Saturday, December 31, 2011

"Corporatizing" Hospice- More Heart Needed

Across the health care system, the quest for efficiency is tightening processes into numerically competitive strategies.  Each behavior has to generate a profit.  Does hospice have to follow suit?

Is hospice becoming too corporate?

I wonder because I think of the changes over the years that I've seen in hospice procedures.  As a family physician, I usually have a patient or two in hospice care at their homes, with me as their "attending" physician.  My small business mentality has to merge with some aspects of the big business mentality of our two larger hospices in the Dayton, OH area.  The personal nature of Family Medicine gets me used to relating to the patient and their family in the context of their life and work.  The relationship-based nature of the specialty makes it more meaningful for both patient and doctor.

Large hospice corporations, whether for profit or not-for profit, have more functions and people per unit of time to consider, making their management less able to personalize with patients in the same way.  They often have wonderful front line professionals (about whom I've posted to this blog before) to interact with patients, but sometimes hamstring them with bureaucracy.  They are not used to dealing with individual physicians who aren't tightly connected to their system of policies and protocols.  I've found this to be true repeatedly for the last eight to ten years.

On weekends, there have been surprising obstructions to patient care generated by the use of regional call centers to triage information about patients.  I suspect that the business people of hospice noticed a cost savings with this decision.  People, though, don't benefit by the efficiency.  Especially dying people and their families.

I remember a weekend call to our office phone system that allows a recorded message and pages the doctor on call.  A hospice nurse was at my patient's home and left a message that she needed an order for more morphine.  The number she left was a call system for hospices located in another state.  It took four more calls (and an hour) for me to connect with the nurse who was no longer with my patient.

Another of the large hospices has a similar regional call center on weekends now and the same type situation happens.  The physician who isn't a hospice medical director may have to call the patient's home and speak with family members to find a number for the weekend hospice person (I did).  The number may be the regional call center in another state (like Illinois).  The non health care professional at the center may then connect the physician with Cincinnati where a hospice nurse manager can provide the phone number for the hospice nurse who is covering my patient for the weekend (she did for me).  The local weekend hospice nurse may answer her cell phone or be occupied and have a voice mail system record my message and phone number.  We either talk about my patient right away or later when she calls back (which is always very soon for both our large hospices).

Ordering the "Comfort Pack" which includes morphine (Roxanol), lorazapam (Ativan), atropine and other medications to help with patient comfort toward the end of life is another sometimes cumbersome undertaking with the corporate minded hospices.  I remember giving admitting orders, including the Comfort Pack, on a Friday evening for one of my patients who also had a medical condition which would be helped by the morphine if it flared up.  It did flare up two days later, so I gave the order to use the morphine in the comfort pack to relieve the symptoms.  "It won't arrive for another couple days," I was told, since the hospice orders it from a center in another state.  I was stunned, and disappointed.  Four phone calls later in the local  private health care system (and to the family) had the morphine available for use.

Do we have to "corporatize" hospice to this extent?  Can these big corporations fix the weekend hassles?

Suggestion:  Put nurses in charge of the hospice.  CEO's should all be nurses.  They have a heart for patient care.  They are especially sensitive to end of life issues for individuals (patients) and families.

Dying people are not widgets.  Death is not efficient.  It is natural, though, and should not be over-medicalized.  It is not seen by the dying and their families as a business opportunity.  It should not be corporatized.  Can we upgrade hospice leadership and management to realign with the heart of the hospice movement?  Please.

Wednesday, December 28, 2011

Family Medicine: Spiritual Sensitivity Enhanced in Training

In the context of the patient-physician relationship, a variety of roles for each person in the dyad are manifested.    Each seeks information and clarification over time in the context of the relationship.  Beyond the usual elements of health and wellness are the spiritual explorations that patient and physician undertake.  Both think of the usual medical phenomena, but sometimes the thoughts and comments reflect on the more spiritual aspects of life and the hereafter.   How does the Family Physician respond to this aspect of practice?  How do they learn to allow this discussion to happen?

Many persons in the medical world don't know that Family Physicians all are exposed to behavioral skills training by Family Physician and Behavioral Science faculty in their Family Medicine Residency Training Program.  Clinical encounters are reviewed by those faculty with the resident Family Physician to enhance their ability to integrate physical, intellectual, emotional and spiritual aspects of the patient's life into the discussions and decisions.  Gaining insight into the importance of the entire context of the patient's life and belief system enables the Family Physician to have a broader response repertoire to patient concerns throughout their career.    

The teaching and training about multiple cultures and belief systems in Family Medicine Training Programs enable the residency graduates to adjust to a wide variety of individual, family and community cultures.  Birth, death, loss and grief are daily subjects in patient clinical encounters about conditions and disease processes in all organ systems.  The spiritual issues that patients share with their Family Physician are seldom a surprise to the doctor.  The integration of the behavioral sciences with the biological and clinical sciences contribute to the spiritual sensitivity.

"Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity."....AAFP definition.

Saturday, December 24, 2011

Family Medicine: Christmas in the Office with Patients and Doctors

We've been seeing several patients getting "end of the health plan year" check ups or chronic disease visits.  Christmas is an issue for most.  "What are your Christmas plans?"  I ask almost everyone.  Their individual and family traditions are interesting to hear.  Most involve family and two family oriented sites.  The shared custody situations and multiple adult children with grandchildren are the driving force in their Christmas travel and activities.  Many of their plans are impacted by their current illness, especially when it is infectious.  I include in my recommendations the implications for the context of their Christmas endeavors on their therapies.  They get to decide what they will do with my suggestions and the contingencies that I list for them.

