Tuesday, March 21, 2017

Adding Value by Talking More

A recent article in the New England Journal of Medicine - Adding Value by Talking More - caught my eye. For me, having practiced psychiatry for 43 years, the authors' argument was preaching to the choir. But what is special about the article is the hard-nosed way it cites data that demonstrates cost savings from investing time and money in well-planned conversation.

Here's the final paragraph of the article:

As these examples illustrate, increased physician communication is time very well spent when it leads to better patient outcomes and lower total costs. Clinicians who are reimbursed under new value-based payment plans should seize the initiative to determine how much of their valuable time should be spent in the various types of productive conversations, especially as they become more accountable for their results. Physicians now have the discretion, incentives, and accountability to use their time wisely and productively to reduce the total costs of patient care and improve the outcomes they deliver.
The otherwise excellent article omits one crucial element. Talking more with our patients also increases physician satisfaction. In conversations and CME sessions, when physicians are asked about meaningful clinical experiences, relationships with patients and moments of empathic connection predominate.

I encourage readers to go to the NEJM article. The three authors are all from the business school and the consulting world. They makes the kind of case for "talking more" that administrators will understand and be influenced by. I also encourage readers to go to the website of Avant -garde Health, a health care technology and analytics company founded by one of the authors.

Some harried physicians, unhappy in practices in which talking with their patients feels like a luxury they can't afford, choose to move into a concierge model of practice, in which they (a) limit the number of patients they care for and (b) charge an "entry fee" to be part of the practice. This solves the morale problem for the individual physician, but it weakens the health system itself by reducing the number of available primary care physicians.

The kind of work behind Adding Value by Talking More is addressed to the same problem concierge physicians are dealing with, but at the population level. As such it is a more socially responsible approach to the effort of making our health system more "patient centered."

Sunday, March 19, 2017

Access to health CARE vs access to health INSURANCE

A dear friend who follows this blog sent me an email about the two posts I wrote last week about my own recent medical experiences (here & here). With my friend's permission I've copied the message he sent, edited to protect confidentiality and to highlight the themes I want to emphasize:
Thank you for the very informative posts. In general, however, I think the blog doesn't describe the experience of patients who are not MDs and/or are not in an integrated group practice such as the one you belong to. In my own experience, PCPs defer to specialists and won't contradict them. Further, the placebo effect of the PCP relationship is reduced if not nullified by the patient's difficulty in contacting the PCP over the phone. I can never get an appointment on short notice with my PCP; I can only count on seeing him if the appointment is made months in advance, or if I am in an emergency ward or am admitted to a hospital as an inpatient. If I have an immediate problem that is not an emergency (e.g., burn, sprain/suspected fracture, bronchitis), I have to work through two layers on the phone (secretary, medical assistant) -- and then the outcome will be an examination by a nurse practitioner. I therefore now prefer to use the XYZ Hospital's Walk-In Clinic rather than even trying to reach my PCP's office by phone. Finally, your encomium to the email system doesn't apply to the sharing of medical records between hospitals on different systems (e.g., XYZ hospital and ABC, where I have also had care) or to practice groups that are located in one and the same hospital office building but that don't share the same medical records system.
My friend is well insured - s/he [I'm deliberately disguising gender] has no problem with insurance access. And the community where s/he  lives is replete with medical services.

In a follow up conversation I will ask my friend about experience with the nurse practitioner. Over the decades of my clinical practice, and in my own care, I've had terrific experiences with nurse practitioners and physician assistants. Assuming that the NP is indeed a skillful clinician, the PCP can foster trust and comfort with the NP by explaining how they collaborate and demonstrating how they work together.

My positive experiences have definitely been fostered by the fact that I'd been a clinician in the group practice from which I was getting my care. But I'm convinced that a patient who had not had a career in health care and had not been part of the group could have a comparably positive clinical experience if they had the same skills I have in managing my care experience.

I anticipate that in the future, patients will routinely have electronic access to their own medical records. That kind of access, combined with a robust secure communication system with and within the practice, would promote more secure connection to the medical home than my friend experienced.

From 1975 until I ended my clinical practice I was paid a salary. That meant I was not dependent on billing for each in-person service for my compensation. One of my patients who had significant depression and was dealing with major stressors strongly preferred the convenience of electronic interchange rather than coming to my office. After we had gotten to know each other in 5-6 in-person appointments, we switched to email, which we used for ten years. When we met to say goodbye in person when I retired from practice, we felt we knew each other very well, but neither remembered what the other looked like, which made for some amusing uncertainty in the waiting room. Being paid by salary meant that I was not "penalized" for providing care to my patient with so few in-person meetings.

