Here’s a conversation, probably imaginary, that I might have had with my father in the last years of my grandmother’s life (she had Alzheimer’s disease):
Dad: “What should be get Grandma for Christmas?”
Me: “Well, she loves chocolate chip cookies.”
Dad: “But I need her to eat something more healthy than cookies.”
Me: “Why? If all she wants is chocolate chip cookies, let’s give her chocolate chip cookies. What the heck does she need to eat healthy for?”
While I am not condoning a diet of sugar and fat for all end-stage Alzheimer’s patients, the conversation does raise an interesting question: At what point do we quit trying to be healthy and live longer and just live? This point was eloquently addressed in the New York Times yesterday by Jason Karlawish, a professor of medicine, medical ethics and health policy at the University of Pennsylvania. http://www.nytimes.com/2014/09/21/opinion/sunday/too-young-to-die-too-old-to-worry.html?ref=health. Here is a quote:
“Aging in the 21st century is all about risk and its reduction. Insurers reward customers for regular attendance at a gym or punish them if they smoke. Physicians are warned by pharmaceutical companies that even after they have prescribed drugs to reduce their patients’ risk of heart disease, a “residual risk” remains — more drugs are often prescribed. One fitness product tagline captures the zeitgeist: ‘Your health account is your wealth account! Long live living long!’ But when is it time to stop saving and spend some of our principal? If you thought you were going to die soon, you just might light up, as well as stop taking your daily aspirin, statin and blood pressure pill. You would spend more time and money on present pleasures, like a dinner out with friends, than on future anxieties.”
The analogy of an “account” is a useful one. People who want to be responsible with their money usually try to set a little aside every month in some sort of retirement account, against the day they can stop working and start sleeping late. They are saving their money, or delaying the gratification they could have gotten by spending the money right away, so that they can be financially healthy later in life. People do this with physical health, too. They eat their vegetables, exercise, get their screening tests and take their medication as a sort of health savings account, the idea being if they are responsible now they’ll live longer and be healthier later.
But what if you work your whole life to save for retirement but never retire? Or what if you work your whole life to save for retirement but you’re too sick once you retire to do all those gratifying things you were delaying in order to have money to retire? What have you sacrificed for? In a similar vein, if you denied yourself chocolate chip cookies your whole life because they aren’t good for you and might shorten your lifespan, what good is it if you can’t cash in that sacrifice when you’re old and your lifespan is no longer amenable to shortening?
Think about this when you or an elderly loved one are spending every day in a doctor’s office waiting room. Think about that quote from “Twelve Years a Slave”, where the slave says “I don’t want to survive. I wanna live.” Personally, in my final years I expect my children to surround me lovingly with mountains of chocolate chip cookies and gallons of California Cabernet, not a doctor or pill in sight.
Meaningful Use Stage 2 is coming to a theater near you.
A brief history: in 2008-2009 two acts created the incentive program for implementation of EHR that resulted in the Meaningful Use requirements: HITECH (Health Information Technology for Economic and Clinical Health), and ARRA (American Recovery and Reinvestment Act). The idea was that doctors who billed Medicare and Medicaid could get financial incentives to help them install EHRs in their practices, but only if the EHR and the doctor both ensured CMS that the EHR had “meaningful use”, i.e, that it did what CMS wanted it to do. It was supposed to be a phased-in process, and stage 2 requirements are more stringent than stage 1.
AMA board chair Steven Stack says that the AMA “has provided ongoing input since the inception of the EHR incentive program and has urged greater flexibility to make the program more reasonable and achievable for physicians.” This is sort of true. On March 15, 2010 AMA executive vice president and CEO Michael Maves wrote a letter to then-head of Health and Human Services Kathleen Sibelius. In it he said the following:
Last year, the American Hospital Association and the American Medical Association sent a joint letter to HHS Secretary Kathleen Sebelius asking for greater flexibility in the requirements of the meaningful use program:
“We appreciate the Department of Health and Human Services’ (HHS) decision to extend Meaningful Use Stage 1 through 2014. Physicans and hospitals have made significant investments in health information technology (IT), which is evidenced by the increasing numbers of providers who are using EHRs and attesting to Meaningful Use. We also share the administration’s commitment that no providers – or the patients they serve – are left behind as we proceed to Stage 2. However, our members, and the vendors they work with, report growing concerns that the rapidly approaching start date for Stage 2 is on a trajectory that will not provide enough time or adequate flexibility for a safe and orderly transition unless certain changes are made.”
