To achieve great clinical care, avoid perfection!

There is an aphorism generally attributed to Voltaire which says that "perfection is the enemy of the good."  I happen to like this one a lot, because it serves as such a helpful starting point for almost all organizational improvement work. More on that another time.

Right now, however, I'm thinking about the way this phrase applies to clinical decision-making and the selection of treatments.  I was chatting recently with a very smart infectious disease specialist about my observation that every third patient on our Medicine service seems to have pneumonia and a urinary tract infection.  Not pneumonia or UTI, but both.  I confessed to her that I'm a little reluctant to use my (pediatric) reflexes to form opinions about Geriatrics, but that I was nonetheless skeptical about so many patients experiencing two, simultaneous and unrelated infections.

She said there was a simple explanation. "Most of those patients don't actually have UTI."  What they likely have, she went on, is asymptomatic bacteriuria, a common condition in which the urinary tract is colonized with bacteria in a quiescent state.  There are generally few inflammatory cells, and no symptoms.   Now asymptomatic bacteriuria is neither uncommon nor obscure.  So why would our physicians so routinely mistake it for UTI and prescribe unnecessary antibiotics?  Here's why.

Usually, infections of the lower urinary tract cause painful and frequent urination, while kidney infections cause fever, chills, abdominal or back pain and other signs of systemic illness.  Once in a great while, such infections may cause patients with dementia to be especially confused; moreover, many believe that the elderly are less likely to experience the typical symptoms of UTI. It is this confluence of facts that sets the stage for over-treatment.

In fact, we have seen this many times before.  Here's the syllogism. Condition "X" may be associated with vague symptoms. My patient has vague symptoms.  Therefore, my patient has condition "X." (This is of course a medical illustration of the famous false syllogism: A coffee table has four legs.  My dog has four legs.  Therefore, my dog is a coffee table.) In this equation, X may stand for low blood sugar, occult systemic candidiasis, Lyme disease, gluten sensitivity, various vitamin deficiencies and a host of other conditions.  Which one depends on the newest "under-diagnosed" condition, the patient's age and the physician's personal preference.

What, you ask, has this to do with Voltaire?  It is the fool's errand of seeking perfect diagnostic sensitivity that leads us astray.  The probability that each of the patients on our service diagnosed with UTI actually has the condition is not zero.  But absent any symptom but confusion in the setting of dementia, the probability of urinary tract infection is low.  Since asymptomatic bacteriuiria with or without pyuria is quite common in the elderly, the diagnostic significance of any positive result is likely small.  The question is, how does one best plan a diagnostic evaluation, and then assemble the evidence into a coherent impression?  And in doing so, how does one accommodate diagnostic uncertainty?

Some try to sidestep the problem.  "Better to over treat than under treat," they say - often with great confidence.  Sometimes that's right, as when the consequences of delayed intervention are dire.  Other times, however, the opposite is true.  No, one cannot expect to get the best clinical outcomes by ignoring the obligation to make the best decision possible under conditions of clinical uncertainty.

Osler, of course, said it best,"Even the best of men must be content with fragments, with partial glimpses, never the full fruition."

Doctor, Is this surgery good for me?

An 80-year-old nursing home resident has a colon mass and has been scheduled for a colectomy. Has he been told that 30% of elderly nursing home patients who undergo colectomy die within 3 months after the surgery and that 40% of the survivors have a significant decline in functional status, or that 12 months after surgery, half the patients have died and half the survivors have a sustained functional decline?

So begins a Perspectives piece in this week's New England Journal that addresses surgical decision making.  As we look on, in April 2014, what is the likely narrative for this patient's care?  Perhaps the initial diagnosis was made by a community gastroenterologist who found the mass.  How does he proceed?  It is unlikely that the referral would be other than to a surgeon.  As a matter of fact, the very language of Medicine reinforces the pathway:  the patient has a "surgical" problem.  Preoperative evaluation by colleagues in General Medicine, Cardiology and/or Pulmonary Medicine serve to address our hospital's requirements (some of which are imaginary).   Often this process delays the surgery or threatens to do so as data are assembled in the eleventh hour. Occasionally, additional testing is identified that will reassure us.  Ultimately, the patient is (almost always) "cleared."  (What does this really mean?)  

