The “Dreaded” Return to Medical Practice

Returning to medical practice after a 4 years hiatus can be very unnerving. The physician who took a break for whatever reason, is understandably concerned about competency, age-related deterioration (both mental and physical), finding the proper niche for success, and trying not to relive “past glories” (whatever they may have been).

The concept of dread, as applied to emergency physician experience, was imparted on me by one of co-workers many years ago whenever he had to work the Saturday night shift knowing full well potential lurking disasters awaiting him. He named this experience “Getting a “Dread-on’”.  The Dread-on could start hours or days before the next shift, but its intensity was directly proportional to the time he had been away.  If he’d been off for 5 days, or worse, vacationing for 10 days, he would “sweat bullets” (another direct quote). The change from life off-duty to being in the busy ED was just too drastic to be without psychological impact.

Wikipedia defines the existential concept of dread as“Existential angst", existential dread, anxiety, or anguish. It is a concept commonly found in the work of many existentialist thinkers and is generally held to be a negative feeling arising from the juxtaposition of freedom with responsibility. The archetypical example is the experience one may have when standing on a cliff where one simultaneously fears not only falling off, but also the possibility of acting to throw oneself off. In such a moment, existentialists say, there is conjunction of experiences. While “nothing is holding me back", nothing predetermines the choice to either throw oneself off or to stand still. Consequently, one experiences an ultimate form of freedom that can manifest as dread.

While the return to actual work by this former partner was not usually quite as dramatic as one might think, sometimes the anguish was so overpowering that he was known to say “I seriously thought about running into the oncoming headlights, on my way in tonight.”  One could only shake one’s head.

In my return, I have found that even though medical knowledge changes rapidly, basic treatment plans require little adjustment. Re-sorting of antibiotic priorities has been the biggest minor hurdle. And, not surprisingly, the largest hurdles are getting re-credentialed and learning new computer systems.

Re-credentialing is fraught with delays, form, letters, and the task of convincing everyone that the same “idiot” who was doing this 4 years ago without too much difficulty, is still quite capable of the same performance. More daunting, you also have to convince yourself. That part is a bit of a psychological battle that reminds one of the current admonition among youth: “get your life together.” Overall, be prepared for the whole process to take 90-120 days at minimum.

Technology issues are pretty much the same as they have been for the last 10 years, or worse. While healthcare software systems have generally been designed for counting, billing, and data collection, and maybe some record-keeping, provider usability is a lower priority in most systems. One copes, though.  Coping is accomplished by learning shortcuts, giving-up on trying to make it better, and being a minimalist in documentation.

The adjustment to returning to the workforce was stressful for me but practicing medicine has always been enjoyable and rewarding. If you are considering such a move, be courageous, and do not be fearful. You can do it!

Clinical Decision Support to Alleviate “Misdiagnosis”

The Institute of Medicine found that “most people will suffer from at least one wrong or delayed medical diagnosis during their lifetime, according to the latest data. Americans experience about 12 million diagnostic errors a year.”

“Conservatively, the report found that 5 percent of US adults who seek outpatient care will experience a diagnostic error. Further, such errors are thought to contribute to 10 percent of patient deaths and 17 percent of adverse events in hospitals.”

In the article Is Misdiagnosis Inevitable, the reality of misdiagnosis is discussed with potential solutions through clinical decision support from Electronic Health Records.

Unfortunately, the term misdiagnosis is misused to include everything under the sun. It neglects the concepts of over-diagnosis, over-treatment, irrelevant diagnosis, and mostly that people the majority of the time get better without treatment. “Tincture of Time” solves most problems while potential erroneous treatment plans can pose harm and drive the Medical-Industrial Complex to more and more.

Assuming that the missed diagnosis has clinical relevance (affects patients not statistics) , it would be important to reduce these errors.

Common factors causing problems are poor communication, inexperience of the various providers (providers is now generic for physicians, nurse practitioners , Physician assistants, and all other medical providers), pressure to see patients in a strict timeframe, minimizing test ordering, and finally unfortunately poor cognitive distillation of the present information by allowing acute on chronic biases to cloud judgement.

The IOM’s 1999 report said to “To Err Was Human”. Human beings probably have not evolved significantly since 1999 to fantasize that errors will not be made. The goal should be to limit critical errors by avoiding common recurrent mistakes.

