Thursday, May 30, 2013

Expensive Medical Decisions are Increasing Along with Overuse of Unnecessary Care

A quandary that I sometimes notice as a Family Physician is the paradox between the flawed brain and the loving heart.  Which one leads?  Which one follows?  Which one may lie to patient or doctor?  Which one seeks to protect?

The brain uses flawed decision processes to allow exploration of a limited amount of biased information to come to conclusions.  Can it be trained to develop better protective mechanisms against unnecessary, overused, low yield, expensive and sometimes harmful medical tests or therapies?

Can a patient brain register a strong decision rule about medical waste?  Who will give the patient the rule or help them to develop the decision rule?

OK, I'm getting troubled by the massive waste in our flawed medical system.  A patient  wakes up and complains to the nurse in his new assisted living that he has a headache.  She checks his blood pressure.  It's elevated.  He feels woozy.  She calls the paramedics.  They take him to the local emergency department.  BP is still up, otherwise he has a normal physical exam.  He gets a CT scan of his head, EKG, Lab Studies for heart attack, kidneys, CBC, urinalysis, and Chest XRay.

He had the same tests 2 months earlier when he got nervous before eye surgery and the eye doctor insisted that he go to the ED.  The eye Dr didn't call his Family Physician who would have seen the man the same day and resolved the problem.  Charge to Medicare: about $18,000 for emergency care and overnight observation.

The patient notes that he didn't get to take his blood pressure medicine before the squad brought him to the ED.  He is given his BP med- one pill.  In 30 minutes, he feels fine.  Headache is gone.  BP is normal again.  He goes home.

Estimated charge: $6000 to Medicare.

If he or the nurse at the assisted living had called his Family Physician, he would have received his blood pressure med and had the BP rechecked in a half hour.  Charge $0.

The Family Physician knew of two other instances with the same patient, over 90 years old, in which his BP jumped and came back down with conservative measures through the family physician's office.  Cutting out the Family Physician is one way to bankrupt America with medical charges.  If you follow the money, you'll notice how the system maximizes charges, not health or health care.

Who can be trained to have a brain that acts more toward reasonable use of the scarce, valuable resources in our health care system?  Almost all of the over 90 patients don't want "machines" to keep them alive and have a living will.  Some have the official Ohio DNR Form and have heard numerous times to call our office 24/7 if they have a problem, so we can protect them against the excessive use of medical services that is an epidemic in America.

We all have to get together over and over to fix some of this overuse and under care.
Our hearts are supposed to help our brains to balance difficult decisions.  Can we do better?

Monday, May 27, 2013

Memorial Day 2013, An Opportunity for Peace

Memorial Day is a reminder, a release and a reconciliation opportunity.  I first knew it as Decoration Day when my grandmother and other women would decorate the graves of veterans and other deceased persons, mostly relatives.  Three miles from the Dayton Veterans Administration Health Center and Hospital was my childhood home, which kept me aware of veterans and their graves.  Thousands of identical appearing headstones with perfect alignment serenely greeted passers-by.  My childhood sense of this burial ground was that a peaceful resting place awaited soldiers.  The quiet, organized beauty was a reminder.

Then I became a soldier, and a veteran.  Along the way, as a Cadet at West Point, I spent a week in Walter Reed Hospital (as a patient for brain tests- I was "normal") in Washington, DC in the summer of 1966, among those wounded in Vietnam who had brain problems.  I remember how they were encased in body casts or bald from the head shaving associated with their brain surgery.  One man was shot by a sniper through the temple out the eyeball, leaving him blind in one eye.  He was happy to be alive, amazed at his "good fortune".

As a Family Medicine Resident, part of my training included learning dermatology in the Dayton VA.  I loved interacting with the veterans.  Their stories were enlightening and heartening.  Most of their stories didn't have a direct relationship to their skin condition, but a Family Physician- in training is still interested in the person first and their condition/diagnosis second.

As a West Point graduate (1968) I recently read in a book titled West Point that one of the unwritten missions is "To put old souls into young bodies".  At some level, the ghosts of The Long Gray Line wanted us to understand the meaning of what we were experiencing in our education and training.

The heart of a soldier evolves in its understanding through teaching and experience.  Friendship and human connection are two more of the inputs.  A spiritual anchor and cultural insights add to the heart's development.  At the end, when the soldier's heart hears, "Well Done", it accepts the honor, even as the soldier's brain is embarrassed with feelings of unworthiness, since "we're just doing our job, and pleased to be able to serve".  This paradox between heart and brain seeks to be reconciled over the years or in the hereafter.  The reconciliation seems to be unpredictable.  The "old souls" may have something to do with that.

