Thursday, December 18, 2014

Idolatry

Julie was lost in thought.

Her right pointer finger slowly traced the edges of the metallic trinket.  It was tucked far enough into her pant pocket that only the longest digit could reach.  Back and forth, her hand moved caressingly, pausing from time to time to inspect any irregularity, any imperfection.  In such a manner Julie built a mental image of the old forgotten piece of jewelry.  Her hands visually occupied a space that her eyes had long abandoned.

There was not much to the frigid, sterile room  A few rickety chairs. A  worn carpet.  Some posters placed haphazardly on the wall. The smell of bleach wafted through the waiting room and mixed with the alcohol emanating from where the IV had been placed in her forearm.  Julie had grown used to the metallic explosion of iodine assaulting her palate shortly after the injection.  There were all sorts of explanations.  It reminded her of fear.

She drank it in.  Every few months.  Much like her mother had.  Cat scans and blood tests, radiation and chemotherapy.  At least there was action.  Waiting is what slowly killed her mother.  Desperate moments lost in rooms such as these.  Waiting to be poisoned.  Waiting to be irradiated.  Waiting to be informed and then consoled.  If one could string all those moments together side by side, surely there would have been enough time for one last trip to Mexico, or maybe Vegas.

Julie's mother allowed the life to spill out of her in such a pathetic, untidy manner.  She grasped the tarnished cross in her hands.  She never bothered to remove the chain, although it was seldom worn around her neck.  She would clutch openly at the pendant while she waited, until she was called back to the office.  Then she would slip the cross back into her pocket, and hurry after the nurse who most likely had already disappeared behind the cantankerous doorway.

No matter how hard Julie tried, she couldn't stem the flood of memories that threatened to drown.

The night her mother died, her father fastened the necklace on the lifeless chest, haughtily displaying all the agony and fear.  He said it looked nice.

After everyone left, Julie leapt to her feet and snatched the horrid idol from where it lay.  The flimsy chain snapped and disappeared into the murky abyss of the casket.

It was the last time that Julie would ever touch her mother,

or see the hapless chain again.

Wednesday, December 17, 2014

A Year Of Concierge Medicine

A year ago, I embarked on a voyage at the leading edge of modern-day health care. I abandoned my traditional office-based practice of 2000 patients for a much smaller membership (concierge) model.  My reasons were varied. They mostly focused on the dwindling time and concentration afforded by so-called  “advances” in medicine, such as electronic medical records and the ever-increasing deluge of paperwork that plagues today’s physician. As I begin year 2, I would like to share a few things I have learned...

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

Wednesday, December 10, 2014

Attention #HCSM Meeting Planners. Would You Like Me to Speak At Your Event?

The only thing better than blogging is having the chance to tell one's stories in person.  While I have been asked to speak at a number of events over the years, I have developed a new talk that I am especially itching to give to a live audience.  I expect it will have all the emotion and impact of the DotMed 2013 appearance below.



Details
Topic/Running Title: The Medical Narrative, A Tie That Binds Doctors and Patients
Style: TED style, no visuals, no notes
Content: Narrative heavy, didactic light
Running Time: 15-20 minutes

Requirements
Will accept multiple offers, but will give video rights only to one.
Need a few months in advance to arrange my schedule.
Expenses and stipend to be negotiated.

Please respond by email: grumetjordan(at)yahoo.com

Tuesday, December 9, 2014

A Small Island Next to a Hulking Continent; A Parable

There once  was was a kind humble physician who worked for years in an office building across the street from the hospital, toiling day to day to take exceptional care of his patients.  He was open and deliberate, calm and thoughtful.  He himself hired every secretary and medical assistant, every nurse and biller.  His staff formed a protective family who fiercely advocated for both patient and doctor.

And he prospered.  For a time.

