Sometimes, the Best Care is to do Nothing

The dynamics, interactions, and expectations that are played out in the office between doctor and patient can lead to some uncomfortable moments.  Most of the time, as a provider, I feel the need to obtain some test or order new medication to address the patient's issues.   Often, the provider feels obliged to prescribe something, or to obtain a study, even when there is no a clear indication for doing so.  This may be an attempt to provide a satisfactory encounter or to avoid professional liability risk.  Often, appropriately, the provider may be simply giving the patient the benefit of the doubt.  However, it may be a disservice to the patient to prescribe a test or medication if the doctor believes it isn't necessary.  We should, as providers who are committed to high quality care, renew our commitment to carry out the most appropriate course of action, regardless of whether that may lead to an awkward moment with the patient.  Here are a few simple illustrative examples:

• Patient has respiratory illness, probably viral, but requests antibiotic treatment.
• Patient has headache, probably tension, but feels a CT scan should be ordered "for good measure".
• Patient has chest pain and chest wall tenderness, but gets admitted to "rule out" a myocardial infarction.
• Patient has fatigue and mild depression, with "low normal" testosterone level, and asks you to prescribe testosterone supplement.
• Patient has had trouble losing weight with dieting and requests amphetamines for weight loss to "jump start" the process.

These are representative examples, but there are many other scenarios in which the cost or risk of side effects from the treatment likely outweigh the potential beneficial effects.  It is often tempting, rather than taking the time and effort to explain the reason why "a" or "b" is not needed, to go ahead and provide the prescription or order the test, then move on to see the next patient.  When we do this, we not only do the patient a disservice, but we contribute to the unsustainable cost of health care.

I consult a variety of financial, legal, and other professionals expecting them to render their honest appraisal and recommendations.  If this is a recommenation not to do something, I would certainly accept, and appreciate their candor; as a doctor I should do no less!

Your comments and dissenting opinions are always welcome!

What to Do If You Have the Flu

Flu season is in full swing this year, with thousands of Americans suffering from its symptoms. The Centers for Disease Control (CDC) has estimated that an average of 36,000 people in the U.S. die from influenza or from its complications each year. Influenza is particularly hard on the elderly, people with a weakened immune system, children, and those with chronic illnesses, such as emphysema and diabetes.

Several weeks ago, a Health Tip went out encouraging everyone 6 months or older to receive the flu immunization. As expected, most of this year's flu cases have occurred in those who were not vaccinated. Unfortunately, getting a flu shot does not guarantee that you will not get the flu. While immunization remains the most effective way of preventing the flu, recent statistics from the CDC indicates that the effectiveness of the vaccine this year is 62%. This means that if you received the vaccine you are about 60 percent less likely to get the flu, but not completely immune.

How do you know if you have the flu? Mild cases of the flu can be similar to a common cold, but typically, the flu is much more severe. Muscle aches, severe fatigue, cough and headache predominate over common cold symptoms of runny nose and sore throat. Characteristic of the flu also is fever (100-102 degrees F) that can last for three to four days. Of particular concern in those who contract the flu are its complications, including bronchitis and pneumonia, which are responsible for the majority of flu-related hospitalizations and deaths.

What you can do for the flu? Most people with the flu end up being miserable for a few days, but recover on their own. A number of non-prescription medications, while not treatments for the virus itself, can help with flu symptoms. Over-the-counter medications and self-care measures include:

1. Limiting activity and getting plenty of rest.
   
2. Staying hydrated by drinking water, sports drinks or electrolyte replacement fluids.
   
3. Gargling salt water (1 : 1 ratio) or using throat lozenges for sore throat.
   
4. Taking acetaminophen (e.g. Tylenol®) or ibuprofen (e.g. Advil®, Motrin®, others) for fever or muscle aches.
   
5. Taking decongestants (Claritin-D, Sudafed, others) can ease discomfort from stuffy nose, sinuses, ears, and chest.
   
6. Using cough medicine or cough drops for temporary relief from coughing.

It is important that aspirin be avoided in anyone under the age of 18 with the flu because of its association with Reye syndrome, a condition affecting the nervous system and liver. In most people, medical attention or antiviral drugs are generally not required.

When should someone seek medical attention? People at increased risk of serious flu-related complications, including young children, elderly persons, pregnant women and people with chronic illnesses, such as diabetes, should contact their medical provider with the first signs of an influenza infection. Emergency warning signs in children include difficulty breathing, bluish skin color, extreme irritability, inability to keep food or liquids down, and high fever. Adults with shortness of breath, confusion, chest or abdominal pain, and persistent vomiting should receive urgent medical care. Someone in whom flu symptoms improve initially but later develop worsening cough and fever may have a bacterial infection and should receive medical attention.

