Sunday, May 27, 2012

Better Patient Satisfaction – Which Model to Follow?

Patient satisfaction is an important element of medical care. It was always important, but it has taken on a new significance since hospitals and physicians will be graded on their bedside manners. And, these grades count for cash. Money motivates. Who believes that a leopard can’t change its spots? Throw a leopard into the pay-for -performance arena, define spots as inferior quality, and watch what happens. We would all witness a Darwinian tour de force as leopards would become spotless in just a few generations.

Recently, I was exposed to 2 models of customer service. First, I endured the experience of setting up cable service for TV and wireless internet. Sounds easy, but I would not advise this task for anyone who has a heart condition. What should have been easily accomplished in one phone call took multiple calls to screw it all up. Of course, every single call ‘was important to them’ and required a generous amount of waiting time for me. With one exception, every customer service agent I reached was located in another continent. I am not railing against outsourcing here. Companies make products and hire workers abroad because it is in their economic interest to do so. However, since my specific and simple question was best answered by one of their local folks in Cleveland, none of the reps in India or the Philippines could answer it.

Try also explaining to them that it is hard for a working person to be home to greet the local installer when you are not given a specific time of their arrival.

I can’t wait when I need to contact these guys when the system is malfunctioning. I don’t yet have coronary disease, but I might pop a nitro under the tongue then just in case. The headache the pill might give me will nothing compared to the throbbing migraine the phone calls will cause.

In addition, different reps offered entirely different advice, which I think were total guesses. This is always fun for the customer. See excerpt below.

     Rep #1: I recommend that you do this

     Rep #2: I recommend that you do not do this.

     Rep #3: I recommend that you contact Rep #4.

I tried to beg or bribe them for a local Cleveland phone number to contact, but this classified information was on a ‘need to know basis’, and my need to know didn’t cross the threshold.

And then, there’s the Apple Store. My beloved iPhone unexpectedly suffered a cardiac arrest, a total meltdown without warning. Cruised over to Apple and was immediately greeted by an affable rep who actually seemed to care about my misfortune. I was siphoned over to another rep who in a few minutes recognized that my iPhone’s soul had already ascended to heaven and would no longer enjoy an earthly existence. He provided me immediately with a new device and waited by my side until he could verify that it was operational. I’ve been to this store on other occasions and am always impressed with the courtesy, efficiency and competence that their outstanding staff show to their customers. It reminds every time me how inadequate and undervalued customer service is in the marketplace.

Is Apple simply doing what all companies should do, or is this standard unreasonable? Do other companies make it tough on us on purpose to discourage us from complaining or asking for refunds or rebates? How many gazillions of dollars to insurance companies reap because we simply give up seeking relatively small amounts of money that we believe we are entitled to?

Which model of customer service do we physicians use with our own patients? Do we emulate the airline industry? Or, do we look to a group of young and energetic geeky types for guidance?

Remember the adage, an apple a day keeps the doctor away? I suggest that we doctors keep an apple on our desk to remind us why we come to work.

If you are inclined, leave a comment below. I assure you that ‘your comment is important to us.’  You comment may be monitored for quality assurance.

Sunday, May 20, 2012

Pharmaceutical Gifts Corrupt Doctors: A Physician Confesses

I write now in a moment of introspection wondering if I am a corrupt doctor. Why would I even consider that my integrity is in question? I am not on the payroll of any pharmaceutical company. I am not paid to speak to physicians or the public about the latest medical breakthrough for flatulence. I submit squeaky clean billings to Medicare and insurance companies. I do not order medical procedures on patients for personal gain.

My failing, if it truly exists, is an example of the power of the pen. In our office, many of the pens floating around are labeled with the name of a new drug. I assume that these evil instruments are left by pharmaceutical representatives, but I never actually see them make the drop. They are the ‘Adam and Eve’ of medical practices; they are fruitful and they multiply. These pens over time have mutated, like bacteria and viruses, and can now exist in a variety of harsh environments. For example, when I am in a restaurant about to sign my credit card bill, the sly server hands me a Nexium pen. Is he a doctor, I wonder? Is he part of the nefarious Nexium network? What’s next? Will we see President Obama signing important health care legislation with Viagra pens, which he will then present to the legislators who spearheaded the bill? How can this plague be ‘penned’ in?