None of the actors in this play are positioned to address the broad issues outlined above. Appropriately, the surgeon will explain the purpose of the operation and the expected recovery.  He will diligently outline a number of potential complications - bleeding, thromboembolism, infection, adhesions and so forth, and will tell the patient, accurately and reassuringly, that (individually) they occur in only a small minority of patients.  Age-specific risks of deconditioning or cognitive decline and overall outcomes are not - to the best of my knowledge - part of this discussion.  (And not because of any conscious intent to withhold information.  My best guess is that most surgeons would view such considerations as both speculative and beyond their scope of practice.)  

We stand at a cross roads.  In the current, fee-for-service world, significant change would create few winners (the patient) and many losers (the surgeon, consulting physicians, the hospital) so efforts in shared surgical decision making have been limited to a limited number of promising experiments by payers and integrated health systems.  In the Accountable Care world that is emerging, however, the right alignments exist to make it feasible for patients to routinely receive team-based consultation, and comprehensive disease-management planning that does not proceed from the premise that the patient possesses "a surgical problem."  Notably, our own Health System - now that it has embarked on the path of integration with the Care Connect insurance product - is positioned to engage in this kind of work.  

It will take time.  Some patients and families, steeped in the culture of "more is better," will be skeptical of such well-intentioned efforts.  Additionally, physicians will need the right knowledge and skill sets to have these conversations.  (Currently, these are the discussions that Palliative Medicine physicians conduct, but that field will require a make-over for pre-procedure consultation to make sense to patients and families.)  One thing is clear, however - there is change in the air.

Ref:  Lance, G. et. al.; Redesigning surgical decision-making for high-risk patients. New Engl Jl Med 370(15):1379; April 10, 2014

Narrative Bioethics

For many of you, Pediatrics is a foreign country and Neonatology an exotic destination. Nonetheless, I would invite you to think about a report in the January edition of Pediatrics that explores the topic of "futility" in healthcare. (1)  As you may know, some professional bodies have cautioned against invoking "futility" as we advocate for limiting aggressive medical intervention in the care of dying patients.  Why is that?  We do know that state law has something to do with it, but beyond this, the whole topic is mysterious to many informed clinicians.  

The authors report on the case of a mother admitted in preterm labor at 25 week gestation with a history notable for a large fetal omphalocoele identified at an 18 week ultrasound.  The parents had planned to deliver at a tertiary care center to facilitate neonatal surgery and associated care.However, with the occurrence of preterm labor, the Neonatologist was confronted with a very different set of considerations.  According to the report, a 2:00 am discussion with the parents proceeds as follows:

The neonatologist explains that because of the combination of extreme prematurity and severe congenital anomaly, delivery room resuscitation will be futile. She explains that the pediatric surgeon concurs with this assessment. She informs the family that the infant will be given excellent palliative care so that she will not suffer. She encourages the parents to hold their infant after she is born.The family is irate. The mother says, “This is wrong. You can’t just let her die. Please try to save her life. Do everything that you can.” The father says, “We are calling a lawyer. We demand that you do something to help our baby!”

Every physician will recognize this as a tragic failure of physician-patient relationship. Could  this doctor have predicted it?  More important, was it avoidable? To understand this better, at least two points deserve thought. And yes, we do well to be sensitive to the fact that at two in the morning, this neonatologist may not have had the luxury of reflection. First, what do we mean when we say to a patient or family that a proposed course of action will be futile.  The authors suggest that the term may have any of the following meanings:  (1) the intervention will succeed (biologically) but the patient's quality of life will be poor; (2) the intervention will succeed temporarily, but serve only to postpone death; (3) the intervention is not likely to succeed even in the short run; (4) to the best of our clinical judgment based on the information at hand, the intervention cannot succeed even in the short term.  Consider, then, the ambiguity inherent in the unexplained declaration that a proposed intervention is "futile."

There is a second and even more critical point.  A physician whom the parents have never met walks into their room in the middle of the night and, for all intents and purposes, delivers a death sentence on the as-yet-unborn child of parents who had just recently adapted to the idea that their infant would require life-saving surgery…

Commenting on all this, co-author Theophil Stokes wonders whether 

"...a lack of empathy might be to blame. I would want to know more about her previous conversations with this family. Did she acknowledge the grief and the fear that this family was assuredly feeling? Did she find out if they had a name picked out for their infant? What was it like to learn of the omphalocele? What have their experiences been with doctors? What are they hoping for? What do they fear most?