Several patients asked me how I am doing.  It takes me out of a patient centered "trance" and I'm temporarily fumbling to reflect on myself.  Once I shift my role back to human from doctor, I find reference to myself and how I am doing and I respond to their inquiry briefly.  It's not easy in the exam room after decades of patient focus, but it's important.

At about 3:45 Friday before Christmas, I start to feel a little glow of delight:  Christmas Joy has arrived.  The last patient is thankful for a diagnosis and helpful strategy to treat his condition.  I'm off to Christmas.  Home to wrap presents and watch black and white movies on Turner Classic Movie Channel.  Christmas is near.  I'm ready ahead of time.  I sense the part of me that is bubbly about Christmas and the part of me that has layers and layers of memories about Christmas.  That should have been my response to the inquiring patients.  The bubbly feelings have to be more readily accessible.  I'm working on it.  Patients and doctors have to stay close to their humanity.

Merry Christmas!

Friday, December 16, 2011

Family Medicine Prescribing: Some Benefits and Harms of Statins-Cataracts and Diabetes

"I threw the Simvastatin in the trash", my patient emphatically stated.  "The nurse at the operating room for the ophthalmologist said that statin therapy for cholesterol is one of their top reasons for early cataracts (in younger people).  That cataract surgery isn't something I want to duplicate."

How can these "wonder drugs" for lowering cholesterol and decreasing risks for heart attack, in people with known coronary disease, cause problems?  How do physicians analyze the potential good and bad effects of prescription medication, including statins?

One way of considering medication effects relates to "benefits and harms", including the number needed to treat (NNT) and the number needed to harm (NNH).  How many people need to take the drug for how long to prevent a major event or death in one patient?  And, how many need to take it to cause a major event or death?

In the presence of known coronary artery disease, the NNT for Simvastatin is 64.  It is estimated at 250 for those with no coronary disease.  The NNH is 137 to make one diabetic, 1100 to make a cataract.  A helpful article exploring these aspects of statin drugs from a blogger who reflects on an article about statins from Business Week is here.  Another NNT comment about statins is in The NNT.

The NNT and NNH are useful concepts in making decisions about prescribing medications.  More later.

Friday, December 9, 2011

Family Medicine: Duh!

Three or four times during each day in my Family Medicine office a patient arrives at a Duh! moment in their story.  One of the benefits of the electronic era will be the ability to add emphasis to these moments with a flashing Duh! sign on the computer monitor or my tie or the wall of the exam room.  It might even entail a Duh! Duck that drops from the ceiling like the duck on the old Groucho Marks show that dropped down when a contestant would say the secret word.

Have you experienced any health related Duh! moments worth commenting on below this post?  I bet that many of you have the Duh! story of the week, month or year.  What do you think?

Wednesday, December 7, 2011

Family Medicine: December Issues

Here we are in December again.  What are we seeing in the office?
Hypertension, diabetes, asthma, depression, generalized anxiety disorder, abdominal pain, upper respiratory infection, urinary tract infection, emphysema, osteoarthritis, neck pain, low back pain, knee pain, throat pain, well baby check up, annual physical, changing skin lesion, perioral infection, vitamin B12 deficiency, vitamin D3 deficiency family stress, otitis media, eustachian tube dysfunction, shingles, marital discord, parotitis, facial pain, blurred vision, hypothyroidism, insulin resistance, morbid obesity, obesity, insomnia, fatigue, pneumonitis, colon cancer, breast cancer, renal failure, palpitations, gastritis, grief reaction, atrial fibrillation, lumbar disc disease, lumbar radiculopathy, sciatica, sacroileitis, constipation, nicotine dependency, acute situational reaction, medical management of opiates, carpal tunnel syndrome, coronary artery disease, gastrointestinal reflux disease, sinusitis, bronchitis, eczematous dermatitis, urticaria (hives) and puncture wounds.

Saturday, December 3, 2011

Family Medicine and Personal Health: Habits

Now I have this habit of writing daily since participating in the National Health Blog Post Month Challenge from WEGO Health.  Word is that it takes 3 weeks or so to develop a habit.  In health care, we see and/or hear about lots of habits from our patients.  Many of the habits are very positive health behaviors and many are negative health behaviors.  How do we address the habits of our patients?

1.  Honor them for something whenever possible with precise behavioral language that has meaning to the patient.  "Your knees are hurting less because of the weight reduction you've achieved.  The four pound loss this month was enough to decrease some of the inflammation in the knee joints.  You are helping yourself.  Congratulations on developing new eating habits that helped you."

2.  Allow them to teach us about who they are, what they believe about health and why.  As they educate us about their uniqueness and their health beliefs and habits, we can better relate to their life and values and personalize health strategies for habit continuation or alteration.

3. Use self disclosure about our habits to the patient as appropriate to enhance the patient physician relationship and trust levels of the dyad.  "As appropriate" may take a while to accurately define, so some mistakes will be made.  Physicians are people, too, and our patients deserve to know it.

These behaviors help us to understand our habits and the habits of others, be they patients or physicians or both.

How do you relate to being asked about your health habits?

Friday, December 2, 2011

Family Medicine: Patient Self-Sabotage

About twelve years ago, a Psychiatrist in town published an article reporting that 9% of the patients seen by psychiatrists in his study sabotaged their care.  I wonder what a similar study would show in Family Medicine.  I've noted recently a trend in the patients I'm seeing toward sabotaging their potential for success with treatment of a chronic disease.  What drives their behavior, or lack of behavior, in the case of non-adherence to mutually agreed to care plans?

How many other Family Physicians are seeing patients who sabotage their care?

How many patients are aware that they are sabotaging their own health (care)?

More later.