Translation: The beatings will continue until morale improves.
This year, the AMA has created a new framework for usability. At least, they’re calling it new. The rest of us have known this stuff for years. Things like this:
1. Poor EHR design gets in the way of face-to-face interaction with patients because physicians are forced to spend more time documenting required information of questionable value. Features such as pop-up reminders, cumbersome menus and poor user interfaces can make EHRs far more time consuming than paper charts. Amen.
2. Current technology often requires physicians to enter data or perform tasks that other team members should be empowered to complete. No kidding.
3. Transitioning patient care can be a challenge without full EHR interoperability and robust tracking. Yup.
4. Few EHR systems are built to accommodate physicians’ practice patterns and work flows, which vary depending on size, specialty and setting. Preach it!
5. Although physicians spend significant time navigating their EHR systems, many physicians say that the quality of the clinical narrative in paper charts is more succinct and reflective of the pertinent clinical information. A lack of context and overly structured data capture requirements, meanwhile, can make interpretation difficult. Yes.
6. Data “lock in” is a common problem. EHR systems should facilitate connected health care across care settings and enable both exporting data and properly incorporating data from other systems. The end result should be a coherent longitudinal patient record that is built from various sources and can be accessed in real time. Bring it to me Lord!
7. The meaningful use program requires physicians to use certified EHR technology, but many of these products have performed poorly in real-world practice settings. Ya think?
“Physicians believe it is a national imperative to reframe policy around the desired future capabilities of this technology and emphasize clinical care improvements as the primary focus,” says Dr. Stack. What would have been nice is if the AMA had pushed harder back in 2008 for regulations regarding usability and opposed regulation regarding meaningful use a little more.
I was recently made aware of a fantastic training video on youtube made by Dr. Richard Griffith. On the surface the subject matter, the preoperative interview, seems routine, but Dr. Griffith, after a lifetime of work as an anesthesiologist, knows the key to happiness after the novelty of propofol and trauma lines wears off. That we could all be constant companions like Dr. Griffith certainly is to his patients. Check it out here:
A good friend of mine recently started freaking out, and asked for my advice. “Help!” she says to me. “I had the MaterniT21 test and it shows the baby has Trisomy 16! What do I do?”
Uhhh… I’m not an obstetrician, and had never heard of MaterniT21. But as a general non-believer in screening tests, I was immediate skeptical. Was there really a blood test that could absolutely tell you that a fetus is abnormal? Really?
MaterniT21 is a test that is actually now 3 years old, developed by Sequenom, a San Diego-based biotech company. Other similar tests that came out after Sequenom’s include Harmony by Ariosa, Panorama by Naterna, and verifi by Illuminata/Verinata. (Sounds like new brand-name perfumes or trendy hip-hop tunes.) The test is a DNA test, which is important to understand. It examines fragments of fetal cells found in the mother’s blood. The cell fragments are from the placenta, not from the fetus. Still, DNA information is more accurate than many ultrasound findings, many of which are termed “soft” markers for chromosomal abnormalities. The company website claims a 0.2-0.3% false positive rate for Down Syndrome and other abnormalities.
Sounds awesome! Sign me up! Here are a few reasons why I won’t (or wouldn’t, since I’m three and out) be getting the MaterniT21.
1. Many patients who are offered the test don’t understand statistics. I don’t really, either, but someone on babycenter.com does: (http://community.babycenter.com/post/a32275977/clarification_about_maternit21_positivefalse_positive_results)
False positive rate = false positives/all tests. False positive rate does not equal false positives/all positives
It’s counter-intuitive especially for low-incidence cases such as Down Syndrome (DS). For example, study shows that Maternit21 has 99.8% specificity, which means 0.2% false positive rate. It also has 99.1% sensitivity, which means it can detect 99.1% of all the DS cases.