"...In taking the time to listen, learn, and feel with these parents, the doctor lays the foundation for a relationship based on trust and a promise to face hardship together. The doctor demonstrates that she is human, that she cares, and that she will be there when times get tough…"

There are insights here that are applicable far beyond the Neonatal ICU.  For example, there are sound reasons for taking care when invoking "futility."  The term, as we have seen, can mean many things.  Further, it is all to easy for physicians to use the term as a bludgeon, to shut down dialogue, to impose our own views and ethical sensibilities. 

As important, however, we are reminded that it is not possible for physicians, families and patients to find common understanding or make hard decisions together without trust. The field of Narrative Medicine has at its core this very point…that it is in our personal stories that human connections occur, and that our values and our individuality are given voice.

Reference:

1. Feltman, D., et al; Pediatrics 133(1): 123 January 2014

Physician Pay-for-performance: Does it make sense?

Physician compensation formulas that account for performance on a range of quality metrics have become commonplace, including at our hospital.  But questions remain:  do they work now?  If not, could they?  And finally, what are the unintended consequences of P4P?  Here are the arguments in brief.

P4P is a rational approach to physician compensation whose time has come.

The history of physician compensation, speaking especially of private practice models, has been all about "production."  More visits, more encounters, and more procedures meant more compensation.  Neither the quality of the work nor outcomes mattered.  It is as though a builder constructed a house with the expectation that he would get paid the same regardless of whether the supporting structures were correctly put together, or even whether it happened to collapse in a year.

The processes in Medicine, of course, relate to a myriad of interventions from primary prevention strategies in the outpatient world, to clinical practice guideline adherence on the Medicine service.  Outcomes are, as we know, a more complicated issue, but at least in principle, some kinds of complications and even patient-reported experience of care are promising.  If the organization wants to send the message that performance to particular specifications matters, then physician compensation should reflect this.

"Bonusing" physicians for providing the right care is ineffective and misguided; it's time to pull the plug.

P4P makes sense in theory.  But as the old saw goes, "in theory there is no difference between theory and practice, but in practice there is."
I was speaking with a physician from another health system about P4P not long ago. Her compensation formula has sections in it for achieving extra credit for meeting more than a dozen quality benchmarks.  There was also a component for resource utilization and one for several patient "experience of care" measures.  She admitted that she could not actually cite what all these measures were, specifically.  And with that in mind, I wondered out loud how they could possibly, even in principle, be influencing her clinical performance.  Then there is the matter of evidence.  A Cochrane database review cited in a 2013 Wall Street Journal article revealed no evidence that P4P programs improved performance at the individual physician level.

Additionally, there is the question: what should we choose to measure? Notwithstanding the foregoing issues, economics CAN drive behavior.  And the question here is whether measuring a few things distorts the process of delivering medical care by crowding out numerous, other, unmeasured clinical activities.

And finally,  there is a culture question.  What IS the message when organizations introduce P4P?  Is it that doing the right things should be rewarded?  Or is it that professionalism is no longer seen as the critical driver it has always been, and what makes us pause to be sure there isn't something we forgot to remember, something more we should be doing for our patient, the one in the bed who is our first and only concern?  Please share your thoughts.

"Choosing wisely" -- a reconsideration of risk and benefit in clinical decision making

First-ever Dartmouth Atlas report on pediatric health care finds wide variation in hospital and outpatient care for children across Northern New England.  Press release, Lebanon, N.H. December 11, 2013. 

Whether children are receiving recommended care or are subjected to potentially unneeded treatments varies widely depending on where they live, according to the Dartmouth Atlas Project’s first report on health care provided to children and infants, which examines care in Maine, New Hampshire, and Vermont.

The new report shows that children in Dover, N.H., had almost twice as many emergency room visits as those living in Burlington, Vt., and children in Lebanon, N.H., were more than twice as likely to have their tonsils removed as children in Bangor, Maine. The study also finds that children in Lewiston, Maine, and Manchester, N.H., are 50 percent more likely to receive head CT scans, exposing them to radiation, than children in the areas served by the region’s three major children’s hospitals: Portland, Maine; Lebanon, N.H.; and Burlington, Vt. 

