Sunday, April 28, 2019

End of Life and the Medical Profession

Physicians and nurses deal with the deepest issues of the human condition – life and death.  Our profession brings new life into the world and does our best to bring comfort and peace at the journey’s end.  It is a profound and emotional experience for medical professionals to be with a patient and family when life ends.

There are other professions who routinely confront loss of life.  Law enforcement personnel, paramedics, firefighters and soldiers all are exposed to events that most of us would never wish to experience.

The medical profession and society is struggling to preserve our humanity in a 'cut & paste' world where one's worth is determined by the quantity of twitter followers.  

Hugging a child.  There's no 'app' for this.

On my very first day of medical internship in Pittsburgh, I was called by a nurse to pronounce a patient dead.   I had never seen the patient before.  The only deceased individual that I had any close contact with was the cadaver we studied in medical school.  I entered the room and did not know what I was supposed to do, never have been given any training or guidance on this responsibility.  I learned an important lesson then.  New interns know nothing.  Experienced nurses know a lot.  Ask for their help.  An arrogant intern will be permitted to sink.  The humble intern will be rescued.

This was an elderly patient from a nursing home and this outcome was anticipated.  The nurse patiently guided me through the requisite steps.  I performed this function multiple times throughout my internship and residency, but the only actual memory of these events is with that first patient on my very first day.  It imprinted upon me, much as the first day that I was introduced to the cadaver as a first year medical student in anatomy class. 

Being present with patients and families at profound moments is a privilege and a responsibility.  As we are all suffocating from dehumanizing technology in every sphere of our lives, there are experiences still that cry out for our humanity.   If you or someone you loved was facing difficult medical choices, who would you want in the room with you?  A physician, who might deliver wisdom and compassion or Alexa?

Sunday, April 21, 2019

Musings on Religion

There is a confluence this weekend of holy days from two venerable monotheistic religions.  Today is Easter, which represents the anniversary of the resurrection of Jesus Christ, a foundational theological principle of Christianity.   Christians await the Second Coming, when they believe that Jesus will return to establish a world of peace and justice.

Passover, which began on Friday evening, celebrates the iconic and gripping tale, chronicled in the Book of Exodus, of the emancipation and liberation of the Jews who were enslaved under a cruel Egyptian regime.  The yearning for freedom and resistance against tyranny carefully documented in the Torah, is truly a universal template that is relevant to this very day. 

Jews Crossing the Red Sea Leaving Bondage Behind

The religions are so deeply intertwined.  While I am neither a Christian nor a scholar, I have taken some effort to study the New Testament so that I might gain some understanding of this ‘offshoot’ of my own religion.   Indeed, true scholars of Christianity teach that it is not possible to understand Christianity without having a deep understanding of Judaism.  When one considers that Jesus, his disciples, the pharisees, the priests and other figures highlighted in the New Testament were all Jews, it is obvious that understanding their birth religion is a prerequisite to understanding how and why Christianity developed and thrived. 

Consider some fascinating queries.  Did Jesus eat matzoh on the Passover?  Was the Last Supper a Passover meal?

I am not na├»ve and am well aware of the deep hostility that Jews have suffered from Christians both centuries ago and in recent times.   There has been a rapprochement, but the work is not finished.  And, my own house is not yet in order.    Many Jews and others are troubled by the principles and actions of the current Israeli government.  I presume these leaders, like Jews throughout the world, were at Passover meals, called Seders, this weekend, when they read about the plight of their subjugated ancestors. Did the ancient Exodus narrative offer them any perspective on current events?  In our own country, ignorance and prejudice against Islam has been used for malign purposes.

Many believe that religion has caused far more harm than good for humanity.  As we gaze around the world today, their argument is very plausible.  Where do we go from here?   Who will reach across rather than turn away?    Who will listen with an open mind and an open heart?  

Must we all wait for an apocalypse, described in Revelation, or a series of catastrophic plagues, as appeared in Exodus, for a peaceful world to emerge?   Is there anything we can do now?

Sunday, April 14, 2019

Step Therapy - Pharmacy Benefit Managers are at it again!

Among the many tools that insurance companies wield to save money is a technique called ‘step therapy’.  This is a technique that exasperates patients and physicians.  Here’s how it works. 
A patients comes to his doctor with a medical issue.  The doctor, who presumably has a decent measure of medical training, experience and judgment, decides to prescribe a medication, in an effort to ameliorate the patient’s distress.  Let us call this magic elixir Pill A.  The doctor zaps this prescription to the pharmacy at the speed of light using the ever trustworthy electronic medical record.  The satisfied patient leaves with the mistaken impression that his cure is just around the corner.