No, I am not overworked or overreacting. Last year, a new set of pharmaceutical industry guidelines, agreed to by 40 companies, was enacted. These companies, aiming to elevate their ethical behavior, have sworn an oath to never distribute any pen labeled with one of their products. As if this draconian ban were not sufficient, labeled coffee mugs and staplers will also be strictly prohibited. These measures are supposed to make physicians more ethical since we will be now free from the hypnotizing effects of all of the labeled kitsch in our offices. This must mean that up to now that I have been an unwitting tool of pens, pads and post-it notes that have induced me to prescribe their medicines to my patients.

Soon, I expect the pen police to start patrolling doctors’ offices. When they arrive for their unannounced inspections, I’ll demand to examine their clipboards to verify that they are unlabeled and conform to the highest ethical standards. When they ask me to sign an attestation that my office is clean, I’ll pretend to search my pockets and then will ask the inspector to borrow a pen. You can bet I’ll be examining it quite closely.

Sunday, May 13, 2012

Informed Consent: The Right to Refuse Medical Treatment

There are some patients we doctors never forget. They linger in our memories for various reasons. Often, it is their serious or unusual medical condition that stays with us. On other occasions, it is a zany or unique personality that we recall, even years later. Rarely, when the doctor-patient relationship becomes injured, then the patient may become unforgettable.

I remember a particular patient from 20 years ago for a very different reason. I recall him clearly because he rejected my medical advice to him with aplomb. Although I haven’t seen him for two decades, I will never forget him. He taught me a lesson, which is not surprising since patients are our best teachers. There are no CME credits for these lessons, but I’ve learned more from them than I have at many medical conferences or from medical journals.

It was July 1991, a month after I completed my fellowship in gastroenterology. I had jointed a multispecialty group, and I was the only gastroenterologist in this particular site of the clinic. There was no senior gastroenterologist to supervise me. What a comfort it was during fellowship training to have seasoned clinicians nod affirmatively to my diagnostic plan, or point out what I overlooked. To this day, I wish I had one of these master clinicians sitting quietly in the back corner of my exam rooms to mentor me. In July 1991, I was now responsible for my own advice. Despite excellent training, I was anxious that it was my finger on the trigger.

I performed a screening colonoscopy on this man and discovered a large, flat lesion in the upper part of the large intestine. A biopsy indicated that this was a pre-cancerous polyp, although it was possible that there was cancer present that was not sampled by my biopsy instrument. (Biopsies only obtain tiny pieces of tissue, which may not be representative of the entire lesion. Physicians call this phenomenon sampling error.)

This concerning lesion could not be removed with the scope, so I recommended that he consult with a surgeon to discuss an operation. He listened and calmly declined my advice. More accurately, he offered a conditional decline. He stated that he would see the surgeon, but not until 4 months had passed. This was unexpected as most patients want their surgeries to occur yesterday. The patient made clear that there was no earthly force that would alter his decision. This mystery entered the theater of the absurd when I learned his reason for the delay. Here are some choices. Take your best guess.

  • He and his family were about to leave on a 4 month cruise.
  • November was his lucky month and he wanted surgery then.
  • It was golf season, which was sacred.
  • His medical insurance coverage would become active November 1st.
  • He intended to travel to Mexico for alternative medical care.
I surmise that most readers did not select the correct answer. This man was a golf fanatic, and even the possibility that he harbored a colon cancer, would not coax him off the fairways. Interesting priorities. We physicians need to remind ourselves that patients make the decisions, even though we often believe that we have the right answers.

The denouement? Months later, he underwent surgery and a large benign lesion was removed. I think I was more relieved than he was.
If this guy’s appendix or gallbladder were to go bad, I hope it happens during wintertime. Surgery can occur in any season. But, golf…

Sunday, May 6, 2012

Reglan and Tardive Dyskinesia: Medical Malpractice or Guilt by Association?