Since launch there have been about 3500 tests. I don’t know what’s the incidence of DS in the tested population but since the test is only recommended to high risk group which usually have a 1/2 to 1/200ish odds of DS, let’s assume the allover DS incidence being 1/100 for the tested population. So by definition, if the study statistics can translate into real life situation, so far the test would have identified:
# of True positve cases = 3500 x (1/100) x 99.1% = 35
# of False positive cases = 3500 x 0.2% = 7
Bottom line is: If you got a positive result from MaterniT21, there is still a 7/(7+35)=1/6 chance that it’s wrong. And that is why a positive result needs confirmation by amnio/cvs.
2. Testing freaks parents out. Mothers almost always undergo prenatal testing, usually in the form of a triple screen or quad screen, which tests for the possibility of the most common birth defects. This blood test, in combination with the woman’s age, gives a risk percentage. So when I was 39 my triple screen results plus my age put me at a 1/200 risk of having a child with one of the three abnormalities tested. You can look at this number in one of two ways: There’s a 5% risk you child has an abnormality, or there’s a 95% chance the baby is perfectly fine. In almost any other realm these would be great odds. They are great odds. But not good enough for parents. I can understand this. A 1/200 may lead to an amnio, where the risk of miscarriage is also 5%. So a parent might opt for MaterniT21 instead. This test gives you a simple “positive” or “negative”, which is worse, actually, because now a positive convinces the mother that the sky is falling. But the test is never either positive or negative. That’s why it is a screening test, not a diagnostic test.
3. The test is only effective for people at high risk. These tests quote a specificity rate, the ability to rule out those unaffected pregnancies, of 99.9%. But mothers under 30 are already at that 99.9% rate based solely on their age. So if, like my friend, you are not of advanced maternal age (AMA) defined as older than 35, and you have no other risk factors, the test tells you nothing. “High risk” is defined by Sequenom as 1) advanced maternal age, 2) personal or family history of chromosomal abnormalities, 3) positive serum test (I’m assuming that 1/200 number or greater), 4) fetal ultrasound abnormality. (Ultrasound findings themselves have a very high false positive rate. Nuchal translucency, for example, has a 5% false positive rate.) My friend had none of these.
4. Somebody is making a lot of money, and its not me. Or you. Sequenom is currently quoting $235 – $475 out-of-pocket, and some insurance programs will cover the test in some cases. Sequenom is, however, charging $2,762 dollars for the test, which somebody is paying. Now, some people say it’s worth every penny for the peace of mind. But it doesn’t guarantee peace of mind, and the peace of mind it does bring is coming to people with insurance or who can afford the out-of-pocket.
Many reading this post will say, “but Shirie, I just know I wouldn’t be able to sleep at night unless I absolutely know for sure that everything is fine, and no amount of money or testing is too much for that assurance.” To which I say “Just understand what you are signing up for. My second child had perfect scores on every imaginable test, and still ended up with a congenital abnormality. Life doesn’t give you these kinds of assurances.”
In anesthesia training, and maybe in other specialties as well, one of the first things that happens when you start your training is that you take the American Society of Anesthesiology certification boards. I don’t know if this is still true, with computerized testing, but when I was a CA-1, within the first two or three months of the first year of residency I had to sit for the boards. Of course first-year anesthesia residents aren’t taking them for certification purposes. The idea behind testing people who don’t know anything yet is, I think, to establish a baseline which can be built on every year of training, until by the last year the resident can actually answer the questions and pass the exam. I thought this was totally stupid and pointless, a waste of an otherwise beautiful summer Saturday. A recent New York Times article now has me thinking maybe it isn’t as useless as I thought.
According to Benedict Carey (http://www.nytimes.com/2014/09/07/magazine/why-flunking-exams-is-actually-a-good-thing.html?action=click&pgtype=Homepage®ion=CColumn&module=MostEmailed&version=Full&src=me&WT.nav=MostEmailed), such pretesting can improve later performance in subjects that are not previously familiar to the test-taker. Here’s Mr. Carey:
“Across a variety of experiments, psychologists have found that, in some circumstances, wrong answers on a pretest aren’t merely useless guesses. Rather, the attempts themselves change how we think about and store the information contained in the questions. On some kinds of tests, particularly multiple-choice, we benefit from answering incorrectly by, in effect, priming our brain for what’s coming later.”
Instead of being a waste of time, my guesses at the answers to the anesthesia certification exam gave me an idea of what I needed to know, eventually, and how the information might be approached. It also, frankly, gave me information about how to study for the test: do a practice test before studying. The pre-test shows me how much I really know.
