Tag: patient

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Clinical General Healthcare Costs Innovation Quality Improvement Technology

Let Me Be Brief: Principles of Value-Based Health Care

A series of briefs by Texas Medical Students

By: Sanjana Reddy, Tsola Efejuku, and Courtney Holbrook

In the seminal 2006 text, Redefining Health Care, Harvard Business School professors Michael Porter and Elizabeth Teisberg describe a healthcare market with a “positive sum” game; a market where all professional and economic incentives are aligned towards the maximization of “value,” defined as the “the quality of patient outcomes relative to the dollars expended.”1 Value in health care is the measured improvement in a patient’s health outcomes for the cost of achieving that improvement.1 Value-based care transformation is often conflated with cost reduction methods, quality improvement, or even evidence-based care guidelines. Rather, the goal of value-based care is to enable healthcare systems to improve health outcomes for patients over the full cycle of care. Tiesberg further elucidates three key dimensions (the Triple C’s) for measuring patient outcomes: capability (the ability for patients to do what is important to them), comfort (relief from emotional and physical suffering), and calm (reducing the chaos of navigating the healthcare ecosystem).2

In the U.S., improving patient-centered outcomes has become a highly discussed topic with ABIM’s Choosing Wisely program3, American College of Physicians’ High Value Care initiative4, and even major publications like the American Journal of Medicine’s recurring column on high-value care practice.5 In response to escalating healthcare costs, the Centers for Medicare & Medicaid Services (CMS) and other payers have shifted from traditional fee-for-service payments to value-based reimbursements such as the CMS Merit-Based Incentive Payment System (MIPS).6 Value-based health care empowers the clinician-patient relationship, places care delivery decisions at the expertise of a coordinated clinical team, and focuses on outcomes that matter most to patients.

The leadership of professional organizations, such as the Texas Medical Association (TMA), is invaluable to the process of defining and upholding the principles of value-based health care for systems and individual practitioners. Current TMA policy recognizes the need to advocate for high-value care principles in undergraduate and graduate medical education (Res. 201-A-18)7 and the adoption of the Choosing Wisely campaign (265.023).8 Although the evidence-based model (265.018.)9 previously adopted by the TMA does not encompass the full principles of the value-based decision making model, TMA resolutions on Cost Effectiveness (110.002)10 and Cost Containment (110.007)11 reinforce the need for cost-effective utilization of care.

On the federal level, exceptions to key legislation have been enforced recently to further advocate for value-based healthcare options. In November 2020, the CMS and Department of Health and Human Services Office of the Inspector General (OIG) released new exceptions to the Anti-Kickback Statute and the Stark law, effective January 19, 2021. These exceptions now allow more providers to participate in coordinated and value-based care arrangements that can improve quality and outcomes, lower costs, and increase health system efficiency, without the fear of severe criminal or civil legal backlash.12

The practice of value-based health care, although strong in theory, is not without flaws. The primary weakness of this system is that physicians are often responsible for things out of their control, such as referred providers’ costs and pre-existing conditions.13 This system requires widespread buy-in from all providers in order to collectively reduce costs and increase quality of care—effectively changing the culture of health care. Notably, this system inherently disincentivizes caring for patients of low socioeconomic status, particularly minorities, who inevitably generate higher costs due to health disparities.14 Weinick et al. emphasize adding a metric to the value-based healthcare system that addresses equity in health care. Their guide illustrates how to utilize value-based health care to reduce racial disparities, primarily by appending equity in pay-for-performance models.15

Goals of the Medical Student Section include staying informed about current policies regarding value-based health care since these policies are constantly changing and significantly affect reimbursement rates. Medical students are afforded the opportunity to learn about the principles of value-based health care from the very beginning of their training. Knowing the alphabet soup of value-based care (MIPS, APM, MACRA, etc.) will benefit patients and providers alike by improving outcomes, reducing costs, and maximizing reimbursements. In an effort to emphasize value-based health care early in the practice of medicine, the American Board of Internal Medicine sanctioned the Dell Medical School Value Institute for Health & Care’s STARS (Students and Trainees Advocating for Resource Stewardship) program. Over the past few years, student representatives across the country have met to learn about the principles of high-value care, review the Choosing Wisely campaign, and start their own initiatives at their respective medical schools. In Texas, students at UTHSC San Antonio’s Long School of Medicine created an ongoing Value-Based Health Care elective and degree distinction pathway. Dell Medical School offers online instructional modules and is a leader in patient-centered outcomes research. Medical students have a tremendous opportunity to impact high-value care through education, research, and student-led initiatives.