It's not likely that we will have enough PCPs to ensure prompt access for all patients in the foreseeable future. To provide the kind of secure connection my friend was looking for we'll have to manage the process of team collaboration better than s/he has experienced, and make use of electronic forms of communication to augment connection between the patient and the team.

The generation moving into adulthood is schooled in making electronic connection with their peers. They will demand that kind of opportunity in their medical care.

Wednesday, March 15, 2017

Chronic pain, Identity, and Health System Ethics

Prior to this past year my experience of pain had been with acute episodes. An especially painful and amusing episode occurred when I started a new job at the Massachusetts Mental Health Center after residency and fellowship. Between painting rooms in the house we were moving into and carrying boxes hither and yon I threw out my back. I lay on the floor, hardly able to move. A helpful neighbor called his PCP who came to the house. (It was 1970 and house calls actually happened.) I could see that he was regarding me with suspicion. Perhaps I was a newly arrived addict who was seeking an opiate fix. And when I started my new job, in some of my meetings I again lay on the floor, giving a rather odd impression of the new hospital ward supervisor.

The pain was severe - perhaps 9 or even 10 on the ubiquitous 0-10 scale. But I knew it would clear up before too long, and it didn't burrow into my psyche and sense of self. In the (slightly altered) words of the old spiritual, it "pained the body but not the soul."

Not so with the chronic pain I wrote about 3 days ago! It's not as severe as the back spasm, but the (a) chronicity and (b) uncertainty about if and when the pain will go away has (c) taught me lessons I only understood from the "outside" during my years of practice and (d) challenged my sense of identity.

Like many physicians, my default mode is to help others. Over the years, when asked "how are you?" my typical answer has been a hearty, upbeat "excellent!" So for the simplest of tasks - taking out the garbage and even putting on my pants (I have to protect the toes from contact with the pants leg - not easy to do) - to become difficult or impossible is a shocking change. My wife has taken over my "chores" cheerfully and uncomplainingly, but I feel ashamed at (my words) "not doing my part."

Before the foot/ankle/lower leg problem set in, I took an extended walk whenever the weather permitted, and played tennis with friends weekly. Sacrificing these activities isn't just a matter of losing forms of "recreation." Being an active, out-of-doors person has been part of who I am. These losses take another bite out of my sense of identity!

In a similar vein, I enjoy being at both of the two offices I use. But parking and walking to the office is difficult, and I can actually do most of my work from home, so I have been largely invisible at my work sites. My "productivity" may not be reduced, but collegiality is down, and loneliness is up.

Coping mechanisms are crucially important and put to the test. As an example, the toe/foot/ankle/lower leg pain is worst at night. When I try to sleep it wakes me up every 60-90 minutes. My initial reaction to these awakenings was anger, but that accomplished nothing useful and made it harder to get back to sleep. By an act of will I substituted humor - laughing at myself sitting in the dark massaging my foot and hobbling around to reduce the pain. Rather than saying "why the bleep is this happening to me" I say various forms of "what a ludicrous situation this is!"

This is a blog about organizational ethics. Readers may reasonably ask "what on earth does a painful foot and difficulty taking out the garbage have to do with organizational ethics?"

A lot!

Nowadays, organizations toot the horn about their commitment to "evidence based practice." Since the Hippocratic era, the practice with the strongest evidence of effectiveness is empathic listening. Organizations can encourage this stance or - all-to-often - squelch it with bureaucratic demands and processes that treat patients as targets for efficient "throughput."

Time pressure is a fact of life everywhere in health care, but there are skills we clinicians can develop to use time well, rather than having time use us. When I joined the mental health practice at the Harvard Community Health Plan HMO in 1975, the insurance limited the number of appointments we could have with our patients. Some clinicians put this limit front and center when they met new patients, by stressing what they couldn't do. Wise clinicians, however, approached new patients differently - "Let's first figure out what you need, and then see how we can best meet those needs." The HMO encouraged me and my colleagues to struggle with the challenge of remaining true to our mission while doing what was needed to make the necessary margin to keep the program going. (See here and here for examples of that work.)

Medical care ultimately comes down to the patient-clinician dyad, but more and more often the dyads occur in an organizational setting. Empathic listening is carried out by individuals, but organizations can encourage or thwart this deeply human process. That's where organizational ethics comes in!      

(A friend who knew about my left foot problem brought to my attention a superb article by the distinguished primary care physician Thomas Bodenheimer - "Lessons From My Left Foot." It's available at  http://www.annfammed.org/content/8/6/550.full.pdf)

Sunday, March 12, 2017

Health System Ethics and my Left Foot

I haven't written a post for more than 6 weeks. My left foot/ankle/lower leg are a big part of the reason for the lapse. So I decided to write about my experience and connect it to the topic of this blog -  health system ethics.

