren land below.

I have lost control.  And I know exactly why.

It's just that I see so many awful things.  My daily menu consists of death and destruction with a healthy serving of sadness on the side.  I swallow these whole, rarely having the time or energy to chew properly.  Yet all that is pushed down must eventually be digested.  I no longer mourn, for after all these years mourning would have morphed from a hobby to a full time profession.  I neither grit my teeth nor curse a deity that often seems indifferent to the suffering of us poor plodding humans.

Instead I cry.  When it's safe. When the joy becomes overwhelming.

Tuesday, October 28, 2014

Ordinary People

Cheryl loved to dance.  There wasn't a time in our house when the the kids weren't jumping up and down on the furniture, the radio blasting, and her body swaying in rhythm.  Ironically, we were dancing when it happened.  It was her fortieth birthday.  The kids laughed and clapped as I dipped her dramatically and she sprung back into my arms.  And then she crumpled.  Tony, my youngest, giggled hysterically thinking it was a ruse.  I clutched at her lifeless body, all muscle tone was lost.

It was the emergency room physician who first used the word "stroke".  But what does a plumber know of such things?  In my experience you could always replace the damaged or diseased part.  I clung to this naive worldview as Cheryl was transferred to the ICU.  Tony and Lisa alternated between collaborating and arguing as I held vigil at her bedside.  And we waited.

Everyday the neurosurgeon came in with worse news.  First there was bleeding.  Then an increase in brain pressure.  The nurses whispered about hospice, but no one had the fortitude to talk of such things openly.  I wouldn't have listened anyway.  How does one give up on their lover, partner, friend?  If there is one chance in a million, wouldn't you take it?

The conference room was full of doctors and social workers.  Tony and Lisa stayed outside in the waiting area and played with legos.  The neurosurgeon was severe and agile, a man of action.  He described the procedure to remove part of the skull to relieve the pressure.  The Internist was mousy and meek. He used numbers and percentages.  He assured that it would be OK to do nothing, to let nature takes it's course.  I visualized Cheryl's brain like a drain clogged and stuffed to the point of bursting.  I imagined reaching with my tools and clearing the debris.  I decided to let the neurosurgeon have at it.

The years that followed were difficult.  Cheryl didn't die, but she never recovered either.  And each fork in the road was met with another gut wrenching decision.  Tracheostomy, feeding tube, nursing home.  Her brain severely damaged by swelling and blood, her recovery was tortuous and incomplete.

She did improve.  The tracheostomy tube was removed.  She is able to move her eyes and verbalize some.  The most coherent thing she does is cry.  Everyday, in the nursing home, by herself, she cries.  She is unable to lift her hands to wipe away the tears nor does she have the brain power to negotiate the psychological torture of her daily existence. She just knows that something is wrong.  And it cannot be fixed.

Lisa and Tony are teenagers now.  They try to visit from time to time but they are in the process of building their own lives.  They are stuck in the chasm between childhood and adult.  Their invalid mother is a constant reminder that life can be horrifying.

And I wonder if I made the right decision that day in the conference room.  Maybe we would have been better off if Cheryl died quietly in that ICU.  Maybe she would have suffered less.  But I try not to think about such things too often.

Because Cheryl, Tony, Lisa and I, we're just ordinary people.

We don't always know which way to go.

Tuesday, October 21, 2014

Parenting And Helplessness

Years later, I now wonder if I overstepped my boundaries.

Nancy was a pleasure to have as a patient.  A physician's assistant in her early twenties, we often chatted amiably during visits.  Our conversations randomly ambled between personal and professional topics.  She recently married and was looking forward to having children.  Her gynecologic history was complicated and after a period of months of unsuccessful attempts to get pregnant, she visited a local infertility specialist.

Although the workup was completely normal, one of her blood tests, while technically in range, was deemed "subpar".  Her obstetrician sent me a letter asking if I would monitor levels and adjust medications.  Appointments were made, labs were drawn, and a few months later a pregnancy test came back positive.

Nancy was overjoyed.  Every so often I would receive a note from her gynecologist documenting her progress.  Ultrasounds were normal.  A litany of screening tests uncovered no abnormalities.  Everything was perfect, or so I thought.

One morning I was surprised to find Nancy sitting in my exam room crestfallen, on the verge of tears.  Her gynecologist was struggling with her levels.  Her previously "subpar" blood test was closer to range, but still had not met the magic number that her infertility specialist had decreed optimal.  With her medical training skills honed from education, Nancy had searched out a bevy of papers suggesting a correlation between low normal values and poor pregnancy outcomes.  Thirty weeks into gestation, She felt like she was in crisis.

While I was unconvinced by the tenuous connection in the literature Nancy produced for me, I couldn't help but feel a lightning bolt rush through my own insides.  How many times had I struggled with these same fears with my own children?  How many times had I painstakingly deliberated over my little ones ad nauseum.  To give vitamins or not?  To treat with antibiotics or wait longer?  Every decision dissected and second guessed.  Each time feeling so sure that my failure to decide correctly would mar my child for a lifetime.

My eyes glistened as I told Nancy that having a child was like ripping your heart out of your chest and then leaving it in the open unprotected by the strong bony architecture of your rib cage.  That to procreate was to feel an uncertain type of helplessness that is unmatched by other realms of human experience.  She will try to control almost every part of her babies existence and fail over and over again.  And yet most likely, despite all her foibles, her child will be more perfect than she ever imagined.

Nancy, I explained, was experiencing the first pangs of parenthood.

We decided on a treatment plan.  We scheduled a follow up visit one week later.  And then she left the office.

I never saw Nancy again.  She cancelled all future appointments

Years later, I wonder how things went.

I often imagine her holding her baby lovingly.