What is the doctor able to do? Antiviral medications are modestly effective in shortening the duration of the flu and may help to avoid complications. For these to work effectively, however, it is important to start treatment within 48 hours of the development of symptoms. Below are antiviral medications approved for treating adults and children one year and older:

1. oseltamivir (Tamiflu)
   
2. zanamivir (Relenza)
   
3. amantadine (Symmetrel)
   
4. rimantadine (Flumadine)

In December 2012, the U.S. Food and Drug Administration expanded the approved use of oseltamivir for treating children between the ages of 2 weeks to one year. Antibiotics used for bacterial infections, such as Ampicillin, Keflex, Cipro, etc., are not used to treat uncomplicated cases of the flu. These may be required, however, with certain flu-related complications, such as pneumonia or ear infections.

When can I return to work or school? The Centers for Disease Control recommends that people recovering from the flu stay at home for at least 24 hours after their fever is gone. While at home, flu victims should avoid contact with others in the household to keep them from getting sick. Also, frequent hand washing will help to keep from infecting others.

Is it Possible to Really Receive "Whole Person" Care?

This week, along with a psychologist colleague, Chris Rule, I began a Balint Group with senior Family Medicine residents at the University of Arkansas.  This approach was inspired by Michael Balint, a general practitioner in London who led groups of GP's along with his partner and wife Enid at the Tavistock Clinic in the late '40's and early '50's.

Balint explored concepts such as the "collusion of anonymity", in which he decried the tendency of specialists to pass patients around to each other with no one caring for the whole patient.  So, through the use of these groups, and the use of case presentations with discussion, he set out to deeply explore the nature of the doctor-patient relationship and to encourage his colleagues to "go deeper", to "listen to patients in a new way" and to recognize that much of the value of being a primary care doctor had nothing to do with ordering tests, writing prescriptions or assigning a physical diagnosis to every symptom.

He noted that, time after time, the groups' patients "offered" up a symptom and the doctor "accepted" it, in a sense allowing that process to thwart the opportunity to explore what was truly going on with the patient.  This process in no way means that the physician seeks to find a psychological cause to all symptoms but it does suggest that no one in the health care system is as well positioned to integrate psychosocial issues with biological issues to truly provide whole person care.  To do this, the physician must learn to truly listen to patients, without jumping to a diagnosis or treatment approach too soon to get to the real issues.

This is why I went into Family Medicine and why, after 39 years of training and practice, I am still inspired to go to work every day.   I'm still learning how to get better at talking to, and understanding, patients.  And, I thank mentors like Michael Balint for providing the model for integrating medicine and psychology for us.

Is Your Doctor Reconciling your Medications?

The Institute of Medicine’s (IOM) seminal study of preventable medical errors estimated as many as 98,000 people die every year at a cost of $29 billion.  Everyone who is taking medications should be concerned about the adverse potential of medication side effects, as well as problems due to drug interactions.  The Joint Commision, recognizing the risks of medication use, has begun to place  major emphasis in its surveys of hospitals on a process called "medication reconciliation". 

Medication reconciliation involves a detailed review of current medications and doses, including assurances that the patient is taking the medications and doses as listed in the record.  This process is especially important during transitions of care such as at the beginning of a hospital admission, transfer of a patient from one unit to another, from surgery to the medical floor, or upon discharge from the hospital.  It is also important, during routine visits to the doctor and, whenever a new medication is listed, determination made that no adverse interactions are likely with the new combination.

I strive to reconcile medications at every patient's visit with me.  This may occur during annual preventive care visits or during follow up visits with patients who have chronic disease states such as diabetes or hypertension.  The process also needs to include over the counter medications and supplements, in addition to any prescriptions provided by another physician.  I am continually amazed that, in virtually every visit, a patient's medication list requires at least one or more modifications.  I am also amazed that, whenever I see someone else's patient, the list is frequently woefully inaccurate and, in many instances, appears to have never been reconciled.

What, then, is the point of this article?  It is to make patients more aware of the importance of medication reconciliation and challenge you to become an active partner in the process with your primary care physician.  How can you do this?  Many clinics print out a medication list for review when you check in to the clinic.  If this is not happening, I suggest requesting it from your team.  Additionally, it will be helpful for you to bring a list of the medications and doses that you are currently taking, as this will provide a helpful and accurate tool for the nurse or physician to use to "reconcile" your medication list. 

A brief list of the various actions that may result from this process will illustrate the importance of medication reconciliation:

1. Elimination of drugs that the medical teams think you are taking, but aren't.
2. Identification of, and deletion of, medications that could be causing a dangerous drug interaction.
3. Elimination of drugs to which you may be allergic.
4. Drug by drug review of potential side effects you may be experiencing.
5. Addition of drugs provided by another doctor that your primary physician did not know you were taking.

You can become a more active participant in your own health care by assisting, or initiating, the process of medication reconciliation and making sure it happens with every visit to your doctor. 

Your comments or opinions are always welcome.

What can patients expect after Health Reform?

Big changes are on the horizon for the health care system. Physicians are going to be paid increasingly on the basis of outcomes of care, as well as effectively managing their practice population as a group; for example for all of the patients in my practice with diabetes, what is the average blood sugar of the group and, thus, how good a job am I doing "controlling" the disease state "Diabetes" in our practice?  Less and less can physicians expect to be paid for doing more tests, ordering more x rays and CT scans, and seeing patients in the office more often.  Instead, we will have greater incentives to be available to our patients, to work more effectively as a health care team, to communicate with patients about their test results outside of office visits, and to encourage patients to contact us via e mails, text messages, or online video tools.

