Monday, July 28, 2014

Adding Motivtion for Visit as part of the Chief Complaint

When writing, Dragoning aka dictating, typing and or clicking a classic history and physical exam, there is a traditional format to follow.  What may be left out is the underlying motivation or deeper concern that led to the actual visit.  Most physicians try to discern a "Reason for Visit (RFV)", and there was an academic effort not too long ago to replace the Chief Complaint (CC) with RFV, but CC is too thoroughly entrenched in the medical world.  This effort was driven by recognition that even the most common complaints - say chest pain- have underlying, relevant forces that make an individual decide to go to the ED.  Such forces can include- "MY wife made me come.", "I thought I was going to die.", or "It was about time I did something."- indicating a longer history of symptoms than might initially have been thought.  Of course, there are many, many other motivating forces of this type.

Motivation therefore includes concerns, worries, fears, family pressure, employer pressures, generalized anxieties, and specific desires.  The list goes on and n, and few are irrelevant.

Concerns about a potential serious illness like a stroke or heart attack are often very real and very present.  Eliciting early on in the encounter that the patient was worried about a stroke, for example, adds quick perspective to the evaluation.  Moreover, a very important reason for trying to elicit such concerns is that addressing them is key to patient satisfaction, and proper thoughtful care of individuals.  The patient who is too embarrassed or afraid to say anything leaves unsatisfied because their concerns were not evaluated.  Hence, it is frequently the physician's responsibility to tease these details out, as best as possible.

Another major and related dimension to motivation is the parallel issue of the real reason for the visit.  For example, we often learn that a family member "made me" and we become less interested in the family dynamics than in ascertaining all relevant key information.  This is the time to ask everyone available about what is actually going on.  How many have not seen the patient checked in with a CC of some non-specific somatic complaint- tired, weak etc., only to learn from the wife that he has had repeated exertion chest pain for weeks or months, mowing the lawn or taking out the trash.

Of course, patients often have specific agendas- medications, antibiotics, work excuses, etc. and once discerned and addressed can expedite care.  Once you actually get to the bottom line, beating around the bush ends quickly.

The benefits of asking key questions to elicit the reasons a patient decided to change his or her normal life course and come to the ED will lead to increased patient satisfaction, decreased complaints- the provider never listened to me- and reduction in liability concerns.  Cost savings are often additionally obtained because a focused evaluation solves the main problem earlier, without extensive testing or time.

When eliciting the chief complaint, try to keep the door constantly open for revealing motivation by adding sensitively phrased questions that do not challenge the patient or appear to disrespect their decision to come.  Saying- what are you doing here at 3 am with this complaint that has gone on for 6 months has the potential to put some patients and or families off.  A bit of rewording that acknowledges the human foibles in us all will help get to the bottom and provide reassurance.  Perhaps adding- help me understand what moved you or I know it must have been especially bad this time, can you tell me what was different?  This may help you to where you want to go without offending anyone.  In any case, finding out motivation for showing up will dramatically increase efficiency and accuracy.  It is perceived that the provider Listened and Cared about Me!

Monday, July 21, 2014

Acceptable Miss Rate

The acceptable miss rate is a concept that realizes even in the best of hands with all the available data accessible, there still will be some errors.  The question is whether society can tolerate without retribution aka law suits a reasonable attempt to keep this below 1% for most significant diagnoses.  The cost of achieving unobtainable perfection is rampant in our medical system, where depending the risk adverse psychology of the provider, the price tag goes from linear to exponential.

In the article The Acceptable Miss Rate, Dr. Jeffery Freeman states the typical psychology of most providers, "What are the odds that if I follow my instincts and send this patient home without any further tests that he'll seize and die, and I will spend the next five years defending my instincts as a defendant?"  The researchers among us may confer analytically on false negatives, prior probabilities, and Bayesian theory, but we all know what it means at a more visceral level.  But, in fact, most physicians do not spend cognitive energy calculating an acceptable miss rate.  Indeed, if the perceived odds re non-zero, it is quite likely that some justifiably preventative - defensive - action might be taken.
Medicine is a combination of art and science that rarely achieves 100% accuracy.  The provider trying to be an excellent clinician, following evidence based guidelines, and providing good follow-up care can still be sued, especially if there is a bad outcome.  Malpractice has on the one hand a financial cost, but on the other it also has a serious psychological cost.  This latter overhead is one that can have significant impact on the ability of the sued provider to continue delivering care while a case is defended.  Anticipatory prevention, then, leads to defensive medicine, and thus to unnecessary testing, more hospital admissions, and care that stays mired in process, without improving over time.
By establishing an acceptable miss rate protocol, it would allow physicians to use evidence based protocols with their experience to provide reasonable, inexpensive care.  These protocols could reflect reality of a 1-2% miss rate per specific diagnosis even in the best of circumstances.  The cost saving would be astronomical.  Moreover, the parallels between the practice of medicine and baseball will take one more step toward being acknowledged.  In baseball the batter aka provider steps up to the plate.  The patient aka pitcher throws him the ball.  The provider can watch it go by or take a swing- there really are no other options unless it is a wild pitch.  But in baseball, when a swing is taken, even those on a full team are allowed a certain percentage of errors.  Why not physicians, too?  We have yet to see a perfect baseball player or a perfect physician.

