For Every New Medication 2 Need To Be Removed

One of Donald Trump’s campaign promises is:  “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 two-fer) 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.

Deterioration of the House of Medicine

Today's guest blog by Dr. Donald Kamens, discusses the top ten things that have led to the destruction of medical care in the 21st century. Unfortunately, the list is endless. These are in no particular order, except to say, that the next item is often more odious than the previous.  Here, then are some of things that have gone terribly wrong, and from which we seem unable to turn back.

From a doc of four decades, these are some of the forces that have served in the continual and progressive plight of medical care. Here is what I think needs to be eliminated from the House of Medicine: What do you think?

1.            DTC (Direct to consumer) pharma ads.  Think of it.  Can you remember when such a thing was actually a heresy?  Illegal?  If so, you are older (like me!). Then, the sound of a jazz guitar did not conjure up male performance anxiety and a reach for the pill. Then, all the side-effects of any drug were not spouted off by fast-talking actors, and “tell your doctor if…” were not fare for a commercial break.  Most of you know that the doctor-patient relationship is totally undermined by this crass pharma commercialism.  Ads for pharmaceuticals needs to be made illegal again. Let the doctor do the analytics and the deciding. This does not need to be a patient activity, one more closely related to recreational substances than to therapeutic medicines. At least allow the patient to choose whether to have to listen, to hear, that baloney or not. And choose whether to explore through research online or not.  In the meantime, we could let football games be football games, instead of marketing venues for various chemicals. Sure, beer is a chemical, but it is fine.  What to do:  pull the plug on greedy pharmaceutical manipulations that do well to nothing but confuse patients, and distort the role of the doctor.

2.            Barriers to doctor-patient relationship:  The prime examples here are EHR screens, creating ridiculous busy-work that makes seeing patients like filling out tax forms, and increasing pressure to see more patients in less time. Seriously?! Despite being an advocate of EHR from long ago, and an early developer, they have gone to another universe. Now we have complexity after complexity.  The EHR is such a pain, we have an ever increasing presence of scribes and other assistants assigned to deal with the clerical. Does this not attest to the progressive marginalization of the physician from the therapeutic relationship?  What to do:  eliminate documentation criteria; eliminate reimbursement based on completed charting items.  A one line should be good enough.  “Put her on antibiotics for the pneumonia, and told her to see her doctor and/or come back if not better in two-three days, or if worse. “ Not much more needed.

3.            Liability. Little more needs to be said about that nasty word, but just to be clear….here I am, on the way to work; here I am going to go help someone today.  And they often need help it seems. But wait!  I have to worry about being sued. Alost forgot! I have to think about being hurt-back by the one I am trying to help-out. Seriously?  What to do:  tort reform is not a good plan.  Why? The complexity of work-arounds would be just as overwhelming.  Simply do this: eliminate liability.  If you are there to help, you are there to help.  If you screw up, you screw up.  It is going to happen at times. The house of medicine should not allow overwhelming vulnerability, hurt to the one trying to help. Do it Shakespeare’s way, or make suing doctors illegal.  If done, the costs of medicine will go down, down, down.

4.            Reset the goals: Make patient outcome goals vastly more important than economic goals. More important than throughput statistics. Outcomes do not have to be specific (e.g. cure of coronary syndrome)...BUT Can be non-negative intermediate outcome based.  EG—the patient did not die in the ED; or the patient feels better, now, though we do not have a definitive diagnosis.  Other examples of how this has gone awry include readmission criteria -an economic goal gone haywire, causing care to be stopped before its time 2. Inpatient census monitoring - the goal should be zero census, as everyone would then be well   3- etc., etc.)

5.            Role confusion - (no one more confused than patients: who REALLY does what...doctor, nurse, PA, NP, pharmacist, unit secretary............and the ubiquitous "I never got to see the doctor"). Eliminate the vague uniforms.  Make it consistent with consistent name tags. 