Here’s where the fun begins.  Of course, the patient may receive the typical denial as Pill A is not on the formulary.  Keep in mind that an insurance company’s denial doesn’t mean the patient can’t fill the prescription.  Insurance companies would never interfere with a physician’s medical judgment.  The patient is still free to take the prescribed drug.  The fact that it costs $2,200 per month is but a trifle.   If Pill A costs a fortune and the insurance company’s alternative Pill B is cheap, then can we really argue that insurance companies are not practicing medicine?

Physicians in Asylum Driven Mad by Step Therapy

In the above example, usually Pill A and Pill B are medically equivalent, so the cheaper drug delivers the same benefit.  Sometimes, however, the doctor’s preference is medically superior.  Either way, the process burns up hundreds of hours per year for physicians and our staffs. 

Step therapy is when Pill A is denied because the doctor has not tried different types of medication first, which are not equivalent and are often inferior.  In order to get Pill A to be covered, the doctor must demonstrate that he has tried other medications first, and that they were not effective.  So, under this genius system, a patient receives drugs that cost money and likely won’t work.  After enduring this experiment, the  insurance company may ultimately cover the medicine that should have been prescribed in the first place.  Usually such approval is for a limited time guaranteeing that the physician can look forward to a sequel in the near term.  

Imagine if a patient suffered a serious side-effect from one of the step therapy drugs that the doctor knew was a waste of time.

I’ve argued on this blog on the need to reduce overutilization and to cut costs.  A fundamental premise of this blog is that less medical care can increase medical quality.  Step therapy managed to both increase costs while it cuts quality, not an easy feat.

We need to step up and step on step therapy.

Sunday, April 7, 2019

Why I Fired Two Patients From My Practice

You're fired!  We've all heard this directive that was popularized by our current chief executive.

It is much more common for a patient to fire a physician than it is for a doctor to cut a patient loose.  Yet, I sent 2 of my patients termination letters in the month prior to my penning this post, which represents a firing surge on my part.  This has been a very rare event in my practice.  Since physicians are patient advocates by training and practice, we tend to extend leniencies to our patients, giving out 2nd and 3rd chances routinely.  But, the doctor-patient relationship is not unbreakable and both sides have responsibilities to maintain it. 

The Doctor-Patient Relationship Should be a Partnership - not a Duel.

Here are some reasons that patients have offered justifying seeking a new physician.  Keep in mind that these given reasons represent patients’ perceptions, which may not necessarily represent absolute truth.
  • Poor or absent communication.
  • Inattentive or rude staff.
  • Unreturned phone calls.
  • Habitual physician tardiness.
  • Diagnostic delay or error.
  • Dismissive attitude toward chronic medical complaints.
  • Insurance coverage change - not a true 'firing' but a common reason to change horses.
  • Suggestion that patient’s complaints stem from anxiety or depression.
  • Refusal to order requested diagnostic testing.
  • Rushed office visits.
  • Arrogance toward complimentary and alternative medicine. 
  • Unavailable timely appointments. 
Here’s why I sent two patient pink slips.

Patient 1:  I saw the patient in the office and scheduled her for diagnostic tests at our local community hospital.  This appointment time requires a commitment from me, the endoscopy department and the anesthesia personnel to be available at the appointed hour.  After the patient cancelled for the 3rd time, we declared ‘no mas’.

Patient 2:  He is on a medication for colitis that suppresses the immune system.  This requires that he periodically check in with me for office visits and laboratory studies.  He missed his appointment and was due for his blood tests.  We called and wrote reminding him that I needed to see him.  He declined.  I wrote him a personal letter requesting that he make an appointment or I that would need to sever him from the practice.  When we didn’t hear from him, we followed through.  

It’s challenging enough to take care of sick patients who are playing by the rules.  When a patient decides to make his own rules, and can’t be coaxed back into reasonable compliance, then the doctor-patient relationship may traverse the point of no return. 

When a patient fires a doctor or a physician dismisses a patient, there is an opportunity for reflection and growth.  Just like in the business world, a person who is fired should want to know why the action was taken so that he can learn from the experience, rather than simply blame the boss.  Conversely, an experienced manager will want to understand why an employee has given notice.   

On those occasions when a patient has left my practice, I have tried to understand if I or we fell short.  Sometimes we have and we do our best to learn from the experience.