What Matters in the End

Some patients come to our hospital to have their condition treated.  They are the individuals seeking joint replacement or bariatric surgery, or they have arrived in diabetic ketoacidosis, or they were the victim of multi-trauma.  For scores of such patients every week we provide a high-tech, expertly delivered and durable fix.

Others, however, come back to us again and again.  It is not just that they have chronic conditions like  heart failure, or COPD, or diabetes.  Rather, it is that they have combinations of these and other conditions and that these life-limiting disorders have already devastated their bodies.  These persons are riding the rim of a maelstrom.   We may rescue them from each crisis, albeit briefly, but they are left weaker and ever more vulnerable to yet another hospital admission, or worse.

When we discuss these patients, I find myself asking time and again, "have we asked our Palliative Care team to get involved?"  And time and again, the answer comes - from nurses, from physicians, from Case Managers, from all of us - "no, the patient (or the daughter, or the son) isn't ready for that." This is a baffling and disturbing statement.  Let me explain my thinking.

Last week I finished Atul Gawande's brilliant exposition on America and the problem of death, entitled "Being Mortal -- Medicine and What Matters in the End."  Much of the book is an exploration of the insights that comprise the field of Palliative Medicine, from the notion that the relief of suffering really matters (and is much more than an asterisk applied to the science of curing) to the idea that our role as health professionals must include efforts to identify what matters to patients and families as the progression of chronic disease comes to define their life stories.

The essential questions are the same.  What are your goals and your expectations?  Is it your wish to fight death with every last weapon in our arsenal, regardless the human cost?  For some, the answer is exactly and unambiguously "Yes!" and it is best that the patient be provided the information necessary to understand this choice.  And it is best that we know the choice so that we can tailor our care accordingly.

At other times, the patient is looking for a plan - to paraphrase Gawande - that is less George Custer and more Robert E Lee.  Fight the battles that can be won, but understand the battlefield, and when victory cannot be obtained, determine a course of action that limits harm and preserves essential human dignity.  This is why I am so frustrated to hear "the patient isn't ready for that."

The statement makes no sense.  What is it the patient isn't ready for?  Not ready to be asked whether we are effectively relieving their suffering?  Not ready to know what lies ahead?  Not ready to have their present and future choices explained?

When the answer is that "the patient isn't ready for that," I fear that we have failed twice over.  The first failure resulted in the need for Palliative specialists in the first place.  As though having honest and sensitive conversations with patients involves a procedure for which only a few physicians are qualified.  And then the second failure, which involves turning Palliative Medicine teams into caricatures of themselves, or of what right wingers like to call "death panels."  Much is implied when we say "the patient isn't ready" - not so much about the patient or her family, but about us.  

We can do better.  The first thing we need to do is to resist the temptation to trivialize the heart-wrenching decisions that patients and families need to make as the end draws near.  Respect the process.  The second is never to forget that even though Palliative Medicine consultations sometimes lead to a movement away from curative treatment and toward comfort care, this is NOT the goal.  The reality is more complex.  The aim of these teams is really no different than that of every physician and nurse - to understand the patient and in doing so learn how to give the care that the person wants and needs.  It is nothing less than a perversion of our mission if we view every instance where life extending care is withdrawn a "success" and every one where it is not a "failure."

Finally, we need to figure out how to deliver "care" -- and not just treatment.  This means inviting questions, promoting dialogue early and often, and giving patients that which has become scarcer and more valuable than almost anything else in healthcare, by which of course I mean our time.

The New York State "No Surprise" Medical Billing Law - To Avoid Being Surprised, Read This

On March 31, 2015, the new "Emergency Medical Services and Surprise Billing" Act goes into effect, with implications for insurers, hospitals, physicians and patients across the state.  The intent of the Act is to protect patients from (sometimes catastrophic) financial responsibility for out-of-network emergency care and to ensure that prior to elective care there is adequate disclosure of the patient's potential out-of-network responsibility.  

Here is what physicians and other healthcare providers will need to do to comply with this legislation, according to attorneys at Nixon Peabody, a NY healthcare firm:

• Prior to providing non-emergency services, providers must disclose to patients their right to know what will be billed for the procedure and, if the patient requests, they must disclose the anticipated cost, warning patients that costs could go up if unanticipated complications occur.
• Providers must provide patients with their network and hospital affiliations in writing or online.
• When patients make appointments, providers must indicate whether they participate in a patient’s network.
• If other professionals will be involved in a patient’s care, the patient must be advised of who it might include and how to learn how much the network will cover for those doctors.

