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EPtalk by Dr. Jayne 12/10/15

December 10, 2015 Dr. Jayne 2 Comments

A couple of reader comments on my piece about employer wellness programs caught my attention. I have to thank Al Lewis, who provided my laugh of the day when he asserted that, “There is no adult supervision in this field, so vendors can do things that doctors would get sued for doing.” He goes on to call out a vendor who provides carotid artery disease screening even though the US Preventive Services Task Force (USPSTF) specifically recommends against screening the general adult population. I didn’t know this was creeping its way into employee wellness programs, so thanks for the warning.

I have, however, seen mass carotid artery disease screening in a promotional offering for senior citizens that I can only describe as predatory. For an upfront cash fee, it touts the benefits of multiple “screening” tests that aren’t recommended. In addition to the carotid artery test, it also offers abdominal ultrasound screening (only recommended for men aged 65 to 75 who have ever smoked, and selectively recommended for men in this age group who have never been smokers). It also offers screening for peripheral arterial disease via an ankle brachial index (insufficient evidence to assess) as well as multiple blood tests that aren’t necessarily recommended for average-risk individuals.

When looking at the flyer and the number of tests offered, it may be easy for some to come to the conclusion that it’s a good deal based on the sheer volume of diseases they talk about. However, no test is without risk and just getting them because they’re cheap and available is a bad idea. Although we did tend to “shotgun” batteries of tests on our hospitalized patients when I was in medical school, by the time I reached residency training, the focus had shifted to doing fewer tests and only those that were evidence-based. That was good, because I can’t even count how many wild goose chases we went on due to abnormal labs that should never have been ordered in the first place.

The worst wild goose chase of my career still haunts me and I wonder if a different attitude (and better interoperability) would have prevented it. The patient was a delightful lady with significant and complex medical problems who had been my patient for three years during my residency. When I decided to stay in town and open a practice, she asked if she could follow me. Although I said yes, I cautioned her that there would be a two-week period between when I graduated from the training program and when I hung out my shingle when I would have no malpractice insurance and could not be her doctor. I advised her to remain with the residency clinic for continuity until my doors were open.

Unfortunately, one week into the gap (while I was cramming for my board exam) I received a call from the emergency department of my “new” hospital where the patient’s caretaker had taken her, not realizing I could not yet care for her. She was admitted and placed in the care of a hospitalist and three specialists who were working up her problems, unaware that they had been worked up thoroughly in the past. Because the patient was non-verbal, her ability to consent to the evaluation was limited. She had abdominal pain and her exam was challenging due to her other conditions, so someone ordered a cancer antigen test, which was positive. They didn’t realize it had been positive for some time with a completely negative workup and a previous informed consent decision to stop pursuing it.

I attempted to reason with one of the house doctors, begging them to request the chart from the residency program so they could provide good care. Unfortunately the goose chase persisted and the patient remained hospitalized, developing a life-threatening problem with her platelet function. This was in part due to the blood thinner injections she was given in the hospital to prevent blood clots due to her immobility. Oddly enough, the patient has been immobile for the better part of 50 years and survived without blood thinners, but the doctors were just following the hospital protocol for giving heparin to immobile patients.

The cancer workup was completely repeated, including several invasive procedures. By the time I assumed care of her barely a week later, she had suffered multiple complications, including a heart attack, and was being considered for bypass surgery.

Thank goodness I was able to corral things before that happened because the patient and I had previously discussed her surgical prospects and she had clearly indicated that she didn’t want anything like that done. I realized that for most of the hospitalization, she had been without the computer she uses to communicate with people (she has mobility of one hand and creates computer-generated speech using it) and probably hadn’t consented to most of what she had been through.

At that point, my goal was just to get her out of the ICU, and then out of the step-down, and then to the regular floors, and then home – one day at a time. Eventually we accomplished all of those and she did well despite the “care” she received. Even years later, just thinking about this scenario wants to make me track down whoever ordered that initial (inappropriate) blood test and give them a good talking-to. Whenever one of my students or supervisees orders an unnecessary test, they hear this story. I hope it sinks in.