References:

  1. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. 2006. Boston, MA: Harvard Business School Press.
  2. Liu TC, Bozic KJ, Teisberg EO. “Value-based healthcare: person-centered measurement: focusing on the three C’s.” Clin Orthop Relat Res. 2017;475:315–317.
  3. https://www.choosingwisely.org/
  4. https://www.acponline.org/clinical-information/high-value-care
  5. https://amjmed.org/advancing-high-value-health-care-a-new-ajm-column-dedicated-to-cost-conscious-care-quality-improvement/
  6. https://www.cms.gov/newsroom/fact-sheets/quality-payment-program
  7. Texas Medical Association. Policy Compendium. Evidence-Based Medicine 265.018.
  8. Ibid. High-Value Care in Undergraduate and Graduate Medical Education 200.054.
  9. Ibid. Choosing Wisely Campaign 265.023.
  10. Ibid. Cost Effectiveness 110.002.
  11. Ibid. Cost Containment 110.007. 
  12. Modernizing and Clarifying the Physician Self-Referral Regulations Final Rule (CMS-1720-F). CMS. Accessed May 27, 2021. https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-final-rule-cms-1720-f.
  13. Burns, J. “What’s the downside to value-based purchasing and pay for performance?” Association of Health Care Journalists. September 6, 2014. https://healthjournalism.org/blog/2014/09/whats-the-downside-to-value-based-purchasing-and-pay-for-performance/.
  14. “Value-Based Health Care Must Value Black Lives,” Health Affairs Blog, September 3, 2020. DOI: 10.1377/hblog20200831.419320
  15. Weinick, Robin & Rafton, Sarah & Msw, & Walton, Jim & Do, & Hasnain-Wynia, Moderator & Flaherty, Katherine & Scd,. (2021). Creating Equity Reports: A Guide for Hospitals.
Categories
Clinical Community Service Emotion Empathy General Healthcare Disparities Opinion Public Health

Let Me Be Brief: Community Leadership

A series of briefs by Texas Medical Students

By: Fareen Momin, Sereena Jivraj, and Melissa Huddleston

In the ever-evolving field of medicine, it is no surprise that the idea of leadership in medicine has changed over the years. Some physicians have engaged in additional leadership in the context of politics. In fact, several physicians signed the Declaration of Independence.1 Today, physician community leadership extends much further. Physicians can engage with their communities and beyond via virtual platforms. Physician “influencers” use social media to provide quick answers to patients, and physician-patient interactions on Twitter alone have increased 93% since the onset of the COVID-19 pandemic.2 With physician voices reaching ever-larger audiences, we must consider the benefits and ramifications of expanding our roles as community leaders.

Medicine and politics, once considered incompatible, are now connected.3 There is a long list of physician-politicians, and community members often encourage physicians to run for political office, as in the case of surgeon and former representative Tom Price.4 Physicians are distinctly equipped to provide insight and serve as advocates for their communities.5 Seeking to leverage this position, a political action committee (PAC), Doctors in Politics, has an ambitious desire to send 50 physicians to Congress in 2022, so they can advocate for security of coverage and freedom for patients to choose their doctor.6-7 There are dangers, however, when physicians take on this additional leadership role. For example, Senator Rand Paul (R-Ky.), an ophthalmologist, has spread medical misinformation, telling those who have had COVID-19 to “throw away their masks, go to restaurants, and live again because these people are now immune.”8

It is not practical for even those medical students who meet age requirements to run for office. What we can do is use our collective voice to hold our leaders accountable, especially when they represent our profession. We can create petitions to censure physicians who have caused harm and can serve as whistleblowers when we find evidence of wrong-doing perpetrated by healthcare professionals. We can also start engaging in patient advocacy and policy-shaping with the American Medical Association (AMA) Medical Student Section and professional organizations related to our specialty interest(s).

To avoid adding to confusion, statements by physicians should always be grounded in evidence. Dr. Fauci’s leadership is exemplary in this regard. He has worked alongside seven presidents, led the National Institute of Allergy and Infectious Diseases (NIAID) since 1984, and has become a well-known figure due to his role in guiding the nation with evidence-based research concerning the COVID-19 pandemic.9 Similarly, Dr. John Whyte, CMO for WebMD, has collaborated with the Food and Drug Administration (FDA) to advocate for safe use of medication and to educate those with vaccine apprehension.10 Following these examples, we should strive to collaborate with public health leaders and other healthcare practitioners and to advance health, wellness, and social outcomes and, in this way, have a lasting impact as leaders in the community.

  1. Goldstein Strong Medicine: Doctors Who Signed the Declaration of Independence. Cunningham Group. Published July 7, 2008. Accessed February 2, 2021. https://www.cunninghamgroupins.com/strong-medicine-doctors-who-signed-the-declaration-of-independence/
  2. Patient Engagement with Physicians on Twitter Doubles During BusinessWire. Published December 17, 2020. Accessed February 2, 2021. https://www.businesswire.com/news/home/20201217005306/en/Patient-Engagement-with-Physicians-on-Twitter- Doubles-During-Pandemic
  3. WHALEN THE DOCTOR AS A POLITICIAN. JAMA. 1899;XXXII(14):756–759. doi:10.1001/jama.1899.92450410016002d
  4. Stanley From Physician to Legislator: The Long History of Doctors in Politics. The Rotation. Published May 15, Accessed February 2, 2021. https://the-rotation.com/from-physician-to-legislator-the-long-history-of-doctors-in-politics/
  5. Carsen S, Xia The physician as leader. Mcgill J Med. 2006;9(1):1-2.
  6. Doctors in Politics Launches Ambitious Effort to Send 50 Physicians to Congress In 2022. BusinessWire. Published May 27, 2020. Accessed February 2, 2021. https://www.businesswire.com/news/home/20200527005230/en/Doctors-in-Politics-Launches-Ambitious-Effort-to- Send-50-Physicians-to-Congress-In-2022
  7. Doctors in Accessed February 2, 2021. https://doctorsinpolitics.org/whoweare
  8. Gstalter Rand Paul says COVID-19 survivors should “throw away their masks, go to restaurants, live again.” TheHill. Published November 13, 2020. Accessed February 2, 2021. https://thehill.com/homenews/senate/525819-rand-paul-says-covid-19-survivors-should-throw-away-their-masks-go-to
  9. Anthony Fauci, M.D. | NIH: National Institute of Allergy and Infectious Diseases. Published January 20, 2021. Accessed February 2, 2021. https://www.niaid.nih.gov/about/anthony-s-fauci-md-bio
  10. Parks Physicians in government: The FDA and public health. American Medical Association. Published June 29, 2016. Accessed February 2, 2021. https://www.ama-assn.org/residents-students/transition-practice/physicians-government-fda-and-public-health
Categories
Clinical General Healthcare Costs Law Opinion Patient-Centered Care Primary Care Public Health Reflection