6.            Stating Lies, such as health insurance = healthcare.   (Being "insured" in 2016 guarantees neither care, nor an affordable bill) 

7.            Middle men (modern medicine has seen an ascendency of middle men, not only for pharmaceuticals, but also for devices, services, etc. Too many hands in the pie, means the cost goes up, and up).  Why (Why???) do you have to have 100’s of companies trying to get a piece of the ACA or Medicare pie by offering to find YOU the right plan? Why.  Make is simple, stop this stupid spending on overhead.

8.            Fostering of unrealistic expectations - patients, very often, expect to have something available that has actually not yet been invented.  It can be a world of science fiction.  “What do you mean that your hospital cannot get/read the record from that place I was at over vacation??? “  You mean you cannot reverse my husband’s stroke?   On and on.

9.            Blindness: Here we are: what you might see does not really matter; what is recorded does.   Hard evidence (numbers & testing) has displaced observation, history-taking, examination. (Ask any plaintiff's attorney).  

10.        Stabilize the rapidly shifting medical model Pick a recent approach; stay with it as long as possible. Get ready for change.  Why?  (During the time from symptom to diagnosis may be enough time for accepted criteria for a given entity to change).  Too fast to keep up with.

#11 – 1000+ Get the EHR thing right: Look it is ridiculous to have an ever increasing percentage of time spent on wrestling with these things, time that could be used for patient care.  There are not getting better. Even the good companies know it. Government criteria are getting more and more burdensome. The absence of true interoperability is not tolerable, especially to patients who simply cannot understand why hospital X does not have the information from hospital Z. Let alone why doctor A does not have the information from doctor B at the same facility.  It is a mess. Acknowledge it.  No problem was ever solved without admitting it exists.

Opportunities for Emergency Medical Services to Modernize

The article Rethinking EMS: Don't Knock Homeboy Transport addresses the value of advanced life support rescues.  The author uses scientific data as evidence that the present paradigm based on advanced cardiac life support and advanced trauma life support may be neither practical nor beneficial for patients overall.  The author also discusses the number of ambulance and helicopter accidents during various rescues, issues with pre-hospital dogma include that the "golden hour" of trauma only reflects a very small proportion of patients; and early cardiac drugs may or may not help survival.

The real issue at hand: Tremendous cost, falls in urban administrations under the umbrella of fire safety and there, one does not comfortably venture, if a politician, without be ready for a career-ending catastrophe.  However, there are ways to modernize and make fire-rescue more efficient, while saving huge quantities of capital and operating expenses.

The historical premise of fire-rescue resuscitation is that a cardiac arrest victims must receive CPR within 4 minutes to prevent brain anoxia-lack of oxygen.  However, new CPR studies show that chest compression without rescue breathing is sufficient to provide oxygenation prior to defibrillation for return of spontaneous circulation.

This means that with good CPR, you have more time to defibrillate.  Keep in mind, that at present time, a fire truck is sent to almost every call - arrives within the 4 minute time limit, followed by a rescue vehicle and supervisor on duty.  With proper triage through dispatch the necessity of multiple fire vehicles may be prevented.  Five vehicles do not a true resuscitation make.  If needed, additional help can be brought in.

A tiered approach toward dispatch and resource distribution can be created to save on manpower and machines.  It would be modern indeed, and might benefit from an approach like this:

• Incorporate the local citizenry through smartphone technology to be first responders.  Without the need for rescue breathing, the public should be more willing to provide CPR
• Have police carry defibrillators. 
• Use "Uber type" drivers with basic life support capabilities and defibrillators available.
• Allow paramedics medical legal liability protection to encourage self-transport.

The bottom-line- resource management is key.  Most rescue calls are not really life and death that can be handled cost effectively as remote triage platforms.  Yes, truly critical patients need rapid transport to the hospital for definitive care.  While our fire rescue personal do a great job, they can be utilized much less expensively and much more judiciously, as true first responders, without needed to be CHST thumpers.

“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”.

This song was 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".

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 multi-factorial. 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.