The well-known ones are illegibility, allergic reaction, drug-drug interactions, lack of follow-up on abnormal tests that were ordered by someone, and systemic errors that create pressure to perform in unsafe environments. Consumerism and the public’s fantasy that everything can be figured out in 24 hours or less are also factors.

With respect to malpractice litigation, the acceptable miss rate on a patient in the United States is 0%. This cannot be achieved without endless unnecessary tests that may lead to unnecessary treatments that leave the patient in worse shape than the initial error.

One must remember that the concept of diagnosis itself derives from the diagnostic medical model:  symptoms examination/testing à diagnosis à diagnosis-based treatment.  There are inherent flaws in that model, especially as the field of potential diagnostic entities grows in its complexity and possibilities.  Consider immunotherapy for carcinomas.  There, the diagnostic possibilities have expanded exponentially because of nuances in genome delineation. Many other sub-specialties are following, each entity with its own specific therapeutic modality, and each with its own heavy price-tag.

What has (surprisingly) never been fully incorporated into the emergency medicine diagnostic model is the impact of time and extended clinical relationships.  That is, we discharge patients with a “diagnosis” which is not-uncommonly some vague re-interpretation of symptoms (e.g. “back pain,” “dizziness, vertigo”).  And the best outcome diagnostically, for us, is admission.  Why? Because, then the admitting physician is responsible for discovering the true nature of the disorder.

The next tier of outcome is arranged follow-up, in which a referral physician agrees to see the patient and continue the care as needed. A sub-tier to that is the more unreliable diagnostic plan of “return if worse” or better “return for a recheck” at a specified time. Finally there is the common discharge plan for diagnostic security:  “see your doctor if worse.” 

The experienced physician accepts that his diagnostic acumen is sometimes on, sometimes off target, and so builds a measure of time into diagnostic equation.  If done well, there is no such thing as misdiagnosis, there are potential diagnoses, there are working diagnosis, but there is no “final” diagnosis until confirmed by time and further evaluation.

What can be done to align these competing forces to allow the “lonely practitioner” to get the diagnosis right? Perhaps creating clinical decision support (CDS) tools in the Electronic Health Record through artificial intelligence (AI) may help. Effective employment of this may be a decade away, and may require buy-in from the tech industry, which seems decades ahead. As one ED physician recently said to his enterprise system that was trying to speak to him: “shut up…..you’re no Siri.” When present, good AI will hopefully function as a real-time consultant to the provider with propositions for differential diagnoses, treatment plans, legitimate warnings, notifications that the data inputted may suggest another serious diagnosis, the tests you never looked at are on page 21, and the nursing notes show major discrepancies with the provider’s input.

Bottom line, the system presently works quite well but can be significantly improved. Misdiagnosis should be a term only applied to situations that cause real harm to an actual patient, and only if the full-force of diagnostic acumen (and time) has been applied.  Accomplishing non-misdiagnosis is difficult in our current system, of course.  But thankfully most cases usually takes care of themselves. Preventive care actually may be the long term solution for serious all-to-common self-inflicted illnesses. If, that is, you can get patient buy-in.

Clicking Your Way to Burnout

The Mayo Clinic published the article Electronic medical practice environment can lead to physician burnout that “shows the use of electronic health records and computerized physician order entry leads to lower physician satisfaction and higher rates of professional burnout.”

The negative effects of decreased efficiency, massive clerical burden, and provider burnout counterbalance the positive potential for quality medical care using an Electronic Health Record. These negative forces seem obvious to any practicing provider but are generally lost on administrators, insurance companies, vendors, and governmental agencies.

Logical reasoning would indicate, however, that when providers, including nurses, are “happy,” productivity, motivation, and commitment are increased, leading to higher quality and greater safety in health care.

The authors conclude that:  "Burnout has been shown to erode quality of care, increase risk of medical errors, and lead physicians to reduce clinical work hours, suggesting that the net effect of these electronic tools on quality of care for the U.S. health care system is less clear."

What is the solution? Some have been mentioned multiple times in previous blogs. But here is a list of EHR functionalities that have great potential to impact quality of care:

1.    User-friendly, site specific, specialty specific documentation
2.    Easy navigation with intuitive, user-friendly interfaces 99.9% consistent every day, every site.
3.    Changes, should be made gradually, to avoid having to relearn the program every outing
4.    Uniform CPOE (computerized physician order entry) that is the same in every system
5.    Institution of a national database to encourage real-time interoperability
6.    Voice activated technology built-in
7.    Bringing back the “Ward Clerk” – that is, let the doc do doctoring, the nurse nursing.
8.    Decreasing the work burden-eliminate unnecessary machine time, as well as homework
9.    “Alert” controls.  Too many alerts are ineffective, become “white-noise.”
10.    Ability to see what other people are documenting without making lots of clicks
11.     Every click should be counted to help design a better interface, with minimized clicks.
12.    Keep clinical interaction IT separate from bookkeeping and billing IT.
13.    Artificial intelligence that provides an “instant second opinion.”