Discontinuity in Care

My resident tries fairly hard to take care of his patients. When he is with them, I catch him paying attention to all sorts of details that he could have easily let slip past. So it made it all the more difficult when I saw him enraged. When he opened up his list of clinic appointments one morning, on the list was a patient he did not want to see. It was not just that she was a new patient to him. It was not just that her problem list went on like a run-on sentence. It was that both were true, and my resident was still expected to see her in only 15 minutes.

While chart reviewing, he learned that the only consistency in this patient’s medical care at our clinic had been a history of inconsistent providers—and based on their notes, none of them had the complete story. “Why am I even seeing her?!” my resident asked rhetorically, as he frantically searched for answers he knew he did not have the time to find. I wondered, too. This visit seemed to benefit no one except the Billing Department, and even that would depend on whether the Medicare reimbursements actually made it through.

That patient’s experience was hardly unique, though. While rotating through various specialties as a medical student, I have met several patients who were passed from one provider to another. Maybe the provider had to switch services. Maybe they left the institution for better opportunities elsewhere. The reasons were myriad. Stories like those suggest that continuity of care may still only be a priority in primary care literature.

I think one reason for this reality is a lack of incentives to keep doctors and patients together. In any field, including medicine, we see money driving people’s attention and vice versa. Since our country has historically kept primary care on the back burner, there is little evidence to believe that practical incentives for continuity of care will spontaneously appear in the near future.

So, for the primary care fans out there, it might be worth it to start speaking up.

 

Photo credit: Norbert von der Groeben/Stanford School of Medicine, posted by National Center for Advancing Translational Sciences

Categories
Clinical Patient-Centered Care Reflection

“Listen to understand” not “listen to reply”

A two-month stint at the oncology department in a Singapore government hospital has provided me with vivid examples of the importance of doctor-patient relationships and communication. Cancer, in many societies, is still widely regarded as medical taboo – a condition people closely associate with death. While I got to witness very sensitive and depressing conversations in relation to end-of-life care, the most impactful conversation I experienced had nothing to do with end-of-life care. Rather, it was a complaint from a patient about his team of allegedly negligent doctors.

It took place in a private ward room with just Mr. C and his wife. When I first entered the room, Mr. C gave me a hostile look and asked me who I was. Feeling awkward given the cold welcome, I persisted to introduce myself as a medical student who wanted to take his history. Although reluctant, he agreed to talk to me. What started as a cold introduction turned out to be an hour-long avenue for Mr. C to vent his anger and frustrations. It became etched in my mind for the important lesson that came with it.

I understood from Mr. C that it was not the diagnosis that brought about his unhappiness, but how the diagnosis came about.  Mr. C presented with a 6-month history of progressive dull epigastric pain and loss of weight with no co-morbidities. He had no associated fevers, nausea or vomiting. The conversation went well until I asked him the question, “Did you bring this to your doctor’s attention?”

Immediately, there was a change in his facial expression. I divined from his grim expression that the news was not good. He started shaking his head, somewhat in disappointment. His wife started tearing. I had inadvertently asked a sensitive question and was caught helplessly in that moment of grief and sorrow.

Mr. C then explained that he actually went to the Emergency Department (ED) thrice as his abdominal pain worsened. Unfortunately, on the first two occasions, they sent him home after establishing that his vitals were stable with no abnormalities in his test results. He was sent home with a stack of medications but without a diagnosis.

Interestingly, Mr. C actually suspected himself that he had gastric cancer given his strong family history; he expected that he would suffer from it one day. The doctors shook it off despite his persuasion. On the third visit, however, the doctors finally admitted him and performed an endoscopy. It was later confirmed to be Stage 3 gastric cancer. It was at this point in the conversation when emotions started running wild.

The atmosphere heated up. I was shot with questions and complaints by both Mr. C and his wife.

“I would not have been denied earlier detection and treatment if doctors listened to my history,” Mr. C said.

“That period of 6 months could have made a huge difference to his disease stage and prognosis!” Mr. C’s wife added.

“Do you think the doctors have done the right thing for me?” he asked.

“Doctors never bother to hear patients out!” he shouted.

It felt as if the blame was on me, and I felt angry for a moment. I was on the edge of questioning his accusations, and refuting his comments. I was conflicted inside. On the one hand, the manner in which he was treated at the ED seemed unjustified. But at the same time it did not seem fair for me to blame the doctors without understanding what their line of thought was.