Where Does Telemedicine 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.”

​​SMThe 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.  

Should Physicians Join the Union???

With the Brexit vote in the United Kingdom, endless global conflicts, and the 50-50 political dichotomy in the USA, it may be time for providers (physicians, Nurse Practitioners, and Physician Assistants to organize into an effective voting force.

 

In the interesting blog Physicians must unionize.  Here’s why, the author recommends that physicians create a union to protect their interests from governments, health systems, and the endless prevailing forces that the individual has no control over.

I would suggest reading the article as maybe the time has come for physicians to get organized and protect their substantial interests.

 

​​SLXThese interests include autonomy, financial security, work conditions, and protecting the greatest guild ever created. Physicians have reaped the benefits since the 1960’s thanks to a fee for service model and Medicare guaranteeing a financial floor to generate exceptional incomes for 30-40 year careers. Along with social status and respect, it is a great job.

However, practice and personal satisfaction has significantly decreased in the last decade. More government mandates (usually unfunded), hospitals employing physicians, and the destruction of the personal doctor-patient relationship has been steadily on the rise.

Physicians are generally organized if at all by specialty societies with varied interests. This diminishes the overall power and clout of all physicians. Critics would argue that doctors are overpaid compared to the world market and are chief offenders at driving up costs.

A similar argument can made against the National Football League Players Association (NFLPA). It has been called a joke because it represents rich football players. The football players do make great sums of money but their careers last 3-5 years with lifetime physical disabilities to follow.  Physicians can earn significant amounts of money over 30-35 years without similar threat to life or limb.

 

The union could  represent the physician body in the ongoing financial negotiations with CMS, insurance companies and hospitals, work rules, malpractice, contracts, Electronic Health Record implementations, ICD -10 implementation, and etc.

The individual has lost any clout to fight these forces or influence the decision making. A physicians’ union would put the “players” back in the discussion. And yet, there may be ethical and practical considerations that might keep some from wanting to join a union.  For example, would you cross a picket line to help the bleeding patient on the sidewalk?  Most would say yes, despite getting roughed up or jettisoned from the union.  And then, how many times have you seen a hundred or more physicians in a meeting (think union meeting) that agree on anything?  Younger physicians steer clear of medical entities, such as the AMA, which has a pre-union character to it.  Perhaps they realize that the results of joining could include an early retirement a la Jimmy Hoffa.  Lots to think about before unionizing.

Tai Chi for Health-care Practitioners

I recently started taking TAI CHI lessons to improve my balance, flexibility, and coordination.

It looks pretty easy on movies but does take a fair amount of training. People like myself, who cannot dance or suffer from right to left confusion will need to practice to gain muscle and brain memory.

​​SML

The article Tai Chi for Health-care Practitioners emphasizes the value for health care practitioners helping their patients. The programs includes  “applications for balance, geriatrics, stress and pain management, oncolcogy, PTSD,TBI, polytrauma, autoimmune diseases, women’s health. orthopedic, neurological, cardiovascular and respiratory rehabilitation".

           

Wikipedia states that “Tai Chi generally provides health benefits. In all the forms of Tai Chi there are movements that involve briefly standing on one leg, which may improve balance; circular movements of the shoulders and wrists which improve suppleness and circulation; learning the sequence of the set movements may improve cognitive function such as concentration; the social atmosphere can sometimes forge friendships and alleviate loneliness and anxiety; and the exercise itself can boost a person's mood and alleviate depression.[3][4]”

                       

My wife figured out at the first lesson that all the hand and feet movement should be considered preparations for striking and/or blocking an opponent. She’s right to have intuited the relationship between this originally Chinese practice, and the martial arts.  Many in the far east are skilled in both.  Not having 2 left feet will help with the movements. The individual motions are easy but the linkage and flow take practice, practice, and practice.

           

In general, TAI CHI is another worthwhile avenue to explore as we have a tendency to live longer and become quite immobile. You may learn how to dance. And if not, you may be able to defend yourself better.