A Christmas Toast

Dearest family,

I am so thankful to be here with those I love.  It has been a difficult year and the messages of the months just past are grim, indeed.  We are embattled with Nature.  A "storm of the century" did unprecedented damage to our homes leaving too many of our Long Island neighbors without a place to stay.  Much of the repair and restoration still lies ahead and will take a long time.  But we will never restore the lives lost to the storm, and these also included some we know by name.  We have so rarely felt so vulnerable.  And what is worst perhaps is that this nightmare may be the "new normal,"  a result at least in part of human activity, an environmental injury to which each of us contributes every day.  

We are embattled as well with one another. I am reminded of the description a recovering addict once offered to describe how he reached bottom:  "I reached a state of degradation that surprised me by being even lower than my rapidly declining personal standards."  And so it was in Connecticut when twenty young children were murdered in a sudden, random and awful act.  No doubt mental illness played a role.  We must believe this because to believe that a sane human being could do such a thing would be to accept an account of human nature that is beyond our imagining.  

Too many Americans are following too many elected leaders toward a state of paleolithic tribalism fueled by the basest of instincts.  The marketplace of ideas is noticeably unpopulated.  Deliberation is out; ad hominim attacks are in. Take-no-prisoners politics has eroded our ability to respect divergent views, to find common ground, to solve problems together. 

We come together around this Christmas table despite these sorrows...to share what is still beautiful in our world -- this meal, a gesture of affection, your laughter, the Overture to Messiah, a December sunrise over Northport Harbor...and in doing so to stake a small claim to a different future, a better way forward.  Whatever the circumstances of the real, historical Christ child, we believe that He represented the idea that a single soul can re-create the world in ways that defy probability and common sense.   In our modern parlance, what I am describing, family, is your goodness going viral.  

As Andy Warhol noted "They say time changes things, but actually you have to change them yourself."  God bless us every one.

    

Whose body is it, anyway?

A study reported recently in the Journal of the American Medical Association found that three strategies for regulating long term asthma medications produced similar results.  One of these involved symptom diaries, while a second used sophisticated nitric oxide exhalation testing.  The researchers found that neither produced better results than a third strategy, which was simply to suggest that patients regulate their own medications based on symptoms.  

Two things struck me about this study.  One was that simple solutions turn out to be best more often than we may expect.  The second was what the authors said about their findings:

“The data from the study are reassuring that we’re doing no harm in allowing this flexibility.”

Allowing this flexibility?  First, I hope these academics know that patients regulate their own medications - for asthma and a host of other conditions - with or without permission.  Second, and more fundamentally, this inadvertent expression of paternalistic medicine sounds weirdly out of synch with the contemporary movement toward collaboration between care providers, families and patients.  After all, the person with a chronic disease will only enjoy the best possible health if she becomes as expert in her own care as her physicians.  Or more so.

Which is not to say that I favor the practice of laying out a smorgasbord of choices for those who come to us for care.  (Back pain?  Tell me what you'd like - an X-ray?  An MRI?  Referral to a chiropractor?  How about a nice spine surgeon?)  While this latter approach, which has become common in some quarters, seems to empower the patient and support her autonomy, it deprives the person seeking care of what is most helpful, and that is the thoughtful and informed opinion of the physician.  

But some raise an objection here.  Bioethicist Robert Veatch has suggested that since literally every medical decision is value-laden, and for the most part physicians do not and cannot understand their patient's values, it is impossible even in principle for the physician to make medical judgments in the "best interest" of the patient.   One treatment carries more side effects but the alternative costs so much that I'd need to sell my house.  What textbook tells my doctor which one is "right for me"?

When I pick a primary care physician to supervise my health I want him to have the right knowledge, skill set and dedication to do a really good job.  I'll also want to make sure that he's flexible enough to work with me when I need to call the shots,  but confident enough to tell me what he thinks is best.  It's a tall order.