Many physicians have written about their own experiences of illness. Here's my  story.

In the fall of 2015 my left big toe itched. I didn't pay much attention until it began to hurt and develop redness. My primary care physician (PCP) was on a medical leave for a serious medical problem, so I saw another physician in his practice group. By that time I had red blotches on my foot as well. The physician had two hypotheses:

   (1) It might be an early stage of "vasculitis" (inflammation of the blood vessels). She did some blood tests, all of which were normal, and referred me to a rheumatologist (a specialist in autoimmune and musculoskeletal conditions).
   (2) It might be a circulatory problem, and she referred me to a vascular surgeon.

The  rheumatologist did a thorough evaluation with many blood tests. Except for two minor abnormalities, all were normal. He concluded that I did not have a systemic illness.

The vascular surgeon also did a thorough evaluation and a CT scan to visualize blood flow to my legs and feet, which showed adequate circulation with no visible blockage.
Lesson # 1: The specialists were excellent, but when they didn't find a problem within their purview, I was left with a "what now?" question. Given the absence of my long term PCP I decided to be my own case manager. I believed more than ever in the importance of primary care as the key hub of the health care system.
The pain was better during the summer. Perhaps the warmer weather explained it. Whatever the explanation, I enjoyed the summer.

In the fall of 2016 the areas of red discoloration spread onto my left ankle and lower leg. Happily, my PCP returned to practice from his long term medical leave.
Lesson # 2: Apart from all of the valuable things PCPs do, at least for me, and I would guess for many others as well, there is a powerful placebo effect from having a solid relationship with a clinician one trusts for skill, knowledge, and a genuinely caring attitude.
On examining me and hearing my history, my PCP said - "This is really weird. I have no idea what's going on. I think we should involve a dermatologist." A couple of weeks later I saw a dermatologist who suggested a few possibilities and did a biopsy. The biopsy came back "non-specific" - i.e., it didn't tell us anything. She thought we should get a second opinion.

It took several weeks for this to be arranged. The very knowledgeable consultant I saw put forward some additional possibilities and recommended repeat biopsies. These showed (a) tiny clots in the small blood vessels and (b) no signs of an inflammatory/autoimmune process.

This told us what was happening, but not why it was happening.
Lesson # 3: Humility is a virtue. My PCP acknowledged having no idea of what was going on, but did have an idea of what to do next. The first dermatologist suggested getting a further consult within her own specialty. Their non-arrogance paid off!
On the basis of seeing blood vessel clots, the second dermatologist suggested that I  see a hematologist, who put together (a) the presence of clots and (b) the fact that in the previous month I had a mild elevation of my platelets (blood cells involved with clotting) that was (c) a bit higher on repeat measure. Before our appointment she had me do further blood tests. We'd been colleagues in the past and she sent me the following email:

"I had you do some special blood tests beforehand and, indeed, you have a JAK2 mutation which is present in people with Polycythemia Vera and Essential Thrombocythemia.  This likely explains your elevated platelet count. I will be suggesting starting Hydroxyurea pills – very easy and well tolerated, to bring down the platelets and hopefully prevent more problems in the future."
Lesson # 4: In the previous 14 months I'd seen 10 different physicians. Without good coordination, this would be a surefire recipe for chaos. When  my PCP returned he carried out the coordination function very well, but throughout the 14 months the secure email system my practice group uses was invaluable. I could write to one physician and copy the note to others. This aspect of the electronic infrastructure really paid off.
I've started the new medication (Hydroxyurea), but I'm very aware that we're still proceeding on the basis of hypotheses. Blaming the elevated platelets is a plausible explanation, but two elements don't fit. A year ago, after the problem was clearly underway, a blood test showed normal platelets. The hematologist speculated that "perhaps your platelets are more 'sticky' and clot more easily." That could be true, but it's a speculation. And if the platelets are the villains of the situation, why are the symptoms limited to my left foot/ankle/lower leg?
Lesson # 5:  In 1865, the French physiologist Claude Bernard, who, among other discoveries formulated the concept of homeostasis, wrote “physicians make therapeutic experiments daily on their patients . . . . [M]edicine by its nature is an experimental science, but it must apply the experimental method systematically.” When faced with illness and suffering, patients and physicians want certainty. But as Bernard recognized 150 years ago, certainty of the kind we can have in mathematics is not to be had in medicine. Patients, physicians, and the public, need to learn how to work with and live with the absence of bedrock certainty.
 In this post I haven't touched on the powerful psychological impact of chronic pain and disability. I'll do that in future posts. If you've read this far - thank you for your attention!