But the most important provisions of the law place significant limits on the physician's ability to seek out-of-network payment for emergency services. The Surprise Bill Law provides new protections for consumers from “surprise” bills for emergency medical services. For example, consumers who receive emergency services will not have to pay more than their usual in-network cost sharing and/or copayments, regardless of the network status of the providers. 

This means, for example, that a plastic surgeon who repairs a laceration in the ED will be prohibited from billing the patient for the difference between the patient's out-of-network benefit and the surgeon's usual charges.  Instead, the practitioner will have the choice of accepting the insurer's rate or submitting the matter to an independent review process that is outlined in the law.

Finally, consumers who receive other out-of-network medical services when there were no in-network providers available or when they did not receive the disclosures required by this new law can assign their claims to the out-of-network providers and pay only their usual in-network cost-sharing. In both of these situations, the medical bill is negotiated by and between the provider and the health plan. 

There are additional implications for payers, hospitals and patients.  If you are interested in reading more, go to…

http://www.nixonpeabody.com/files/169463_Health_Alert_3JUNE2014.pdf

NSLIJ HealthPort will update guidance for physicians in the near future.

Let's meet in the Doctors' Lounge

In September of last year, we participated in a System-wide survey of you and your fellow physicians --  community-based voluntary staff, full-time staff, the young as well as old timers like me.  This was called an "engagement" survey, and it was about how good a job hospital leaders are doing at making YOUR hospital a very positive part of your professional life.

Some of what you told us was reassuring.  A very high percentage of you felt that the hospital "cared about its patients" and about "providing high quality care."  You gave very high marks to our Nursing staff, Radiology services and the Laboratory.

Other areas were not as positive.  Many felt that the "climate of trust" was not what it should, that your input into matters that affect your practice was insufficient and that leadership up and down the organization could do a better job communicating with you.

Which brings us to The Doctors' Lounge.  These days, sustaining communication among ourselves as physicians is more challenging than ever before.  Which means, to my mind, that we need to find each other everywhere we can - on the floors, in the ED, at old-fashioned live meetings (if we can find the time to get there), via email and other electronic media -- like this blog, intended as a place for us to get together and exchange ideas.

I'll tell you what.  Don't meet me half way.  Just 1/10th of the way will do it!  I'll maintain the blog site and set up the posts, and monitor the Comments.  What I'd like you to is to commit to going onto the blog once in a while, just for the two minutes it takes to read what's there.  If you're inspired, perturbed or otherwise motivated to say something, please do so!   Challenge us, so that we can work together to create and sustain an environment that helps you take care of patients, helps you with your educational needs and maybe even enriches your professional life.  Meet me in the Doctors' Lounge.

Respectful care: usually, but not always

“Listen to the patient and he will tell you the diagnosis.”

-- Sir William Osler

I was reminded this week that listening to the patient will also tell you what we do and do not do well in delivering the care that patients need.  It baffles many physicians, I think, to see survey reports from the federal Hospital Consumer Assessment of Providers, Hospitals and Systems (HCAPHS) and in particular their results on the following question:  How often did doctors treat you with courtesy and respect?  Respondents can answer always, usually, sometimes or never, and to our collective dismay they don’t always say “Always.”  And yet, when do we approach the bedside with the intention to treat our patient any other way?  We are failing without meaning to or even knowing it. 

Once a week I visit patients on “leadership rounds,” often with our Director of Patient and Family Centered Care.  We find patients and families facing many different circumstances: one is preparing to leave the hospital as we enter her room, another was just admitted, one is thirty five and homeless, and many, many patients are elderly, often too ill or tired or demented to converse.  On these rounds, as the primary caregiver team must, we improvise and we adapt. 

 

One of our visits was to Mrs. Cunningham (not her real name, of course), an octogenarian with thick, large glasses. Her calm face was pallid and creased, but with strong bone structure, just a few age spots, and white, wavy hair that I thought was surprisingly thick.  She regarded us mildly as we explained carefully why we were there.  It was hard to know, at first, whether she understood a word of it.  My associate came closer, held her hand and looked into her eyes.  Our patient’s voice was thin and her speech was halting.  One needed to adapt to it as one would to a person with a foreign accent.  But she was very clear indeed.  Why was she here?  “Because I have health problems and need them taken care of…That’s enough detail for me! Oh yes, the nurses answer the call bell fast enough.  But they are very busy, you know.” 

Did you work in healthcare? 

I worked for the air force for many years, in Finance. 