The winds of change were slowly gaining force in his small town.  His beloved hospital joined a larger medical Goliath.  His fellow practitioners abandoned their private practices, and eventually became employed by one medical group or another.  Office overhead was on the rise.  Each year he looked carefully at the cost of medical insurance for his loyal employees.  Each year he wondered how long he would be able to afford such steep increases.

He valued the control of owning his own business, but most of all, he wanted to expend as much energy as possible in the care of his patients.  So when an administrator from the hospital came knocking at his door, he couldn't help but listen carefully.  These were difficult times for the lone physician.  Would he not be better under the protective shell being offered?

He felt unbearably isolated in his current situation.  He was a small island next to a hulking continent.  His practice was in good financial shape for the moment, but how long would that last?  He better be proactive and join the medical group before the offer was rescinded.

He was assured that all parties would work together to provide the best clinical care possible for his patients.

He felt great relief when the medical group's office manager arrived.  He literally handed over the reins of every administrative task that was drawing him away from the examining room.  The clouds parted, the air cleared, and free to concentrate on that which made his heart sing, this humble physician prospered once again.  For a time.

The medical group embraced a new practice called open access.  All walk in appointments were accepted regardless of severity.  Physicians were asked to work more nights and weekends.  When he argued with his office manager about such changes he received a response that was hard to argue with.

He was assured that all parties would work together to provide the best clinical care possible for his patients.

In order to do so, the doors must be open to the customer when they have a perceived need, regardless of how minor.  Besides, medicine is also a business, how could they attract more patients if they were not providing the same services as the competitor down the road?  Furthermore, since medical group primary care doctors were no longer seeing patients in the hospital (now using hospitalists), he would have plenty of time to meet the unmet needs of his clientele.

Although he missed taking care of his patients in the hospital, and he bristled at the nontraditional hours, he once again adapted to his new situation.  And he prospered once again, for a time.

The medical group was exited about the new meaningful use regulations put forth by the government, and quickly partnered with a company that provided electronic medical records.  Instead of dutifully working in his office one morning, he sat in front of a classroom full of grumbling doctors being instructed on the newest medical record technology.

This humble physician, however, was a terribly slow typist.  He found fiddling with his fingers difficult when he was trying to concentrate deeply on his patient's complaints.  He lamented that his hands were awkwardly occupied when he wanted to reach out for the shoulder of a sobbing husband or wife, child or parent.

He was assured by his office manager that all parties would work together to provide the best clinical care possible for his patients.

Electronic medical records when used meaningfully, as defined by the government, would maximize clinical integration and lead to leaps forward in collecting and utilizing big data.  He was also reminded that his clinical productivity was flagging, and that the bonuses and eventual penalties of not complying could bankrupt his practice.  Although he found it ironic that all of the sudden it had become "his" practice, he put his head down and tried to confront all the changes he faced in the office.  Except, he did not prosper.

Confused by the electronic medical record, unaware of what had taken place with his patients when they were in the hospital, and crazed with the checking of boxes, it was a short time before the quality of his clinical care began to falter.  Months later he received his first summons.

The torte system was arduous.  Hours of preparation and deposition took their toll.  All the virtues highlighted by the practice manager became vices in the judiciary system.  He was chastised for his consuming medical record, and second guessed for not visiting his patient in the hospital.

He faced the onslaught alone.  There was no medical group representative on the stand with him.  There was no reassuring voice at night when he climbed into bed with a head full of doubt and eyes that would remain open thirsting for sleep.

His office manager was unapologetic when confronted with accusations of leaving him out to dry.  It was not the administrative staff that was responsible for such things.

He was assured that the medical practice is a business and could only survive as long as it made money.  It was his job to provide the best clinical care possible for his patients.  Not theirs.

He was then fired.

His low productivity could no longer support the hefty administrative burdens needed to run the medical practice.  Perhaps they would hire a nurse practitioner.


