Dr. Social Media, MD: suggestions for practice integration

If social media were integrated into my practice: a wish list.

1. Patients could willingly sign away bits of their confidentiality so they could participate in a conversation with other folks suffering from the same problem. "What did Dr. Berger not tell you about diabetes," they could ask each other, and I - listening in - could improve. (Or get sued, too. Malpractice reform is another discussion.)

2. There are so many issues many of my patients face together, here in Baltimore: poverty, single parenthood, substance abuse, tobacco use, food deserts, obesity, etc. Couldn't we share information and experiences, without the sterility of anonymity?

3. The Perils of Procedures: talk about your history, what tests you underwent that Dr. Berger recommended (or advised against!), and share what happened.

4. Patients could recommend specialists they have seen, medications they have taken...

5. In short, it's like wrongdiagnosis.com or the innumerable disease-discussion boards, but connected to a particular doctor and his/her environment.

Multiple diagnoses ... and multiple diagnoses

I feel certain scruples about blogging about my new workplace (Johns Hopkins) - I suppose that's a good thing. I like it, is what I'll say to start.

The patients are different. Half of them are very well educated and knowledgeable about their conditions, bringing in lists of diagnoses.

The question I try to address - well, the question I haven't addressed yet, but would like to, is: do these long lists of diagnoses serve a purpose?

I mean, there are lists and there are lists. Let's say

List 1. Diabetes, hypertension, coronary artery disease, depression, tobacco use

List 2. Cervicalgia, autonomic dysfunction, benign prostatic hyperplasia, degenerative disk disease

List 1 is more than the sum of its parts, and list 2 - not so much. Which doesn't mean the problems in list 2 are minor (every one has a right to think that their problems are not minor! why else would they come to the doctor?), just that the multiplicity of the diagnoses is less important.

"This is Dr. Berger. He is visiting Australia to see what a modern medical system looks like."

I spent the day enjoyably. I gave a talk this morning to the folks at VMA General Practice Training, one of a number of provider training centers throughout Australia. (Recently - within the past decade or so - the Australian government has decentralized the training of general practitioners, formerly under the College of General Practitioners, in order to promote competition.) I had a feeling of being at home among people like those at the primary care program I just graduated from. Now, primary care doctors in the US are (with the addition of philosophical self-consciousness and their own advocacy organization) just like internists, while their equivalent in Australia is the GP. Australia is civilized because about half their practitioners are GPs. What struck me was how little difference there seems to be, on a brief first glance, in outlook and sensibility.

Then this afternoon and evening I have been shadowing the clinicians at Parkridge Medical Centre in Melbourne. Besides the obvious differences (namely, that Australia has a "modern medical system" with universal healthcare coverage) I noted, again anecdotally, a relative reluctance to spring first for the pharmaceutical solution, something I know I did as a resident (mere weeks ago!).

Pots of money pretty please for primary care training and diversity programs!

Here's a call to action (read: e-mail petitioning) from the Society for General Internal Medicine. Unfortunately, I don't know explicit criteria for judging the stimulativeness of any given line item, but I would hope curing sick folks (some of whom work and make things!) would rank somewhere pretty high.

Later this week, a joint House-Senate conference committee will meet to reach a compromise on a massive economic stimulus bill. The House version of that bill includes $600 million for primary care health professions training, diversity and nurse education programs. This would double the current level of funding, a long needed beginning to healthcare reform.Unfortunately, the Senate version of the economic stimulus bill does not include funds for these Title VII primary care training programs.

Please contact your two senators and your representative today! Lawmakers need to be convinced that the compromise bill they send to President Obama must include $600 million to help ensure the supply of primary health care providers, namely internal medicine, family medicine, pediatricians, dentists and nurses.

"What we do in improving quality can also help us address costs"?

That's what Neera Tanden, a member of Obama's transition team, had to say in this morning's conference call organized by Doctors for Obama, which had over a thousand people listening in.* I wish it were true. 