Fast forward to today at a playground near Carrboro, NC with the grandchildren.  "Thank you for your service, Sir," I heard from a mother near the swingset. (She must have noticed the hat I wore with the word ARMY on the front) "Thank you", I replied quietly with a sense of relief.  She had touched my heart with her appreciation and part of me was relieved that I could recognize and appreciate it.  A touch of sadness followed as I had a vision of "The Wall" in Washington, DC and thoughts of Vietnam and "The Wall" again. The sadness was balanced by something and weighted with meaning.  Thank you, God, for providing the balance and meaning.

The fifty thousand plus names on "The Wall" speak to us all about life, love, war and death.  And Peace.  A peaceful presence helps us to reconcile the losses with the part of our heart that hopes for a lasting peace, beyond human understanding.  Thank you, God, for that peace.

Monday, May 20, 2013

Raccoon and Dog

It's 1:30 AM and our dog is outside protecting our home from a raccoon which was on our deck going after the bird feeders.  He is sniffing repeatedly in hopes of learning more about the raccoon's whereabouts.  I hope he doesn't connect with the raccoon.  Skunks would be even worse.  And so, back to the door to see if Marty is content enough with his efforts that he'll come in for the night.

More later.

Friday, May 17, 2013

Family Medicine: The Differential Diagnosis

What could be causing this?

This is a question that Family Physicians often ask as they interact with patients.  The list of possibilities that is actually considered is called the "differential diagnosis".

The list can be huge, but the active considerations are limited by the brains of the patient and physician and time, sometimes supplemented by decision aids in print or online.  Processing the possibilities via the history, physical and differential diagnosis is part of the fun of Family Medicine.

Added to this intellectual component is the human centered, relationship based engagement of patient and physician in a unique decision making dyad.  The roles assumed by the members of the dyad alter the process of engagement and decision making, affecting the differential diagnosis and the subsequent diagnostic, therapeutic and patient education decisions.  The personal values of the dyad enter into the discussion frequently as do other contextual phenomena, such as life, family , education and work considerations.  One contextual element frequently encountered is the migration narrative or movement of the patient.  Where are they going?  What is next in their life, work or play?

How does their migration impact the differential diagnosis and the plan and follow-up?

What does the patient believe about their condition and the plan to address it?  Sometimes I'm surprised by the patient's activity on the agreed to plan.  Someone with a serious heart condition may stop a medication that keeps them out of emergency rooms and end up in an emergency room.  At the follow-up to the emergency visit, I want to determine where their heart is in its degeneration and consider dosage adjustment of medication or addition of other medications until it comes up that they stopped the medication.  "I thought that might be the cause of my indigestion" "I wasn't sleeping well and I thought the medicine might be part of my insomnia."

As we share better with each other, especially as we share the development of the differential diagnosis, it becomes easier to seek clarification about how and when to use the medication.  And when to share information with their Family Physician.

The Differential Diagnosis is one of the anchors of medical care.  It keeps us focused and engaged.

More later.

Wednesday, May 8, 2013

George Jones, Tim Tebow, Marcus Welby MD and Healthcare

George died, Tim was fired and Marcus was a re-run.

I always liked the music of Tammy Wynette more than George Jones.  I used to sing her songs when I was in Vietnam.  "Our D-I-V-O-R-C-E Becomes Final Today" was as fun to sing as "Stand by Your Man." I learned about George by listening to Tammy's songs.  I thought he might have some anger management issues.  Unless it was all about the alcoholism.  If he or Tammy had seen their Family Physician for help, the outcome of the marriage might have been better (but record, CD, DVD, downloads, and other sales might have suffered greatly). 

Tim, I like the way you play football, but traditionalist coaches in the NFL don't connect well with your unique value.  Wait a minute, that makes me think of my medical specialty- Family Medicine.  We're the most important health care professional in the fight to "bend the cost curve" of healthcare that's bankrupting America- BUT- we're unique and not understood, therefor have to be TRANSFORMED to REALLY be good.  In the process, we're being destroyed, dumbed-down, and looking for the exit or the independent practice using a Direct Primary Care business model across the street from the BEAST of healthcare.

Marcus, Marcus Wherefore art Thou, Marcus?  Where's Dr Kiley and Nurse Consuelo to help us when we're overloaded?

OK, maybe looking backward could be discouraging.  Onward EHR, Meaningless Use, Payment Centered Medical Homes, Phony Quality Initiatives, Evidenced-Based Shareholder Value and other key components of the future of healthcare.

George, I hear you singing "Who's Gonna Fill Their Shoes?"

What do you think?