Thursday, December 4, 2014

Good Luck to the #dotMED14 Crew, @RonanTKavanagh

I don't go to healthcare social media conferences that often.  There are three partial reasons for this.  First, I don't have much time.  Second, I'm usually too cheap to pay for it.  Third, I only tend to go to those meetings that I am asked to speak at.  I'll let you decide which of these three is truly the rate limiting step.

The DotMed 2013 conference, however, was an exception.  I was asked ( I also begged/pleaded/cajoled some people-you know who you are) to come to Dublin and speak on the topic of narrative medicine and social media.

The trip was magical.  Dublin was everything I could have hoped for: friendly, gregarious, cold.  The hosts and speaking venue were impeccable.  We met for dinner before and after the event.  There were bars, and food, and alcohol (gasp!), and banjos.

But really, it was two aspects of the trip that really make me jealous on the eve of DotMed 2014 which I will not be attending.  One is that I got to give the talk of my dreams.  A narrative that I had been building over years of blogging and decades of life lived.  A presentation that was, for me, pure joy.  There is nothing better than getting up in front of a group of people and talking fluently about something you are truly passionate about.  I live for these moments.  Every blog post I write is a mini sermon.  A talk I'm itching to stand up and give.

The other, of course, is the utterly cool people I got to meet and spend time with.  The creators, speakers, and attendees were a group that I truly admire.  Their words, ideas, and laughter will stick to my bones long after I have sloughed off the minutia of what had been said.

A year later, I am still in awe of all of you that I spent such precious short time with.

It's like it was just yesterday.

Good luck to the #dotMED14 crew.  Enjoy.

Monday, December 1, 2014

What If Our Healthcare System Made Sense?

The conversation was almost comical, until I thought more deeply about it later.  Apparently I was on "the list".  Insurers make such lists for customers who are  searching for a doctor who accepts their coverage.  Every so often my name comes up on these lists, and I get a smattering of phone calls from perspective patients. Maybe a few times a year.

This particular call came around three thirty in the afternoon.  My personal assistant had already signed over the phone to me, so my office number came right to the mobile.  I answered quickly expecting one of the nursing homes.  The voice on the other end was hesitant.  He was looking for Dr. Grumet's office, but quickly realized he had the doctor himself on the phone.  This felt odd for a guy switching physicians because the next appointment at his current practice was two weeks away.  But his toe was hurting something fierce and he was desperate.

So he searched his insurance web site for a list of available providers.  He quickly crossed off any physician that belonged to his current practice or the hospital based medical group because he knew from experience that those doctors rarely had openings.  They almost never returned phone calls.  Although I do not accept his insurance, I somehow had landed upon the sacred list he was scrawling through anxiously.

He told me that I was the tenth phone call he made.  He came up empty with the first nine doctors.  Many claimed that they were closed to his insurance because they were too busy to take on new patients.  One was retiring in a few months.  Another was leaving medicine to work for a pharmaceutical company.  A third was transitioning into a hospitalist position.

I regrettably informed him that I would be happy to bill his insurance but also charged a yearly fee for non covered services.  He paused for a moment.  I could feel the wheels spinning in is head.  He hated to pay extra, but was dumbfounded to find that he was actually talking to the doctor himself without jumping over any roadblocks or scaling any walls.  His foot ached.  And I knew that it would probably take little mental effort to assess and treat his problem.  Whether stress fracture or gout, infection or inflammation, I felt certain that I could help.

We talked a little longer.  Not about his medical problem in detail but more what was happening to our healthcare system.  It was a pleasant unhurried conversation.  He eventually decided that he would try his luck with the rest of the names listed in front of him  He thanked me profusely for my time and hung up with a sigh of resignation.

I hope he found the care he needed.  I doubt I will ever hear from him again.  These types of calls rarely end in the signing up of a new patient.

I wonder if he marveled, for just a moment, about how easy it could be.

What if you could talk to your physician whenever you needed to?
What if Doctors and Patients had time to form strong mutually respectful bonds?
What if our healthcare system made sense?

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.