I further understood that Mr. C had explained his case to a senior consultant, who was also the surgeon who performed his gastrectomy. The surgeon brushed Mr. C off, and told him rudely to switch to another hospital if he did not like it here. It was at this point that I stood in favor of Mr. C. I actually could not believe such an insolent comment would come from the mouth of a senior doctor, whom I thought was supposed to possess the maturity and authority to handle such a complex matter.

Mr. C and his wife were evidently distraught with how the diagnosis came about, compounded by the fact that he was still relatively young to suffer from stage 3 gastric cancer. He explained that gastric cancer is one of the most aggressive and treatment-resistant cancers with the highest mortality rate, as evident from the young deaths of his family members who succumbed to the illness. My heart immediately sank after coming to terms with his bleak prognosis.  I recalled what was taught in my clinical skills classes, and took on an empathetic coat to try and calm them down. I felt an ephemeral sense of shame for the apparent lack of professionalism Mr. C’s doctors had displayed. Furthermore, I was sunk in guilt for initially doubting his comments.

I continued with the rest of the history and thanked Mr. C and his wife for their time. I walked out of the room and told them, “Thank you for sharing with me. Both of you have taught me about the kind of doctor whom I do not want to emulate in the future”.

It was an eventful hospital experience for Mr. C, and a rather eventful conversation for me with him and his wife. Despite the awkwardness and negative emotions, it taught me a great deal about the nature of difficult situations, the qualities a doctor should possess, and the importance of communication.

It was no doubt a challenging conversation. It was unlike all the other conversations I have had with patients, that were full of praise for their doctors, which always reassured me of my choice to become one.  My limited exposure to issues that arise from the lack of proper doctor-patient communication caught me off guard during this particular conversation.

When I mentioned to Mr. C that I was a medical student, his facial expression and body language conveyed his bitterness and dissatisfaction. It was almost as if he had something against me. I was filled with self-doubt and hesitancy. I was unsure if I should persist with the conversation given his hostile appearance but I knew that he had a story that he was dying to tell. Mr. C’s experience at the ED has probably altered his perception of doctors, and it was worth it to hear him out.

In hindsight, I am consoled by the fact that I had that conversation with Mr. C because he gradually opened up to me, treated me as an avenue to vent his frustrations, and perhaps subconsciously, taught me a lesson or two about being a doctor. I have learned that patients are always keen for a listening ear, be it to share their joy, or to pour their sorrows. It is hence important for medical students like me to not be doubtful when approaching patients for the fear of intruding in their privacy or taking up their needful rest time. Never be afraid that you are just an unqualified medical student.

Communication is the crux of medicine. As Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” History-taking is not just about the whims and fancies of signs, symptoms, investigations, and differentials. It is in fact a conversation, an opportunity to build rapport and trust with the patient. We are not community health surveyors ticking off boxes in our questionnaire; we are there to hear our patients out by expressing their problems and concerns. There is no better opportunity than in medical school, where you are not confined by the “rush hour” situation in hospitals, to hone these human skills.

Fortunately, patients tend to given you their trust, and willingly share their most personal information with you. This has shown me the power imbalance of the doctor-patient relationship, which arguably has been exploited in Mr. C’s case – i.e. doctors sometimes do not give patients enough attention.

Another issue that I struggled with was handling the complaints that were hurled my way. My lack of maturity was evident from my agitation, and the urge I had to refute Mr. C. Deep down, I was conflicted and defensive. Mr. C’s story contradicted my own impression that all doctors do their best for patients. It felt as if I was taking the blame on behalf of all doctors. However, I decided to stay quiet about it. I learnt that doctors aren’t  “super-humans” who will never make mistakes. It was only when I started consolidating my thoughts and weighing out the situation that I was eventually convinced that Mr. C’s care was indeed compromised by the negligence of his various doctors.

Admittedly, I handled the situation rather poorly. I reckon it was largely due to lack of exposure to such situations, especially given the sheltered, cozy environment we enjoy in medical school. Clinical interactions are based around simulated patients who, more often than not, have simple presentations that are short enough for us to take a history and perform a physical examination. Everything is staged for us to learn in a protected environment. Even in hospitals, the patients we see are recommended by interns as “cooperative enough” for us to take a history.

Medical students should be taught how to deal with complicated cases through the use of simulated patients. When I say complicated, I mean in a psychosocial sense rather than in a medical sense. The skills needed to deal with these situations are those that cannot be taught through textbooks, but through practice. These are human skills; skills that define the art of medicine. These non-scientific skills may not be as interesting as pathology, physiology or anatomy, but are equally, if not more important than the scientific aspects that students are often keener about.

Students are often enthusiastic to ask senior doctors about the scientific aspects of a patient’s presentation. Similarly, they should not be shy to ask them about approaches they should adopt when such situations arise. I am inclined to believe that most students underestimate the importance of communication, which often takes a backseat in their learning priorities.

Medical schools can no longer assume that their students are equipped with the necessary communication and social skills from just clinical skills examinations, which are often not representative of an actual hospital setting. Rather, explicit emphasis on the mastery of such complicated yet common social presentations, should be made an integral part of the curriculum.