How Your Doctor Can Provide Safer, More Effective and More Efficient Care: The Role of Clinical Decision Making

During the last decade, health policy experts have devoted much thought to faulty "systems" and their influence on healthcare quality.  The idea is that even very qualified and devoted professionals will fail if the infrastructure of the healthcare system fails to promote effective information management, communication and coordination, while creating safety nets for high risk situations - like surgery and medication delivery - that keep inevitable human errors from actually harming patients.

This represented a significant departure for the medical profession, which for generations had focused single-mindedly on the individual physician as the unit of quality. However, as we confront run-away costs and uneven quality at a level that constitutes a national crisis, our focus must shift once more.   The safety agenda circa 2000 was about executing on the physician's plan of care.  Now we must re-direct our attention to the way physicians create that plan, and indeed to the way physicians diagnose and treat.  We need to think about thinking.

The "Medical Student Write-Up" was the place where past trainees (like me) first practiced diagnostic thinking and patient management.  It begins with a series of steps which, truth be told, physicians practice and, one hopes, improve upon over many years.  The patient arrives with "complaints" - like fever and abdominal pain - and the physician decides what other information is necessary to narrow the list of possible causes.  These "hypotheses"are then tested against the physical examination which may reveal findings (like right sided tenderness) that increase the likelihood of some diagnoses while ruling out others.  It is only at this point that additional tests, if any, are considered.  The thoughtful practitioner selects each test because the result - whatever it may be - materially changes the relative likelihood of one diagnosis as opposed to another. Additionally,  tests are prioritized based upon the urgency of the particular diagnosis under consideration (appendicitis, for example), the invasiveness of the test (like radiation from a CT scan), and, possibly, but not usually, its cost.

Here's the thing.  Busy, experienced practitioners see patients with certain complaints often enough that the sequence of steps becomes (somewhat) predictable.  And if the test is done often enough in a particular setting, it becomes a "standard of care" whether for the doctor individually or at the level of his peer group.  Sometimes this is a good thing, especially when the benefit of a test easily exceeds its risks and costs. There is a problem, however.  The more often such decisions are placed on "automatic pilot," the more removed the physician becomes from engagement with the facts of the case, hypothesis testing and critical thinking.  Over-use, diagnostic errors, over-exposure to harmful studies and excessive cost are ALL side effects of over-reliance on the "automatic pilot".

How do we know when doctors are on auto-pilot?  The fact is that it can be hard to tell.  And the reason for that is that many physicians have fallen away from the habit of recording their thought process in medical records.   Production pressure is one reason for this. Another is a misplaced notion that writing less is protective against medical malpractice (it isn't).  And paradoxically, the advent of electronic health records has made the situation worse, at least temporarily, as practitioners try to figure out how to use a combination of point-and-click, drop-downs and "free text" to replace what they once wrote with a ball-point pen.

The next time you see your doctor with a problem that needs diagnosing and she orders a battery of tests, ask the question.  What will this blood test or that MRI tell us?  Will it change the treatment?  Good diagnosticians have a reason for every test they order.  So if the answer is that "these are just the routine tests we do," think about another physician.  One who can share her thoughts and has thoughts to share.

      

Getting through the storm

Superstorm Sandy.  The waters have receded and the roads are (mostly) cleared.  But our homes are still largely dark and cold, and many have been rendered homeless.

I am writing this evening from the Riverhead, NY residence of my very generous father-in-law, who has opened his home to my wife and me, my mother and several friends.  Meanwhile, back at the hospital, nurses and physicians, ancillary staff and administrators are still working round the clock in the face of high volume in the ED and an overcrowded facility.  Why?  We can't discharge patients to unsafe conditions at home.  We can't discharge patients to long-term facilities and nursing homes that won't accept them, because their facilities are dark and their workers stranded.

Gridlock.

I have to say that like many, I have done my share of eye rolling when, in previous weeks and months, our COO called special meetings about disaster preparedness.  When the facility is humming along, the skies are blue and a dozen other challenges call out for attention, preparing for hypothetical catastrophes just doesn't seem like a good use of limited time.  We all feel differently now.