Another comment was from John Lynn, who asks that if a patient showed up in my office and said they were healthy and wanted to stay healthy, what would I do? I agree with him that some doctors would offer a physical and try to find something wrong. However, many physicians (especially those trained in family medicine and other primary care specialties in the last two decades) would know exactly what to do. We’re well trained in health promotion and disease prevention, but many of us don’t get to use those skills often enough. My personal recipe includes the following:

  • Find out if the patient has any concerns about their health, even if they think they’re generally healthy. Those concerns should be addressed through additional history and a targeted exam and a specific workup if warranted.
  • Take a detailed family history to review the patient’s risk factors and discuss ways to mitigate those risks or avoid developing additional risk factors.
  • Discuss general health behaviors (diet, exercise, tobacco, alcohol, caffeine, sexual behaviors, seat belt use, etc.) and advise accordingly in line with current evidence. Refer to appropriate resources as needed (nutritionist, smoking cessation, psychology, social work, etc.)
  • Assess psychosocial and other determinants of health as needed (social supports, financial ability to get care if needed, etc.)
  • Targeted physical exam as recommended for evidence-based screenings and to establish a baseline rather than “looking for” something.
  • Recommendation for additional screening tests and preventive services as appropriate based on evidence-based recommendations. This may include in-office services such as vaccines or external testing such as mammograms, colonoscopies, etc.

There are more things involved, but you get the idea. It’s about the doctor and the patient sitting down and talking about things. Which in our system doesn’t get you paid very well, and because of that, we don’t have anywhere near the time we need to do it right.

Add in the fact that patients often have to change doctors every year or two due to insurance changes and it’s hard to develop the rapport needed to work together on some of the more challenging situations that come up when you actually talk to people and get to know them. I’d love to be able to have a solid hour with patients to do a wellness visit and to leverage proven techniques such as motivational interviewing, but that’s just not how it works.

In my ideal world, I’d not only have the time to do it right, but the resources – access to other clinical professionals as needed (psychologist, social work, nutritionist, health coach, etc.) at times that work for the patient so they don’t have to take off work. I’d also like to see these preventive services fully covered by insurance. Although the Affordable Care Act mandates coverage for preventive services recommended by the USPSTF, patients on so-called “grandfathered” plans may still not have coverage. Until recently, I was on one of these plans so know exactly what is involved.

I’d love to see all preventive services fully covered. Not only because it’s the right thing to do, but also because they have been proven to be cost effective. I remember the first time I realized that Medicare wouldn’t pay for blood sugar monitoring supplies for certain diabetic patients but they would pay for amputations. I was appalled.

If that ideal world existed, I’d likely still be a primary care physician rather than a mercenary CMIO and part-time emergency doc and blogger. It’s something for the politicians and pundits to think about when they talk about the shortage of primary care physicians and wanting to bend the cost curve. But unfortunately, I don’t think it’s anything I’m going to see in my lifetime.

What’s your ideal care paradigm? Email me.

Email Dr. Jayne.

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Currently there are "2 comments" on this Article:

  1. Believe it or not, I am almost moved to tears as I read this one. Three items in particular if I may “share.”

    First, I have fought many a battle over years of doing locum tenens in areas where there had been no local primary care for as long as years. Civic clubs had those mercenary screeners in as fund raisers and the local community health center had piles of abnormals just waiting for an MD to sort through. Invariably the local Jaycees or Elks Club did not cotton to an out of towner trying to point out they had really not helped people. I also had those folks who now wanted me to order the more dangerous followup work for low ap priori screenings and even more tediously explain that they did not have that long list of problems the pitch implied. As the years passed and experience accumulated with this situation, it also got harder and harder to explain that beyond the problems with more testing, the worried patients failed to grasp the impact of hours on the phone trying to get preauth from their insurance companies while the rest of the town just needed their chronic illnesses managed, young families needed family planning services, the depressed needed something more than cognitive care from undertrained clergy or guidance counselors and children needed immunizations, well-child care or a doc to figure out why they were failing to thrive or do well in first grade.

    Second, long before it was fashionable, I got an MBA with a concentration in IT, figuring just a few robust computer networks and open sharing of records could save money and avoid the debacles that you had with that loyal averbal patient–quite a stoory and far more common than not. I was so naive. We are still telling patients they have to “hand carry” their X-rays to the orthopod. Thanks goodness at least for cheap and convenient digital media, but if only we could get the ortho offices to contact the radiologist who got paid for the films and not the primary care doc!

    Third, and the tear kick starter, was your final comment, “If that ideal world existed, I’d likely still be a primary care physician rather than “. In my case playing out the few years left trying to maximize the value of board certification and licensure to fully fund a retirement where I can go off and do other mensch-like things to satisfy the urge to do good. FP or any other primary care physician role especially in the employ of one or the other hospital owned “systems” in the regional olipology just doesn’t seem worth it.

    Thanks for all your columns, but this is my nominee for Best of ’15 with just a few days left!

  2. Kevin,
    Thanks for your comments. Although it can be somewhat depressing at times, it’s validating to hear from others in the trenches who are sharing the same “Groundhog Day” type stories. May the New Year bring you closer to your goals (and not just in the calendar way!)


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