I have learned the importance of giving patients the space to talk. For example, in my encounter, I was close to interrupting Mr. C when he was complaining about his experience. Having done so, however, would have prevented me from comprehending the entire situation in context. As medical students, we need to appreciate the difference between “listening to reply” and “listening to understand”. Practice the latter, not the former. Never be too quick to cut off your patients halfway through, and jump to conclusions. Let them tell their whole story, and you will be surprised to find that it contains most of the answers you need.

Photo Credit: Ky

Categories
disability Emotion Lifestyle Patient-Centered Care Psychology

Nodding Along

My grandmother was a strong and compassionate Egyptian woman, a mother of three, and a pathologist. On a glass slide, exactly like the ones she used daily, cells from her colon biopsy were identified as undifferentiated, and within days she was diagnosed with Stage IV Colon Cancer.

Although I am learning how to care for people in sickness and health, someday, the chest compressions will be applied to my chest. Disease knows no discrimination, and death unites us all. Thousands of cancer diagnoses and precise and growing knowledge of cancer cell types did nothing to protect my grandmother from that which she knew so much about.

In Egypt, cancer is called ’the bad disease’, and bad it is. Over the next couple months, we watched as the bad disease took our beloved grandmother away from us. During that time, my family members, and my grandmother, had to make a series of challenging decisions that they were very obviously not prepared to make.

Medical advancements, although the main reason we are living longer lives, have caused the complexity and variety of end-of-life decisions to be ever increasing. Uneasy about the series of decisions that my family had to make and handicapped by my ignorance, I found myself reading Being Mortal by Atul Gawande. Atul Gawande led me through a vulnerable and imperfect but inspiring conversation about death and dying, exposing our medical system’s inability to understand health beyond the one-dimensional, and presumptuously noble, endeavor to prolong life at any cost.

While reading Being Mortal, I found myself enthusiastically nodding along, agreeing with the theme of the book: we need to change everything about our simple but destructive approach to aging and our increasing elderly population. Our singular approach to prolonging life simplifies complex social and medical decisions. It seems the attitude now is that longer life is all that matters. Ensuring nutrition and shelter is our only standard for a viable living environment for the elderly. We are failing our parents and grandparents.

Atul Gawande’s presentation of ideas changed how I perceive aging and our healthcare decisions at the end of life. I became a strong advocate of having conversations about the inevitability of our death and the choices we want to be made during our end-of-life care. I was convinced that society and healthcare should ensure that the elderly remain the authors of their own stories for as long as they are willing, and actively empower them to do so. Nutrition, shelter, and minimizing fall risk are minimums of care, not acceptable standards.

The Literature in Medicine Student Interest Group at my school decided to read Atul Gawande’s Being Mortal, and I could not be more excited. In the middle of our meeting discussing the book, as I was passionately sharing my ideas, it occurred to me that although I was full of strong opinions, I had done absolutely nothing to be a part of the solution. My grandfather had come to live with us after his wife of 55 years, my grandmother, passed away from colon cancer, and my only roles/concerns in his care have been to ensure food, sleep, and meds. My strong opinions had not inspired my actions.

Nodding along to Atul Gawande’s criticisms of our medical system is easy, but having an honest conversation with my grandfather about his priorities and end-of-life care preferences as he reaches 90 years of age is not so easy. How might I empower my grandfather to continue to be the author of his story? Believing that healthcare is a right and not a privilege is easy, but carrying out the responsibility that this belief invokes is not so easy. How might I work to help provide all my neighbors with equal access to high-quality care? Practicing the invaluable intervention of presence is not easy, and working day after day to hone my abilities at the art of empathy is not easy. How might I overcome my doubts, fears, and insecurities, and avoid being frozen into lack of compassion?

Too often my strong opinions do not inform my actions. Too often my hate for dysfunctional and unjust systems overshadows my love for the people in the systems. I call myself to love my neighbors more than hate the systems, for love is actionable and hate is stifling and tiresome. Let love fuel the tank, for compassion-based activism is the only kind that goes the distance.

Photo Credit: Dan Strange

Categories
Clinical Patient-Centered Care Psychiatry Public Health

If you don’t ask, you’ll never know

On the first day of my first rotation as a medical student, my preceptor shared this bit of wisdom: if you don’t ask, you’ll never know.  In the nearly 18 months that have followed, I think about those words on a daily basis. To my mind, asking questions does more than just help us gather data. Asking questions establishes the type of relationship we are going to have with our patients. There are so many questions I wish I would never have to ask, whose affirmative answers are often indicative of the cruelty of this world. But when I ask about things like whether a patient has been the victim of abuse, I hope it sends the message that the relationship we are about to embark upon is one that can withstand such unpleasantness.

Not only can it be excruciatingly frustrating when other practitioners don’t share this point of view, it potentially has grave consequences. Unfortunately, patients with mental illness often seem to be the victims of physician “brush-off.” As someone who plans to devote her life to working with the mentally ill, I can only hypothesize as to why the same patients I find so much joy in working with are often given sub-par medical care as compared to their non-mentally ill peers. Perhaps physicians feel uncomfortable providing care for patients who come across as different than the norm, or perhaps their medical problems are too frequently attributed to psychiatric causes.