There have been positives.  On a personal level, I have been gratified to have opportunities to spend time with people one-on-one that I would not ever have had otherwise.  (Having spent Monday morning to Tuesday night in the hospital through the heart of the storm, I found many chances to engage my colleagues in discussions we would never had had under other circumstances...)  And then there was the camaraderie, the high spirits despite fatigue and the sense of shared purpose.  When every thing is going well we can be pretty self-centered.  The sommelier telling us that the Pinot Noir is unavailable becomes A BIG DEAL.  It takes a little disruption to set us straight.

There was one other lesson.  We have been conversing as a healthcare community about the issue of waste.  Unnecessary CT scans,  unwarranted consultations, inappropriate consultations. Under conditions of duress, these problems are magnified.  When the scanner is down, it MATTERS that we not order tests thoughtlessly.  And so, at a recent meeting of hospital leaders, I suggested that we keep this experience in mind when the dust settles, and get busy with the problem of eliminating waste from healthcare.  More on that next time.

To those of you in the path of Sandy, please accept my most sincere wishes for a safe recovery.  Keep the faith.

By my side

The federal Center for Medicare and Medicaid Services has enacted new rules for hospitals to ensure the right of every patient to have someone - such as a spouse, relative or friend - to help them make medical decisions and to provide emotional support.  This is a very good thing.

The experience of serious illness carries with it not only the crisis of confrontation with our own mortality, but also, all too often, alienation and a sense of powerlessness.  Our hospitals and medical profession have, in the past, done much more to exacerbate this kind of suffering than to address it.  From Doctor's Orders to Visiting Hours, it is no wonder that in his role as a terminal patient in "The Bucket List" Morgan Freeman's character talks about "busting out" of the hospital.  Indeed, leaving "Against Medical Advice" is as unsanctioned (and liberating) as a jailbreak.

Persons receiving hospital care have the right to appoint a "representative." The healthcare team, led by the physician-of-record, communicates with this individual just as it does with the patient himself, and so allows the patient the opportunity to share decision-making with another trusted person.  The new rules also provide for a "support person" who may or may not be the representative.  This person helps with visitation, ensuring that anyone the patient wants to visit can do so while also helping to protect the patient's privacy by limiting visitation in accordance with the patient's wishes.  

Among the traditions that may be most offensive to the autonomy of hospitalized patients is that when certain procedures are undertaken, the patient's visitors - even a spouse - may be asked to step out.  This goes on regardless of the patient's wishes.  A variety of explanations are offered: the procedure will be too upsetting for the visitor, or the visitor may faint, or the staff will be distracted.  None have ever been studied scientifically, and to the extent that unrestricted visitation has been evaluated, we know that it is helpful to patients.  Moreover, it is their right.

When I need the services that can only be provided in an acute-care hospital, I will want my wife or my children there.  I will understand that the number of visitors may need to be limited if I have a room mate, although I think that double rooms are a questionable practice and need to be abolished.  I will probably ask my wife to be there if I need a tube inserted into my stomach or chest, unless I am asleep for the procedure.  If I have grandchildren at that time, I will decide with my wife whether it is in their best interest to come into the hospital, and not leave that decision to hospital staff.  And if I become unable to make decisions on my own behalf I will expect my physicians to treat the decisions of the person I have pre-appointed as though they were my own.

Surely not all patients will want the same things or decide in the same way.  This is very much to the point.  But every patient will have the right to decide how they decide and how they live within the walls of the hospital, walls that we can hope will represent not incarceration, but patient-centered care.

 

What IS Romneycare? And can we possibly afford it?

With the rhetoric flying in every direction in this pre-election season, separating fact from fiction is a daunting task, especially in the complex world  of healthcare delivery and finance.  Figuring that his party's own websites would provide the most favorable take on Mitt Romney's healthcare position, I visited www.mittromney.com/issues/health-care.  This is what it says:

"On his first day in office, Mitt Romney will issue an executive order that paves the way for the federal government to issue Obamacare waivers to all fifty states. He will then work with Congress to repeal the full legislation as quickly as possible.