As I expected, the focus of the call was on outreach and recruitment. Tom Daschle (Obama's pick for HHS Secretary) spent some time talking about the transition team's Change.gov and the umpteen zillion comments that have been offered up there about needed healthcare reform, all of this by way of example of the transparency Obama emphasized during the campaign. "He wants the administration to change the way people interact with their government," said Daschle, "and this is especially true when it comes to healthcare." "We have to have better transparency," he said later - "we can't understand problems until we see them effectively."

The more interesting part of the call was policy, though Daschle averred that no decisions were being made yet: "That's not the role of the transition team, we're working to prepare the president-elect about healthcare options." 

To a question about prevention: "The new paradigm has to be a recognition that prevention has to be a central feature of a new healthcare delivery mechanism. ... But there are serious problems about whether we have the infrastructure to deal with the opportunities that an attention to health and wellness can bring. There need to be more roles for nurse practitioners and physician assistants. We need to make sure we incent people to become general practitioners and family physicians." 

Daschle also talked about improving healthcare delivery ("We have 21st-century operating rooms and 19th-century administrative rooms. The solution to that is electronic medical records and health IT") and quality ("we see an extraordinary lack of best practices and quality of care implemented in procedural ways across the country"). 

To his credit, he did not make the explicit claim (as has been done by others) that improving quality, emphasizing prevention, and implementing efficient delivery of care will reduce health care costs. (I think this claim is difficult to believe.) Nira Tannen made the claim, though: "Making sure our people are healthy will lower long-term costs for everyone and in the meantime ensure that everyone is covered."

To quote Bob Laszewski of the Health Care Policy and Marketplace Blog:

Define quality for me. Then show me a system in which there won't be as many winners as losers--how else do you save 30%? Then I will show you a real health care policy debate and we will see how much consensus we have.

Wellness? Wellness programs today look an awful lot like the voluntary education oriented wellness programs we were selling in 1988 and things are far worse. Prevention? Most of the commonsense steps in prevention were available to us years ago.

We have been avoiding the heavy lifting in health care reform for 16 years. For me, all of these new ideas aren't so much new ideas as one more "Ground Hog day" in the long-running health care debate.

I believe Laszewski over Tannen, though I wish I didn't. The stronger argument for universal care (and perhaps truer to the facts) is to say that covering everyone will cost more money, at the very least in the short term, but (a) it's the right thing to do, because healthcare has become as much a public as a private good; and (b) it's a stimulus to economic growth that people who understand the economy (not me!) say is necessary in times like these.

I should say I was encouraged by the speakers' attention to workforce issues. More primary care physicians, please. But we need more fundamental (re-)thinking about changing healthcare delivery.

*All quotes paraphrased.

Right on, Max Baucus!

From today's press conference:

We need to train more primary care doctors. I heard only 2 percent of last year's doctors were primary care, because the money wasn't there. We need more medical homes, a more holistic approach to care. There must be a greater role for primary care then there is in America today, and this bill has incentives to do that.

Needed renovations, or setting the roof on fire?

Our exposure to health care policy - as part of our primary care curriculum - ran the gamut recently.

Last week we went to Washington to advocate for increased support for the primary care workforce. (In brief: we need more primary care health care providers. There aren't going to be enough of them, especially if we start covering the uninsured. We need to create incentives to help people choose to go into primary care rather than the oversubscribed and overpaid subspecialties.) We spoke to young, fresh-faced, intelligent, and hyperinformed health care staffers of some of the Capitol's most influential senators - they were genuinely friendly and happy to see us.

One senator's office is working on a creative idea left over (so they said) from Hillarycare, a "foundation" to ensure a funding stream for primary care education, training, and loan repayment, paid for by a tax on insurance companies. Of course, no one in the room disagreed with that. Everyone realizes that primary care training needs to be dissociated from the current system, private insurance companies and hospitals included. (Our very friendly lobbyist, paid for by NYU Medical Center and along with us to make sure we didn't say anything stupid, was not very excited to hear about this idea.)