I recently cared for a patient who was two weeks post-partum from the birth of her first child. Though she was being seen for psychiatric admission, multiple aspects of her health were addressed during our initial evaluation.  When asked about her post-partum health, she denied having been scheduled for a post-partum visit with her obstetrician. Casually, she mentioned that she was having some malodorous green discharge since giving birth. It doesn’t take a medical degree to know that green, foul-smelling discharge is not a good sign, let alone when it occurs in the immediate post-partum time period. We were able to secure a next-day appointment with our hospital’s obstetrical practice, and with the patient’s permission, called ahead to the clinic to alert them of her complaints.

The next day, the care team gathered around to read the note from the obstetrician who had seen our patient. The note comprised all of five lines.  There were no pending labs. There was no mention of a physical exam.

There was no mention of the discharge at all.

The American Congress of Obstetricians and Gynecologists (ACOG) states, “It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being.”[1] The issue here, though, isn’t really about post-partum care. The issue here is about how we as health care providers need to provide equal care for unequal bodies and minds, and how we need to protect and advocate for our patients.

Patients with mental illness undeniably have poorer overall health. The average lifespan for an American adult with mental illness is a striking 30% shorter than for a non-mentally ill individual.[2]  While it is known that mental illness itself creates difficulty in accessing the healthcare system, for mentally-ill patients who do access healthcare, their quality of care is demonstrably lower than it is for those without mental illness. Literature consistently demonstrates that patients with psychiatric diagnoses receive fewer preventative health measures and have overall poorer quality healthcare than patients without psychiatric diagnoses.[3],[4] No matter what field of medicine you are in, you will see patients with mental illness. For these patients who sometimes cannot speak for themselves, the role of the physician in patient advocacy becomes even more crucial.

I will never know exactly what transpired during that appointment between my patient and the obstetrician, but I do know that obstetrician did not ask the questions that needed to be asked, and therefore did not ascertain the information necessary to appropriately care for the patient. At our request, a different practitioner saw the patient again. This time, the appropriate questions were asked, the appropriate testing was completed, and ultimately the patient was diagnosed with a sexually transmitted infection. Left untreated by the first obstetrician, this infection could have caused my patient systemic symptoms and permanent infertility.

As future physicians, it’s important for us to keep asking questions. So often, I have been surprised by the information I find when I ask a question about which I almost kept silent. Equally as important as asking the questions, however, is doing something with the information that you receive. The good doctor isn’t necessarily the one that stops the green discharge; they’re the one the identifies the problem in the first place and advocates on behalf of the patient to get the best people for the job.

[1] https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

[2] http://europepmc.org/abstract/med/19570498

[3] http://journals.lww.com/lww-medicalcare/Abstract/2002/02000/Quality_of_Preventive_Medical_Care_for_Patients.7.aspx

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951586/

Photo credit: airpix

Categories
Clinical Lifestyle Patient-Centered Care

Running Low and No Longer Running

I recently completed a rotation in endocrinology, and I learned valuable lessons about diabetes management in both the inpatient and outpatient setting. Today, I wanted to share a clinical pearl generally not discussed in lectures: Diabetic patients often gain weight because of the fear of hypoglycemia.

That’s right. The fear of hypoglycemia drives patients to eat a little more at meals. Let’s backtrack. Patients who have persistently elevated sugars are often started on insulin in addition to oral agents. Depending on their insulin regimen, patients may not eat enough after an insulin dose to prevent a drop in blood sugar. Patients who experience a hypoglycemic event try their best to prevent it from occurring again. This is understandable—fainting is scary and should not be taken lightly (pun intended).

The problem is that patients counteract this fear of hypoglycemia by either eating more after an insulin injection, or by exercising less. This impedes diabetes management. In addition to advising our diabetic patients to monitor their carbohydrate intake, we urge them to start some form of physical activity. Physical activity enhances the body’s insulin sensitivity—it gets to the core of the problem (insulin resistance) and improves overall cardiovascular health as well. But how can we encourage these lifestyle modifications if our patients are getting lightheaded after injections?

The answer: carbohydrate counting and education.

Not the answer: increasing insulin.

My attending explained that “increasing insulin” is actually what happens in some cases. For example, let’s say a patient named Sara comes in for her follow-up appointment and unknown to us, has “fear of hypoglycemia.” Sara brings her glucose meter, and the sugars are poorly controlled. Part of the reason for this poor control is secondary to a) eating more after an injection to prevent fainting and b) decreased physical activity to prevent fainting. Now, if we just treat her numbers, we would increase her insulin.

The lesson here is that one can’t just treat the number in medicine. Talking to the patient, even for a few minutes, will provide the story. Increasing the insulin perpetuates a viscous cycle, and breaking the cycle comes from better regimen management. Validating patient concerns about hypoglycemia and educating them on injecting based on carbohydrate intake is invaluable.

Photo Credit: Melissa Johnson

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General Patient-Centered Care The Medical Commencement Archive

“Becoming Healers”: Dr. Jonathan LaPook, 2017 Commencement Address of Quinnipiac University School of Medicine

I am pleased to present this week’s Commencement Archive piece: Dr. Jonathan LaPook’s keynote address at the 2017 Quinnipiac University School of Medicine Commencement.