Since the original reports by Wennberg and Fischer more than a decade ago, overuse of diagnostic modalities and treatments has been documented for almost every patient population and clinical condition.   "But wait," you say.  "This press release doesn't prove anything about overuse.  This merely points out variation in care."  And this is entirely true. However, in the US (and the answer would presumably be different in Haiti or Guatemala) every systematic study has found either no difference or improved outcomes in low-utilizing regions.  The harsh reality is that we expose patients to risk in excess of benefit.  Routinely. 

Recognizing this, many physician leaders and national organizations are now turning their attention to this previously-neglected dimension of quality.  Consider the Choosing Wisely campaign of the ABIM Foundation, which has collected examples of over-used interventions from more than three dozen professional societies, and developed education materials that urge patients and families to ask about the necessity for these tests and treatments. 

In discussions with our physician leaders, I am seeing examples of strong work already done, but also many opportunities to improve our practice.  In our ICU, for example, sedation vacations are routine.  There have been inroads into the appropriate use of thoracic CT in the diagnosis of pulmonary embolism in the ED setting.  We are in discussions at the Dolan Center to measure & increase guideline adherence to reduce antibiotic overuse for acute otitis media and sinusitis in children.  

More serious attention to "appropriate use" will have many benefits.  Our hospitalists spend hundreds of hours a month "reconciling" medication lists at admission and discharge.  How many of these medications can we safely eliminate?  How many drug interactions and outpatient med errors can we prevent?  

The use of advanced imaging for Emergency and inpatients has increased dramatically and it has been estimated that overall population-level exposure to diagnostic irradiation has increased 600 fold in the past twenty years (1). In many cases increased imaging has been observed without improvement in disease detection or outcome.  At the same time, there is growing concern about the increased risk of imaging-associated malignancy.  It has been estimated that as much as 1.5% of all new cancers  result from medical radiation exposure.  We should be concerned about this, especially in the young although recent data suggest that this complication is also a significant factor for the adult population.  

The marked increase in advanced imaging also challenges the clinical community to followup findings of uncertain significance.  One prospective study (2) identified that factitious lesions occurred in up to 50% of such images, often occasioning further images (and radiation), invasive investigations, patient risk, anxiety and cost.  

Finally, I want to share a thought about over-use and "standardization" of care.  It seems to me that clinical excellence is very much about knowing when to default to check-lists and lock-step standards.  These can help reduce illogical variation, simplify care, improve teamwork and keep us from forgetting important steps.  But true excellence is also about knowing when NOT to standardize - when, instead, to individualize care based on this patient's particular clinical presentation.  Much overuse grows from the adoption of pseudo-protocols - the shortness of breath work up…the abdominal pain work up…the headache workup.  The protocol for each of these should include an incisive history and a thorough physical exam.  Everything else…depends.  

What do you think?  Is there overuse in your department?  Can we do better, and if so, how do we start?  Write a reply.  Let's talk.

1. National Council on Radiation Protection and Measurements. Ionizing radiation exposure of the population of the United States. NCRP report no. 160. Bethesda, Md.: National Council on Radiation Protection and Measurements; 2009.

2. Swensen SJ, Jett JR, Hartman TE, et al. CT screening for lung cancer: five-year prospective experience. Radiology. 2005;235(1):259–265.

The Road to Transparent Medical Records - Is the Future Clear?

Forty years ago, Shenkin and Warner argued that giving patients their medical records “would lead to more appropriate utilization of physicians and a greater ability of patients to participate in their own care.”1 At that time, patients in most states could obtain their records only through litigation, but the rules gradually changed, and in 1996 the Health Insurance Portability and Accountability Act entitled virtually all patients to obtain their records on request. Today, we're on the verge of eliminating such requests by simply providing patients online access. Thanks in part to federal financial incentives,2 electronic medical records are becoming the rule, accompanied increasingly by password-protected portals that offer patients laboratory, radiology, and pathology results and secure communication with their clinicians by e-mail.

Walker, J. et al; The road toward fully transparent medical records N Engl J Med 2014; 370:6-8January 2, 2014

In the first 2014 issue of the New England Journal of Medicine, Walker and colleagues describe the history of patient access to their medical records and make some predictions about the near-term future of medical information management.   

As physicians, we are already quite aware that the medical record is many things - a legal document, a financial instrument, and a regulatory tool…in addition to its primary role as a means of communication among colleagues in real time, and over time.  Given that the nearly absolute right of patients to access their own medical records has been established, it would appear that we will need to adapt to an information environment in which the medical record is also a teaching tool for the patient and family.   