There was phone message on my desk to call a lawyer. I had no idea what he was seeking, but knew that I couldn’t be a target since plaintiff attorneys do not personally contact their victims to make a introduction. I had no idea if his inquiry even pertained to a medical malpractice issue. Perhaps, he was cold calling to convince me that his estate planning skills could enrich the next several generations of Whistleblowers. Maybe he was going to notify me about a huge inheritance. Could it be that he wanted a screening colonoscopy for himself ASAP, and threw out his lawyer title to assure he would get a prompt call back? I then drifted into a reverie where lawyers were lined up outside my office all waiting for me to perform colonoscopies on them.

I returned the call and he asked if I would help in the defense of an internist who is being sued for medical malpractice. Years ago, this physician prescribed Reglan, an anti-nausea medicine, to a patient who subsequently developed tardive dyskinesia, an irreversible neurologic disorder that has a well-known association with the drug. I recall learning about this association when I was in medical school during the late Pleistocene Era. Although this adverse reaction is old news, the FDA has recently mandated a ‘black box’ warning of this complication on the drug’s product information material. Individuals with tardive dyskinesia suffer from involuntary and continuous oral, facial and bodily movements. It’s an awful condition.

Readers should keep in mind that an associated reaction is not proof of causation. It is a much weaker connection, which is not always grasped by the public or the press. Association means there is no proof, only vague suspicion. Yet, as drug companies know, an association can sink a drug.

Reglan is primarily prescribed to treat nausea or to strengthen lazy stomachs that do not empty food properly into the small intestine. I have prescribed it very rarely, not from fear of side-effects, but because the drug is not very effective. In addition, even when the drug does work, it tends to lose its efficacy over time, a phenomenon that we physicians call tachyphylaxis.

I do not know the facts of this particular case. Before making a judgment if the community standard was breached, I would need to know specific clinical details.

  • Was Reglan the best option for the patient’s clinical circumstance?
  • What were the existing therapeutic alternatives?
  • Was standard dosing utilized?
  • Did the patient taking the drug as prescribed?
  • How long was the patient on Reglan?
  • Did the patient follow-up with the physician as instructed?
  • Was the patient aware of the risks and benefits of the drug?
  • Was the diagnosis of tardive dyskinesia in dispute?
  • Could there be another cause of tardive dyskinesia besides Reglan?
We did not discuss any of the relevant clinical information. I declined to participate in the case. Primarily, I did not want to invest the time that this effort would require. Moreover, agreeing to serve as an expert would mean that I would have to be available for depositions and trial. These latter entertaining activities can burn up hours and days of a physician’s time. Patient appointments would have to be cleared, perhaps for days. In the event that a trial would be necessary, how do I know how many days of my office schedule to cancel? Trial lengths are unpredictable, and delays and recesses are part of the process.

I also would not relish the opportunity of being interrogated in a deposition by opposing counsel. In a depo, unlike trial, any question is fair game. The attorney might very well have become an expert on Reglan, being able to ask me about published articles that I am not familiar with, but that he can quote authoritatively. If readers are wondering why I might not know about these publications, it is because specialists and primary care physicians have to read so broadly on their specialty, that we cannot have deep vertical knowledge of every medical topic. It is easy for a lay person, however, to develop command of a narrow niche. Capable pharmacy representatives illustrate this phenomenon well.

While I would like to think that I could keep my cool, the attorney has an edge in this duel. Not only might he have deep knowledge of a narrow medical issue, but he is a professional interrogator. This is not a casual conversation. Questions in depositions are asked for specific reasons. While I won’t use the term ‘set up’, questions are asked early in the depo to get the witness on the record. Then, an hour later, or at trial, the attorney may try to ask how those answers can be reconciled with contradictory information you later provided. If you are not accustomed to navigating across a treacherous legal minefield, then it is clear who has the advantage here.

It is an easy task to make any witness uncomfortable. Any of us could do this. If we were questioning an honorable physician, politician, businessman or priest, we could change the subject matter and ask insinuating questions that no ordinary and decent individual would welcome.

I concluded the conversation by telling the attorney that I would be pleased to review the record and offer an informal opinion on the strengths and weaknesses of the case, but I would not do so under oath. For me, there’s a Black Box warning against diving into the medical malpractice arena.