Dr. Jonathan LaPook is the Chief Medical Correspondent for CBS news and has served in this role since 2006. A board-certified physician in internal medicine and gastroenterology, he is also a Professor of Medicine at NYU Langone Medical Center. He attended medical school at Columbia College of Physicians and Surgeons, and completed an internal medicine residency and a gastroenterology fellowship at the New York-Presbyterian Hospital/Columbia University Medical Center. Dr. LaPook has received two Emmy awards for his work in 2012 and 2013 covering the national drug shortage and Boston Marathon bombings, respectively.

 

While Dr. LaPook is accustomed to speaking in front of crowds and cameras, this particular speech was a first for him.   With great pride and humility, he addressed the very first graduating class of Quinnipiac University School of Medicine. While the event was new to everyone involved, the message Dr. LaPook delivered stems from his diverse experiences as both a physician and journalist.

Dr. LaPook discusses the semipermeable membrane—or as he puts it, an emotional wall—that lies between us (as physicians) and the patient. One must be mindful of the emotional balance that exists, and this, according to Dr. LaPook, is the first and last challenge of the art of healing.

“It starts with a decision about the emotional wall we all build between ourselves and our patients. Constructing it is tricky. You don’t want to make it too thin and porous, because that can be emotionally devastating. But you don’t want to make it too thick and impervious, because then you miss out on all the good stuff, the precious moments when you connect with a patient as a person. I treasure the time an elderly patient showed up for an office visit on a beautiful spring day, and I wheeled her over to the Central Park Zoo to watch the sea lions. No medicine I have ever prescribed has had a more powerful therapeutic response. Everybody has to find a comfort level. For me, erring on the side of “too empathetic” is the way to go. Patients pick up on it, and if they feel you really care, they’re more likely to open up to you.”

 

“When we’re watching a movie and an important moment is about to happen, how do we know?”

Unfortunately, when caring for sick patients, other than a few beeps on the monitor, important moments don’t come with dramatic music or close-ups. There is no camera-pan to direct our attention to informative, meaningful information. We are both privileged and burdened with this responsibility of seeking out and interpreting information in order to make informed decisions.

“Well, in life, there’s no close-up and there’s no change of music. You have to play the soundtrack in your own head. You have to control the zoom button yourself. You must catch that moment when the patient—consciously or unconsciously—tells you what’s the matter. You need to get them to open up to you as one human being to another. And they will not do that unless they know they are talking to a human being!”

As Dr. LaPook continues, he begins to discuss his career in journalism and its implications on his medical practice. In particular, covering global health crises has shaped his ability to communicate oftentimes complex medical information to a broad audience.

“The key is taking complex topics and presenting them in simple, accessible terms. Communicating clearly—and succinctly—is an important skill. Work on it.”

Dr. LaPook summarizes with a single piece of advice.

“Be comfortable with uncertainty. If you’ve been practicing medicine for five years and you think you have all the answers, you’re in the wrong profession.”

Although patients may expect us to have all the answers, we must not burden ourselves with this expectation. Medicine is an art, not a calculation. Physicians consume diverse clinical data not necessarily to find an answer but rather to justify a decision.

Dr. LaPook sends the graduating class out with a final message.

“What’s going to distinguish you as true healers is the way you embrace humility, compassion, and empathy. Turn away from the computer screen and look your patient straight in the eyes. Understand the extraordinary importance of listening. And realize that even when you don’t have the answer for a patient in need, you can still help—with a sympathetic ear, a reassuring touch of the hand, and by sticking by them, through sickness and health.”

Read the full speech in the Commencement Archive: https://www.themspress.org/journal/index.php/commencement/article/view/297/314

Categories
Clinical General Public Health

Medical Residents: A Dream Career Can Be Yours If You “Choose Sleep”: Dr. Ilene Rosen, President of the American Academy of Sleep Medicine

Now is the time that many medical residents are considering future plans, and hopefully giving thought to a sleep medicine fellowship. The truth is, we need you. Millions of Americans suffer from chronic sleep disease, and now more than ever there is an increasing demand for sleep physicians. As awareness of sleep health increases, millions of new patients will be seeking evaluations from sleep physicians.

Sleep medicine is an intriguing field with long-term growth potential and the opportunity to have a positive effect on the health of a huge population of patients. By diagnosing and treating sleep disorders, you can directly improve patients’ health and quality of life. In addition, because sleep is still a relatively young field, many research questions still exist. These questions can lead to involvement in cutting-edge basic, translational, and clinical research.

As a new sleep medicine physician, you may have the opportunity to practice in diverse settings. Opportunities abound in teaching hospitals, community hospitals, and independent sleep centers, allowing you to cultivate a work schedule that best fits your lifestyle. In addition, you can expect a call schedule that is quite manageable, as trained technologists at an accredited sleep center monitor most overnight sleep studies, and patients often self-administer their own sleep studies at home.

Another great thing about sleep medicine is the constant collaboration. As a sleep specialist, you will work closely with physicians from other disciplines and lead sleep teams of other health care providers – including nurses, physician assistants, psychologists and technologists. You may find many opportunities to collaborate with multidisciplinary teams, treating patients in coordinated efforts using the latest technology. I think you will find these collaborations eye-opening and educational.