These changes will provide major challenges to all of us, and will pose requirements for changes not only for the health care team, but also for the patients.  Below are the 5 things that I believe will be significant changes from the patient's perspective, and will gradually assume a greater presence in physicians practices over the next two to five years:

1. Patients will not need to visit the doctor's office as often.
As primary care practices begin to function as Patient Centered Medical Homes, they will be paid through outcome incentives and on a "per patient per month" basis rather than fee-for-service, making it more desirable to do things in ways other than using the relatively inefficient doctor visit approach.  Followups will occur via e visits and online portals (see below) will allow transmittal and review of data such as glucose and blood pressure monitoring in order to make decisions about the management of chronic disease.

2. Prescriptions will be routinely refilled, and many new prescriptions provided, using e mail or text messaging.
For established patients, there will rarely be a need to come to the office for a prescription refill; rather, using e mail and electronic prescribing, this relatively mundane, administrative aspect of practice will become much more efficient for both doctor and patient.

3. Patients will be challenged to put increased emphasis on preventive practices.
Rewards will be provided to providers for practices that obtain high levels of immunizations, recommended exams, mammograms, cholesterol checks, etc.  This will result in much more focus on preventive practice by your physicians.

4. Interaction with physicians offices will increasingly be through online electronic portals that are connected to the electronic medical record.
One of the primary reasons this method has not taken hold sooner is the lack of payment for it, forcing providers to funnel their patients into office visits in order to make a living themselves.  With the reform methods in the works, these perverse incentives will begin to disappear and the doctor patient relationship will be freed up to be what it should be, with free flowing communication independent of financial constraints.

5. Patients will be increasingly recognized as the drivers of their own health care.
The Participatory Medicine movement challenges patients to recognize that they, not providers, are the drivers of their own health, and to take control of this through acquisition and monitoring of their own health data and by obtaining the information they need to become, and stay healthy.

These are major changes that will not come overnight, but in order for the health care system to avoid bankrupting the country, and to begin to eliminate the billions of dollars spent on medically unnecessary care, they are sorely needed.

Your comments, questions and dissenting opinions are always welcome.

Working Together to Create an Affordable Health System

As we approach the presidential election next week, health reform is front and center as a key issue for the US. Entitlement programs, liability concerns by professionals, broad insurance coverage plans, and patient requests for expensive care have put the country on an unsustainable course that threatens us financially.

Many of the ideas for health reform, including encouraging more comprehensive primary care through patient centered medical homes, bundling payments to providers, and reclaiming money paid to hospitals for unsatisfactory outcomes are nibbling at the edges of what needs to be done.

But I can envision a radically different system from the one we currently have, one that centers on effective partnerships between professionals and patients in which the focus is on the issues that are truly necessary and really make a difference.

Here listed is a few of these:

• A commitment to nutritional balance and appropriate calorie consumption
• Regular exercise
• Avoidance of smoking
• Moderation of alcohol consumption
• Regular preventive visits to the doctor, using published guidelines for testing
• Commitment to careful control of blood glucose for diabetics
• Patient commitment to blood pressure measurement and adjustments necessary to achieve control.

Finding a physician who will lower the barriers to care, communicate easily and effectively with you to help you answer your questions, and provide guidance as needed is another crucial step in the effective, efficient health care system of the future.  

There is currently a growing shortage of primary care physicians, especially those who are open, innovative, and willing to maintain these types of patient relationships.  An essential part of the effective health reform of the future will require addressing the need to train these additional primary care physicians.  

Far too much effort, attention, and money is currently being spent on unproven or ineffective strategies and far too little is directed towards the outcomes in the bulleted list noted above.  Hopefully, this discrepancy will begin to be increasingly noticed and will start to be addressed.  

The answers to our un-affordable health care lies not in personalized medicine and ever more expensive procedures but in focusing on the basics of health and building a system around keeping Americans adherent to those principles.

Your comments or dissenting opinions are always welcome.

Phone service expands eDoc's Reach

One of the limitations to eDoc's information services is that one has to have a computer linked to the internet. This, of course, is not always possible. So, if you're away from your computer, don't have a link to the internet, or may simply not have internet access at all or may not even own a computer, you can communicate with us by telephone.

Since our service is "asynchronous", meaning provider and client are not connected in real time, we do this by using a unique telephone interface that records your message and transmits it to the eDoc providers in a voice file that we can open and listen to at our computers. We then can type an answer to your question and our system calls you back and "reads" our answer over the phone. It has a little bit of a "robot" sound, since the text to voice technology is not actually a human talking.

I encourage you to put the phone number in your directory and, the next time you need to ask us a question, but aren't close to your computer, give this new technology and try. Then, let us know how you like it or how well it worked for you.

By using technology the folks at eDoc are trying to improve your health, and the health care system, by making it easy and convenient to get the answers you need, from reliable professionals, at the time you them them.

Thanks for using eDocAmerica.