Hopefully, the future will brighter. Bean-counters should remember that clicks have financial and psychological costs. And the wrong click could cost thousands of beans.

The Medical Errors Debate

A recent article published in the BMJ has caused a furor in the medical community claiming that medical error is the third leading cause of death in the US.  In the article Sensationalization of Medical Errors: Breaking Down the Data In Order to Improve Patient, the author makes a careful analysis of the data used to come to these conclusions. The methodology of the data collection makes the claims of the study grossly overstated, but does deliver an important message to the medical-industrial complex. 

Wikipedia states a medical error is an error that is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

This is where the complications arise. Medical errors are and can be dangerously detrimental to certain patients but whether this is a cause and effect relationship can be very difficult to prove. Medical errors are contributory factors.

Medical errors run the gamut of poor communication, failure to diagnose in a timely manner (a complicated legal question), improper medications, not accessing the right data at the right time (a failure of interoperability of the modern Electronic Health Records, multiple intellectual and emotional biases of the providers, system errors (most common) and etc.

Whether a medical error directly cause a death, was contributory to what degree, and/or irrelevant would have to be carefully ascertained on a case by case basis. Making generalizations on death certificates where the data is frequently incorrect leads to suspect conclusions. 

The bottom line is that the medical community should take this article as a warning shot that there are significant problems in the system. Crying foul is not a solution. Moreover, the use of the word “cause” with respect to medical error is totally inappropriate.  We well know, too well, that “proximate cause” without significant other “contributory” factors, is necessary in a tort case. It is no different here.  When the disease is the underlying etiology, and the healthcare system does its best, but fails, as it naturally does now and then, what is the underlying cause?

Certainly minimizing what are termed “errors,” but should more properly be termed “imprecisions” or “flaws” is a goal to which all strive.  But as imperfect beings, subject to many flaws, a perfect medical world is not going to happen. Preventable means zero margin for the humanity under which we all labor. All we can do is our best to keep the imperfections minimized.

Fixing the present Electronic Health Record Systems to give accurate, clinically specific data would go a long way in solving some of the problems. Artificial intelligence giving specific warnings would give the provider an immediate second opinion that may help guide the proper course. Finally society has to come with grips that medical art and science is not perfect and never will be.

Where Does TeleHealth Fit In?

The authors of Telehealth Poised to Revolutionize Health-care review the present and potential trends in telemedicine- "Three trends, all linked, are currently shaping telehealth. The first is the transformation of the application of telehealth from increasing access to health care to providing convenience and eventually reducing cost. The second is the expansion of telehealth from addressing acute conditions to also addressing episodic and chronic conditions. The third is the migration of telehealth from hospitals and satellite clinics to the home and mobile devices."

 The article does an excellent job of delineating the present and potential benefit of telemedicine.

These include:
1.    Availability for underserved areas
2.    Reduction in costs
3.    24 hour service
4.    Providing specialty support in real-time
5.    Real-time ICU coverage
6.    Real-time diagnostic imaging
7.    Clinical consultation on time sensitive dilemmas like acute stroke and emergency treatment
8.    Etc.

These services will continue to expand but eventually spread to ongoing chronic care. A good example is Diabetes Treatment. It has become so complicated with multiple new medications that the average provider may not have the ability or time to coordinate the care. 

Another service will be online support groups for various conditions where the endless questions and concerns of patients can be addressed and supported.

The modern generation will want easy access to health care without the delay and time spent directly visiting a Emergency Department, Urgent Care, and or Primary Care.

Some downsides include: 

1.    Over-consumption of care.
2.    Most illnesses or problems are solved with tincture of time.
3.    Not knowing when it is important to go right to the Emergency Department because of the potential seriousness of the condition.
4.    Getting care from numerous sources without coordination
5.    Almost totally giving up on the regular Family Provider who “knows you”.