The authors of this Perspectives paper go on to cite the results of a project called OpenNotes which provided full on-line access to patients at institutions including Geissinger and Beth Israel Deaconness.   They found that at the end of a year four of five participating patients had read their notes, two of three reported improved medication adherence and a large majority noted better understanding of their disease process.  Perhaps most striking was the finding that despite some privacy concerns, fully 99% of the 20,000 participating patients surveyed wanted OpenNotes to continue after the one-year project. Physicians, by contrast, varied in their attitudes, with some preferring an option to hide some notes, although concerns diminished significantly over the course of the project. In general there was concern about four conditions - cancer, obesity, substance abuse and mental illness.  Even in connection with these domains, however, open access was generally successful.  

As part of the second wave of the federal Meaningful Use standards (with attached dollars for physician practices and hospitals), we will be obligated to provide patient portals, with access at least to laboratory, imaging and related data.  At our hospital and across our Health System, there are plans to launch such a Portal by the third quarter of 2014. Undoubtedly, access to our notes is next.  

What do you think?  Is this a help, or a hindrance to providing the best care we can?  Share your thoughts in this "open access" forum!  

To what extent must generalists be expert in palliative care?

The rapid growth of Palliative Medicine and its recent recognition by the American Board of Medical Specialties are clear signals that this field has provided at least a partial solution to what may be THE quintessential problem in contemporary healthcare: how do we assure that in a hyper-complex and often disjointed healthcare delivery model someone is attending to the totality of the patient's needs, dialoguing with family, assuring symptom control and, as death approaches, re-prioritizing our interventions toward those that support the patients' comfort and dignity consistent with the their preferences and values?

Through the research efforts of Fischer, Wennberg et al, the last decade has seen a new understanding of the problem.  For example, we know that when asked the majority of patients state that they would prefer to die at home, but most (about 55%) do not.  ICU days and physician contacts in the last six months of life vary markedly by region, though the evidence does not support the idea that this is the result of patient preference.  

On the other hand, from 2003 to 2007, the percentage of chronically ill Medicare patients dying in hospitals and the average number of days they spent in the hospital before their deaths declined in most regions of the country and at most academic medical centers. The percentage of deaths associated with a stay in intensive care also decreased in most regions and at about half of academic medical centers (Goodman, et al 2011).  These are encouraging trends.  

These improvements have occurred concurrently with the emergence of Palliative Medicine as a specialty.  Certainly our own experience is that physicians - both generalists and other specialists - have come to recognize the value of the Palliative Care service and "voted with their feet" resulting in over 1000 consultations at our hospital during 2013.  And this has been a very good thing for caregivers, patients and families.

And yet, there are concerns.

As noted by Quill and Abernathy (NEJM 368;13:1173 March 2013), as we integrate experts in Palliative Medicine into the care team there is the possibility that primary physicians and consultants may "begin to believe that basic symptom management and psychosocial support are not their responsibility, and care may become further fragmented."  I would go further.  There is a risk that talking about advance directives, goals of care and the merits of many interventions, from dialysis to PEG tubes, will be seen as the (sole) province of the Palliative specialist.  Not only is such a model of care not sustainable from a resource perspective.  More fundamentally, this would result in the "outsourcing" of a core clinical skill set, much to the detriment of professionals and patients alike.

What is the alternative?  We need to make a high priority of excellence in communication and shared decision-making - for all patients, to be sure, but in particular for those approaching the end of life.  To use the framework of education, this will require knowledge, skills and attitudes - knowledge about the risks, benefits and expected outcomes of specific interventions, including CPR; skills in communicating so as to meet the needs of our patients, and an attitudinal relationship with this domain such that clinicians see expertise in this area as equally important to patient care as the ability to insert a central line.  

I heard an example of expert communication recently from one of our thought leaders in end-of-life care.  Rather than talk to patients or families about what we propose NOT to do, or to withhold, she suggested that we say something like this:  "Mrs. Jones, we have talked a lot about what your husband has said he wanted when he is dying.  With that in mind, when his heart stops, I think we should protect him from CPR, which I do not believe will help him.  We can do that by putting an order in the chart."  This is of course, just one example.  But it shows us what is possible.  

You are the experts in this.  What do you think?