This week (thanks to a colleague of mine, whose father is a fundraiser for the senator in question) we went to the office of the junior senator from New York. We spoke to her for fifteen minutes about the necessity to improve funding for the primary care workforce - she was impressively informed, realistic about the political obstacles, and . . . oh, who am I kidding? We were giddy. We got a picture, too!

On Friday, we visited Jack Resnick, an internist (let's say it: a primary care doctor!) with a practice on Roosevelt Island. "[In Washington,] they're talking about payment reform, which is . . . pffphpht! You have to tear out the guts!" By which he means - you have to alter the incentives so as to drastically reduce hospitalization. It's an open secret that hospitals are not the best places for sick people. They breed infections, deconditioning, delirium, psychosis. Resnick's approach (and the approach of this organization) is to closely monitor the chronically ill patients in his practice, keeping the hospitals at bay by providing patients sophisticated but sensitive care at home. It's more feasible for Resnick because (a) he lives on an island; (b) he's ready to devote himself nearly 24-7 to his patients. But this, he says, is the wave of the future - money saving, intensive, personal primary care for the elderly and chronically ill, taking away money from hospitals where it's not usefully spent (or, rather, uselessly overspent).

Resnick, and the AAHCP (see the link above), are behind the Independence at Home Act, a bill introduced in September which would experiment with cash rewards for house-call physicians that trim Medicare outlays for high-cost patients with multiple chronic conditions.

[revised per comments]

Bits of work, or: Passover primary-care cleaning

Yesterday I taught a class to (better: had a discussion with) my colleagues in the Primary Care program about risk perception.

Today I gave a presentation about some ongoing research: (to what extent) do patients and the medical chart differently report the doctors' reason for their hospital admission?

You can attend the talk too!

From permanent hesitation to mature skepticism: growing doctors

During today's lecture on decision analysis:

Most of our interventions don't help patients. And isn't that a bitch.

Liking the ER

Is a guilt-inducing feeling. I shouldn't like divorcing patients' immediate complaints from their psychosocial contexts. I am in training to be a primary care physician, after all. Primary care should be a lot more than making sure someone doesn't have a heart attack or doesn't have appendicitis (or a cervical-spine fracture, or a really bad pneumonia, or shaking-raving alcohol withdrawal). It should be about treating the whole person.

And that's what the patients think, too. As we know (and our president celebrates), many people come to the ER because they don't want to, or can't, find primary care anywhere else. Thus they step in the door expecting a holistic approach to their problems, while ER docs still cling to their theoretical model of Emergency as triage and immediate treatment.

I could wax abstract here about the difference between deep medical knowledge - holism - and goaltenders' medicine - blocking the bad stuff: each of these has its place. I could connect this to bekius vs. iyun: the long-standing Jewish yin-yang between knowing a lot of Torah and delving deep into it. But there's too much at stake here hour-in and hour-out to allow abstractions. Patients are to be triaged either upstairs or out the door, and few of them (at least in Bellevue) understand how they are to have their chronic problems addressed.

I liked my first day because I felt in charge and in control (though supervised and occasionally countermanded, of course). But, on second thought, I should have tried to grab on to whatever jagged outcroppings of social context I could find in every patient's primary complaint. I should have tried to act like a primary care doctor even while doing the ER triage dance.

Medical epistemology
Or: why doctors and patients think so differently.

I gave a talk yesterday on this topic at NYU's primary care residency program. The outline (together with a bibliography) is here. More later if interest.

Informed consent
Notes for a talk

Mr. C. is a 55-year-old Spanish speaking man with abdominal pain that has migrated from the epigastrium to the right lower quadrant of the abdomen. You are asked to “consent” him for a CT scan of the abdomen. Your Spanish is good enough to talk to him, but Mr. C. does not ask any questions, even when you repeatedly press him on the matter. He keeps saying, “Whatever you say, doctor.”

More here.