There are also legal issues (future malpractice issues), credentialing issues, lack of access to high-speed internet, and the reality that the computer cannot perfor  m life-saving measures or surgery.
Where telehealth fits in with the primary care provider, urgent care, Walmart/CVS, Dr. Google (being your own provider) and the ultimate safety net –The Emergency Department –will have to be figured out.  

“Mama Don’t Let Your Babies Grow Up To Be Doctors”

This is Waylon Jennings' and Willie Nelson's 1978 cover of "Mamas, don't let your babies grow up to be cowboys". The song, originally performed by Ed Bruce, was number 1 on the charts for four weeks in the spring of 1978 and was released on the classic duet album "Waylon & Willie".

In the famous song by Willie Nelson and Waylon Jennings, they opine about the hardships of the “cowboy life”. When asked the question of whether you would want your children or relatives to become physicians in the modern era, the answer is always “YES… but….”

Motivations for becoming a physician are multiple with multiple answers. They are generational in scope and multifactorial. These include:

1. Saving the world

2. Helping mankind

3. A means to an end.

4. Avoiding the draft and the Vietnam War

5. Family tradition

6. Economically motivated

7. Opening doors

8. Raising your social statue

9. Good at “School”

10. etc.

The modern day physician is caught in the trap of the “fantasy” of the good old days and ever-changing landscape. The physician is no longer the perceived expert of their domain but a valued cog in the big picture.

Patients still love their personal physician but want input in all aspects of their care. The paternal system of “I’m The Doctor” no longer works.

The physician is also trapped in the electronic world of endless data capture that is rarely relevant to the individual patient in front of them. Click 18 more boxes and you might get paid. 17 boxes and you get a 50% reduction. Did the patient get better? Who knows?

The modern day physician has become a corporate employee with little autonomy unless you are a dinosaur from the past and cling to your “perceived” freedom. Once you accept Medicare and Medicaid payments, you are indirectly/directly an employee of the government.

Getting back to whether you would recommend it as a career. I would do it over again because of the positives definitely outweigh the negative. Every 10-15 years medicine has been shaken up for financial reasons and everyone survived. The burdens are different but with the proper understanding that early acceptors of change are always the winners.

For Every New Medication 2 Need To Be Removed

One of Donald Trump’s campaign promises was: “I will formulate a rule which says that for every one new regulation, two old regulations must be eliminated.” No matter what you personally feel about the new president this idea makes a lot of sense.  Many would be happy with just “no new rules, period!” But the 2 for 1 rule (a twofer) can easily be transmitted to multiple other areas of consideration, especially in pharmaceutical realm regarding prescribing of endless medications without making the critical decision to eliminate any.

Problems with side effects and medication reactions plague the elderly and/or chronically ill patient who carry or store suitcase full bins of pharmaceuticals. Compounding this, when more than one doctor is involved, they rarely decide in concert what to use, and multiple treatments from a stack of practitioners often lead to serious consequences.

The article Adverse drug reactions in the elderly author quotes, “Medications probably are the single most important health care technology in preventing illness, disability, and death in the geriatric population. Age-related changes in drug disposition and pharmacodynamics responses have significant clinical implications; increased use of a number of medications raises the risk that medicine-related problems may occur. “

The number of patients suffering from polypharmacy, significant adverse reactions, and admissions to the hospital is significant and radically increases with age. Many are dose related which alter blood levels of potentially beneficial medication; these can then become life threatening. A good example is blood thinners whose pharmacology can be affected by multiple contemporaneous common medications like antibiotics or ulcer medications.

In a prior blog, a semi-tongue-in-cheek approach was suggested: if the medication bag was too complicated to list easily then the bag should be weighed, discarded and start new treatment plans from scratch. It is not a bad idea. Why weight it though? Some kind of list should be made before tossing that considers what symptom or problem the pharmaceutical is supposed to address. Then after tossing the bag, one can see if each problem still exists, and if a therapeutic avenue has been taken with the new medications.

In conclusion: many seriously ill patients need multiple medications to survive but after too many, a situation of diminishing returns sets in, and side effects often become more serious than the original problem. Maybe, after 5-6 medications are prescribed for chronic complaints, a serious analysis of the need for “all” of these treatments needs to be done. Taking unnecessary medications can be dangerous, create new clinical problems, and dramatically increase the expense of care. Adopting a policy similar to the regulation policy suggested in the beginning may be a good start.  In fact, any individual on more than 5 medications deserves a review on a regular basis, with the intent of eliminating any that are either ineffective, dangerous, or in excess.