In place of Obamacare, Mitt will pursue policies that give each state the power to craft a health care reform plan that is best for its own citizens. The federal government’s role will be to help markets work by creating a level playing field for competition."

Certainly this is consistent with the Republican platform.  The fix for unemployment: less government.  For the environment: less government.  For energy: less government.  For education:  less government.  

Here are my concerns.  

1.  Policy analysts and experts from many quarters - the Institute of Medicine, National Quality Forum, Institute for Healthcare Improvement, academic centers, various professional societies and others - have weighed in.  To the best of my knowledge, no credible expert has made the claim that "less regulation" is the key to reversing our spiraling healthcare costs. 

2. As we all know by now, the US pays more for healthcare than any other nation in the industrialized West with poorer outcomes than most.  Now, how many of these more successful nations provide examples of the Romney philosophy succeeding in reducing cost and improving quality?  Answer: none.

3. The Romney philosophy fails on the level of principle.  The unsustainable hyper complexity of the private market has been a part of the problem; it can't also be the solution.  So has a fee-for-service market that pays for interventions rather than outcomes.  The predictable result has been a vicious cycle of "more" - more tests, more images, more operations, more hospital admissions - more than are good for us and more than the best medical scientists recommend.  

Mitt ought to have asked some doctors.  Believe me, we understand over-regulation.  But in the doc's Main Street office, it's not "gumment"  that's the bogeyman.  Talk to the staff - multiple individuals in each office - who spend all day, every day interacting with multiple insurance companies (the folks that Mitt is counting on to fix the problem).  Each one has its own separate rules.  What tests require "pre-authorization" (by a clerk).  What antibiotic your doc can order.  What screening tests you can have.  And every time any insurer says "yes" to anything, it is eroding its own profit structure and harming its shareholders.  This conflict of interest is not theoretical.  Your doc feels it.  Every day.

Free markets work exceedingly well in so many areas of our economy.   But even the framers of our Constitution favored public libraries; and (public) fire departments were established in Colonial America to serve the common good.  Romney-style private competition as mis-applied to our national healthcare system not only leaves unperturbed the cycle of spending, complication, quality problems and waste, but worse yet throws gasoline on the conflagration.  Cooler heads must prevail.  

[DISCLAIMER:  the foregoing comments are the private views of the author and not necessarily those of Huntington Hospital or the North Shore LIJ Health System.]

Flu shots for hospital staff -- should they be mandatory?

Backed by a number of studies, healthcare policy experts at the CDC and elsewhere have advocated for some time that all healthcare workers be immunized against influenza.  There are two reasons for this.  First, during an epidemic, an infected healthcare workforce can dangerously strain our national infrastructure at a time we need it most.  Secondly - and this is the major argument - infected professionals can unknowingly transmit this virus to susceptible patients with potentially serious consequences.  This is especially true when the patient is an infant or an individual of any age who is debilitated by chronic disease or an impaired immune system.

Is there any plausible counter-argument to mandatory, universal immunization for hospital staff?  One might doubt this, when experts recommend a flu shot (with rare exceptions) for every healthy child and adult, every year, and when hospitals will immunize their staff members on site and for free.

And yet, predictably, there are naysayers.  This is not a scientific controversy, but a disagreement over the rights of nurses, respiratory therapists, and even doctors as regards a health intervention with a non-zero risk.  (The benefits of the vaccine, which in its most common form contains no infective material, are believed to far outweigh the remote possibility of severe allergic reaction or neurological side effects.)

Whose rights prevail - those of the many (the patients) or of the one (the professional)?   This is no more or less than the familiar red/blue debate of our day.  In the current instance, however, it is colored by other considerations.  How far does our professional obligation go in compelling us to sacrifice for the good of our patients?  "Professionalism" clearly mandates physicians to place the patient's interest before all others.  Does this extend to flu shots?  And does it extend to the rest of the team?  The boundaries of professional obligation (and perquisites) are determined jointly by society and the profession itself.  What do YOU think?  Write a reply and share your thoughts.  And, by the way, don't forget to get your flu shot this Fall.