Even when the subject matter is familiar testing, done correctly, can not only measure progress but be a tool for learning. Here’s an example of why this might be. I studied violin in college. It was always very easy, in my little practice room with the music there on the stand, to convince myself that I had learned a certain piece and committed it to memory. When the time came to actually “use” the information I had memorized, i.e, to perform the piece, I often had slips of memory. When it counted, I found I didn’t know as much as I thought I did, or didn’t know the piece in sufficient depth. Thus the testing, that is, the performance, taught me what I still needed to learn. Here’s Carey again:
“The problem is that we have misjudged the depth of what we know. We are duped by a misperception of “fluency,” believing that because facts or formulas or arguments are easy to remember right now, they will remain that way tomorrow or the next day. This fluency illusion is so strong that, once we feel we have some topic or assignment down, we assume that further study won’t strengthen our memory of the material. We move on, forgetting that we forget.”
This is a very important point in medical education because the focus is so often on memorization. Cramming the night before for a multiple choice test causes the test to be a measurement of feats of memorization, not true understanding. If I stand in the hallway outside the performance space frantically reviewing the transition passages of a Bach partita, my ability to play the piece from memory has much more to do with immediate recall and much less to do with any deep understanding of the chord structure and harmonic arc of the piece.
Perversely, the value of multiple choice pretesting is somewhat counterbalanced by the relative uselessness of multiple choice testing as a measure of understanding. Here’s what Terry Heick of TeachThought says (http://www.washingtonpost.com/blogs/answer-sheet/wp/2013/01/25/the-real-problem-with-multiple-choice-tests/):
“More than anything else, when a multiple-choice question is given to a student in hopes of measuring how well he or she understands something, it manufactures the illusion of right and wrong, a binary condition that ignores the endlessly fluid nature of information. It alters the tone of learning, shifting it away from a constant process of reconciling old thinking with new data, and toward something of a pitch-and-fetch scenario. One question, four answers, and only one of them is right. Just point to the right answer.”
I love it when Karen Sibert, of A Penned Point, gets mad. Her words are truth, and I don’t just say that because she’s an anesthesiologist/blogger like me. Yesterday she wrote a post about a recent article in the Wall Street Journal about doctor dissatisfaction (http://apennedpoint.com/his-diagnosis-is-right-but-the-treatment-is-all-wrong/). Read it.
One of the articles Sibert cites has to do with patient satisfaction surveys. This one, in The Atlantic, is by Richard Gunderman and relates to narcotic prescribing. And let me just say that the terms “Patient satisfaction” and “Narcotic prescribing” go together like Obama and Cheney. Here is what Gunderman says: (http://www.theatlantic.com/health/archive/2013/10/when-physicians-careers-suffer-because-they-refuse-to-prescribe-narcotics/280995/)
“Though attending more carefully to patients should strike any physician as a good idea, such perceptions are not always reliable. For one thing, a patient’s assessment of a physician visit or hospitalization can be colored by a variety of factors not under the control of either. For example, a patient frustrated by the difficulty or expense of parking may assign lower scores to every aspect of a hospitalization, including the quality of care provided by the physician. Such patient satisfaction data are playing an increasing role in a number of important healthcare decisions. For one thing, physicians can be hired, fired, promoted, and compensated based in part on their patient satisfaction scores. Increasingly, these scores also determine how hospitals are ranked and paid. The Center of Medicare and Medicaid Services has been publishing this data and has begun distributing funds to hospitals based in part on patient satisfaction.”
Last weekend I went to a wedding. My husband and I stayed at a very nice, modern hotel and as we were exiting the building we were commenting on how great the service had been. Then my husband turned to the valet and asked to have our car brought up at a certain time. The valet said “Just call us when you need it. Here’s the number.” And just like that, our whole experience of the hotel service changed. The valet should have just said “Of course, sir, we’ll take care of it.” It’s not like we were demanding special treatment. That’s the level of service we expected, based on our experience of the rest of the staff. If we had been asked to fill out a satisfaction survey, we would have had the option of degrading our opinion of the hotel based on the response of one individual (we didn’t).