Monday, July 14, 2014

Over-Diagnosis - Ascension of the Luddites

Technology in medicine has dramatically altered the landscape of care through its ability to contribute to the diagnosis of complicated medical problems.  But as technology improves, results that containing more complex data require nuanced interpretation.  While the sensitivity of tests has increased, those tests that cast wider nets often bring specificity into question.

Luddites were 19th- century English textile artisans who protested against newly developed labor-saving machinery from 1811-1817.  During the Industrial Revolution, artisans were threatened to be replace with less-skilled, low-wage laborers, leaving them without work.  The modern day Luddites are concerned about the cost and possible harm (radiation, more tests, more surgeries) that more high-tech tests can generate.

Underneath apprehensions about over-diagnosis lies the foundational issue of controlling costs as the technology exponentially improves.  A justifiable concern is the ordering of tests when results will not alter or impact the treatment or outcome of the problem.  In a vast majority of cases, providers place such orders in the showdown of a malpractice threat that dwells just beneath the surface, subconsciously informing most every clinical interaction.

The term over-diagnosis attributes too much psychological power to the physician, who might thereby assume knowing just how much data the patient needs to know.  In my home, my wife would want to know every detail and decide for herself, rightly or wrongly, whether she's been subject to over-diagnosis or the findings represent important data.

Emergency physicians generally have a highly trained level of diagnostic accuracy.  The concept of over-diagnosis is therefore fundamentally contrary to how ED docs intuitively function, especially since emergency medicine rapidly accepts and adopts new technology into treatment guideline.  The question becomes how much technology should the provider unleash on the patient.  The Luddites lost in the 19th century and will again lose in modern times.

A problem always arises when ordering newer tests in  the first place and learning to live with the results if ordered.  This is so at least until some experience is gained.  A new name should be created to become the buzz word for the concept, perhaps--Intelligent Ordering.  Optimally, one would be judged not only on the amount of resources used, but also outcome. 

Technology is advancing rapidly.  The concern over radiation will be severely diminished with the new scanners.  Medicine has evolved realty since I began in 1975.  Back then, changes took decades to settle in.  The new time frame for gaining traction for a test is 3-5 years.  We should embrace technology, but use it judiciously.

Monday, July 7, 2014

3 Stikes and You're Out!

In 2004, the 3 strike rule was added to the Florida constitution.  In the article, Three Strikes Rule: It has been almost six years: Is there any discernible impact of its passage?, Gregory Chaires explains what a strike is.  For those not aware, a strike is defined as a final judgment by a court or agency that has been supported by clear and convincing evidence.  A strike occurs when and if there is:
  1. A final order of an administrative agency following a hearing where the licensee was found to have committed medical malpractice;
  2. A final judgment of a court of law entered against a licensee where the licensee was found to have committed medical malpractice in a civil court action; or
  3. A decision of binding arbitration where the licensee was found to have committed medical malpractice.
The impact of the 3 strike rule is unclear with respect to its intent to "eliminate recurrent malpractice offenders".  An initial fear was that the rule would drive high-risk specialists (neurosurgeons, Ob-gyn, etc.) our of Florida.  The present data indicates that such concerns have been due to the legal definition of "clear and convincing evidence."  to establish "clear and convincing evidence" in a case, it must first be reviewed by the Florida Board of Medicine, which then decides that "preponderance of evidence" -- a less stringent standard -- has been exceeded.  Preponderance of evidence is sufficient to win a malpractice judgment, but not necessarily a strike.

Like all laws with good intentions the Devil is in the Details and the net effect is always different than believed.  The goal of getting rid of "Bad Doctors" has not happened so far, but the net effect on all the other providers has probably led to higher costs and more defensive medicine.

The fear of 3 strikes already makes a paranoid medical profession, even more anxious about malpractice and peer review.  Most physicians do not realize a referral to the Board of Medical Examiners is more high risk for their careers than a standard malpractice suit.

Hopefully, the 3 strike rule will be rewritten-- defensive medicine and higher costs will always continue to increase with the present adversarial system in place.  The New Zealand system of no-fault takes a huge step to reimburse victims of medical incidents without terrorizing providers.  After all, even in baseball, there is recognition that the batter is less than perfect.  Three strikes there too takes clear and convincing evident; you can foul all day long, but until there is a swing and a miss or one right over the plate, the batter retains his position at bat.