So, the choice is yours and the options are plentiful to pursue your dream career, just as I did. There are 83 sleep medicine fellowship training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Learn more at www.ChooseSleep.org.

Categories
Emotion Empathy General Humanistic Psychology Narrative Patient-Centered Care Psychology Reflection

Immigrant’s Suitcase: Ordinary people with the will to do extraordinary things

A mother separated from her missing husband flees a war-torn country, her homeland, to provide a brighter future for her children. She’s a dentist by training and practiced dentistry back home; but here, here she’s cleaning homes for a living. Why? When she left her home with her four children by her side, headed to a safer place, to America, what was in her suitcase? Alongside the picture of her missing husband and the few possessions that remained after the destruction of her home, in her suitcase, she has hopes and dreams, fears and doubts. She looks to her children for strength, but she’s terrified every time she looks them in their eyes. She is not optimistic, but she is hopeful; she looks the odds straight in the face and proceeds anyway. Because hope is not logical, it is powerful.

She’s cleaning the home of a happy family; the father is an engineer and the mother is a doctor and the children play piano. Their life, their hopes, goals and dreams are dependent on the stability of their country, but they cannot see it. The same hands that used to place crowns to relieve the pain of the suffering are now scrubbing the floor of another woman’s bathroom. But hope is powerful, and she lives through the dreams of her children. Two of her daughters want to be doctors. Her third daughter wants to be an artist. Her son is eight and he loves math. In her suitcase, she brought with her the dream of a better education for her children. “In Syria, we ate grass. In Egypt, we didn’t have food. In Indiana, I love school.” These are the words of her eight-year-old son.

A man runs to catch the bus. He can’t miss the interview; he really needs this job. It is his third interview in as many days. His last job got him enough money to get his family off the streets for a couple weeks. But motels are more expensive than he ever imagined. He’s homeless. His family is homeless. This wasn’t a possibility he considered when he graduated with his MBA. He had a great job, but the hurricane took everything away. And he hasn’t been able to get back on his feet. He catches the bus and pays the $1.75 in quarters. He checks the email that he printed; the interview is in room 4015. He runs up the stairs; he really hates being late. As he enters his interviewer’s room, a bead of sweat runs down his forehead. What’s in that bead of sweat? Desperation and nervousness, humiliation and self-pity, purpose and resilience.

His interviewer gives him the job offer. He smiles and shakes his head. A tear runs down his face. He can’t take the job; he can’t manage the branch that makes most of its revenue through alcohol sales. Another day and another interview, but his family remains homeless. He needs the job, but rejecting the offer was an easy decision. He believes that although alcohol may have small benefits to people and society, the harm it causes is much larger than its benefits, and wants to play no part in its distribution; he will not be a co-creator in the intoxication of his neighbor’s mind.

A young woman sinks into herself on the examination table. Her husband is holding, squeezing her hand. The doctor is still talking. He looks very sympathetic. The young woman just learned that she has a cancer growing inside of her lungs, an aggressive cancer. The doctor thinks ‘we can fight it.’ The young woman’s mind is overwhelmed into quietness. All she can think about is her daughter’s play after school that she doesn’t want to miss, even for this. The doctor brings her back, ‘Do you feel comfortable about our next step? I think that’s the best place for us to start.’ The young woman shrugs. What is in that shrug? Fear and uncertainty, peace and tranquility, ambivalence, a need for normalcy, a desire for time to make meaning.

The young woman is herself a physician, trained and licensed as a radiologist. She knows enough about cancer and the late stage non-small cell lung cancer she has been diagnosed with to know that the longevity of her future has been called into question. And yet this is not the topic of discussion with the doctor. Instead, he discusses treatment options, which is fancy talk for a long list of big words in different orders and combinations. When asked about the next step, she shrugged. She shrugged because there didn’t seem to be room for her in that room. (Insert young woman with terminal cancer here). Although it is more comfortable for the doctor to rattle off treatment options, the patient wants to take time to acknowledge the inexorability of our life cycle. To the doctor, it was the end of a beginning, and they were, together, supposed to begin a new chapter of strength and resilience. While he rattled off treatment options, she just wanted to catch her daughter’s play after school, and she was running late.

In the words of HL Menken, ‘For every human problem, there is a solution that is simple, neat, and wrong.’  Without taking a moment to explore what’s inside the immigrant’s suitcase, the homeless man’s bead of sweat, the sick young woman’s shrug, we stand a sorry chance to witness, help, and learn from ordinary people with the will to do extraordinary things. This is the power of narratives; the power of listening. I call myself to look inside the suitcase, to investigate the bead of sweat, and to ask about the shrug; I call myself to listen.

I find myself in an imperfect world, full of injustice and oppression. I find myself an imperfect man perfectly given the ability to alleviate suffering, on a personal level with a smile or a hug, and on a larger scale by fighting injustice and refusing to stand idly in the face of oppression. Poverty belongs in a history museum. And hunger…we have enough food in the world for every member of the human family to eat a balanced 3000 calorie meal. When we eliminate poverty and hunger, there will be many other injustices for us to face. I want to make facing these injustices my mission. My mission is to be ‘human’ as best I can; to work to establish justice in any capacity that I can, from a generously given smile to an honest political campaign.

Photo Credit: Robot Brainz