Now, say a patient (i.e, hotel guest) comes to the hospital and everyone is super nice and helpful and the whole experience is great, but as she’s leaving the unit secretary is rude to her, or the guard at the entrance won’t let her husband idle at the curb, or she gets home and can’t find her cell phone charger and the lost-and-found guy is dismissive. In most cases people are able to perceive that the good overall experience overrides the one negative moment, but the negative moment is there. Now say the patient gets a short email from the hospital asking her to rate her experience. She rates a 4 instead of a 5 because of that lingering unpleasantness at the end. A month later her doctor gets a call, saying his satisfaction numbers are down, and he’s getting penalized. This is the problem with patient satisfaction surveys.
Add in now the patient who wants something specific from the system or doctor, something the system or doctor knows she can’t or shouldn’t have, or that the system cannot provide. Narcotics abusers, for instance. Or people looking for antibiotics for a cold. Or people looking for an MRI for their back pain. A doctor who refuses these requests, based on good evidence, fiscal responsibility, and clinical expertise, will have terrible patient satisfaction scores. The customer is not getting what he or she wants. The dissatisfaction of the patient has nothing to do with the level of attentiveness provided by the doctor. This is the problem with patient satisfaction surveys.
In the world of hotels, guest satisfaction surveys make sense because the whole point of the industry is service, especially at luxury hotels. In the world of medicine, the point of the industry is to make people better, keep them well, or help them die well. It is not a service. Patients cannot just demand whatever they want. This is the problem with patient satisfaction surveys.
I’m back, after an August filled with children, swimming, anniversaries and weddings. Two weekends in a row of travel and I’m glad to be home. Which reminds me of a subject I have long wanted to write about: The Medical Home.
Here is how the US Department of Health and Human Services describes The Medical Home (TMH for short): “The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.” AHRQ says that medical homes provide care that is Comprehensive, Patient-Centered, Coordinated, Accessible, and has Quality and Safety measures.
Here’s how the Patient-Centered Primary Collaborative defines TMH: “The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient’s needs.” The collaborative claims improvements in cost, utilization, population health, prevention, access to care, and patient satisfaction.
If all this sounds familiar, that’s because it is essentially a re-wording of the push to control costs by having care channeled through primary care doctors back in the early 2000’s. That initiative, widely implemented, resulted in a lot of jobs for paper pushers but not a lot of cost savings. In fact, the idea of a medical home has been around since at least 1967, especially in the field of pediatrics. I am not against the concept; the goals are all laudable. The problem is that “home” means different things to different people.
The Medical Parasite Host: If you live in a rural area, your medical home likely consists of one guy, or girl. That MD or NP does everything. That person is your home.
The Medical Grass Hut: In this home, everybody sits on the dirt floor and shares everything. This happens in poor communities where a visit to the doctor takes all day and everyone hangs out in the waiting room with their kids and grandparents, sharing two overworked doctors and a medical student. You pay with chickens or potatoes.
The Medical Motel Room: This is where you stop in for some low-quality, one-the-go health care. Like stand-alone clinics, urgent care centers, and pharmacies. It’s quick, it’s cheap, and no one knows you were there.
The Medical Project: Better than a grass hut. It still takes all day to see a doctor, but now you have bathrooms.
The Medical Apartment: Here you get your own doctor. Until your employer changes your insurance coverage. Then you move and find another doctor. It works as long as your medical problems fit in the back of a Ford Escort.
The Medical Single Family Home: Its nice, its comfortable, its stable, you’re insured. You have to drive into the city for your comprehensive, patient-centered, coordinated, accessible, quality healthcare, run by a healthcare conglomerate, but you have a car. Or know someone who does.
The Medical Mansion: You get all the care you want, when you want it. It’ll cost you, but it’s worth it because you don’t have to wait like everyone else.
The Medical Estate: The doctors come to your house. With MRI machines in trailers.
The Medical Home is a nice idea, and it works well in areas of the country where people are insured and have reliable transportation to centers that provide all the services TMH promises, that is, people in the middle. Rich people can buy their homes. Poor people either have low-quality homes provided for them or have no home at all. They drag their health problems with them from place to place, staying in motel rooms when they can, visiting the grass hut when they can’t. The ACA is trying to get everyone into at least an apartment. Even if it’s in a bad neighborhood.