Do you have family? 

Just a relative in Florida and a friend who visits once a week or so.   These days my home is at ________ Assisted Living.  It’s nice enough.

What about the residents? Do you have friends there? Well, most of them are, you know…they have Alzheimer’s.  It’s sad; their minds are just gone.   I like to read the news, but there’s really no one to discuss it with.  Of course with what is going on in the world right now, maybe it’s better not to know what’s going on, you know?

We chatted, and Cheryl asked Mrs. Cunningham if we could get her some books from our Gift Shop.  She declined politely. At a certain point I returned to our mental checklist…Who is your doctor here?  Is he keeping you informed of what is happening with your treatment? 

“Not so much,” she answered, with a degree of equanimity that I found surprising.  “I guess it’s to be expected,” she added.  When pressed to explain, she did.  “Well, the doctors come in together and mostly talk to each other.” 

So this is what it looks like to fall short.  How natural it is to assume that every placid senior is demented.    It takes skill and discipline not to give in to the pressure to move on, to take the time to engage every patient, knowing that the results will be variable. How often do we overlook persons like Mrs. Cunningham without even knowing it?  It matters, of course, because educating our patients is important, because one in five elders is readmitted within a month, because HCAPHS results are publicly reported and drive hospital reimbursement, and because listening to our patients is just what we do.  It is what makes us physicians.

“During this hospital stay, how often did doctors treat you with courtesy and respect?  Circle one…”

Conversing with patients: Powerful medicine for the 21st Century

I think that the federal “Hospital Consumer Assessment of Healthcare Providers and Systems” (or HCAHPS) provides what is possibly the most accurate and actionable quality-of-care data at our disposal.

Those who believe that HCAHPS is a “patient satisfaction” survey will be surprised by this assertion.  But HCAHPS isn’t a patient satisfaction tool.  Unlike Press Ganey, which our Health System also administers, HCAHPS never asks whether the patient is satisfied with anything.   It asks whether a thing happened.  Or didn’t.  Here are some of the items:

• During this stay, how often did doctors listen carefully to you?*
• During this stay, how often did doctors explain things in a way you could understand?*
• Before giving you a new medication, how often did hospital staff tell you what the medicine was for?*
• Before giving you a new medication, how often did hospital staff describe possible side effects in a way you could understand?*

(*Possible answers:  Always, Often, Sometimes, Never)

I have never met a skilled diagnostician who didn’t listen carefully.  I will preempt an objection here: there is no such thing as listening carefully without conveying to the patient that one is offering one’s full attention.  Even if it could be done, it wouldn’t matter, because whenever we don’t seem to be listening, the patient stops sharing.  As Osler said, “Listen to the patient and he will tell you the diagnosis.”

And what about doctors “explaining things in a way [the patient] can understand”?  Certainly, the only one who can assess our success at this is the patient.  The result matters.  In private practice, it matters -- because without this skill, the physician may have talents, degrees, and lots of knowledge, but he wont have any patients.  From a quality of care perspective, communication drives adherence to the treatment plan, limits medication errors and improves a range of important outcomes.  Communication skill is a core quality issue for physicians.

HCAHPS also asks about how we manage medications – did the “staff” tell the patient what the new medication was for and what side effects to look for?  For the most part, hospital leaders rely on our Nursing and Pharmacy colleagues to ensure that this communication occurs.  This isn’t wrong – educating patients should be a team effort.  However, the member of the team who knows first that a new medication is being given, and knows best why, is the person who prescribed it.  Communicating with patients about the medications we order is first and foremost a physician responsibility.   

A review of our HCAHPS results makes it clear that we have "room for improvement" and the solution must involve each and every one of us.  For those who want them, we have improvement tools that can help.  But why expend the effort?  One reason is that HCAHPS results now influence hospital reimbursement under the federal Value Based Purchasing program.  Another is that the results are publicly reported in hospital report cards.  But there are other, maybe better reasons. 

As noted above, important patient outcomes emerge from effective physician communication.  Strong communication begets trust.  Trust, in turn, drives adherence to prescribed medications, physician follow-up and other aspects of the plan of care.  It also alleviates anxiety, and promotes the sense that whatever the patient’s medical situation, he is “in good hands.”  Finally, the physician who communicates skillfully can experience the kind of professional pride and sense of meaning in work that makes the practice of Medicine a uniquely rewarding endeavor, one that stimulates the analytical mind and nourishes the feeling heart.  Maybe HCAHPS has something to do with satisfaction after all.

     

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