Monday, August 31, 2009

When I am not trying to cure ALS, I am thinking about ways to help improve the quality and affordability of health care. Here are my ideas:

Health Care: Fast, Good or Cheap: Pick Any Two During residency, one of my mentors offered this little adage. “Listen to the patient, she’s telling you the diagnosis”. As congress prepares to begin debate on healthcare reform, those of us on the front lines of health care would do well to look inward and consider the ways in which our actions have contributed to the problem and can help solve it. Our “patient” is the individual we care for in our clinics or hospitals but, in a larger sense, our “patient” is healthcare in the United States in general. And by many measures, that patient is not faring well. The choices we make every day contribute to a system of care that is, far and away, the most expensive in the world yet results in health outcomes that are average at best. In addition, 50 million of our fellow citizens are without any form of health insurance at all. Despite our best intentions, the health care we provide is certainly not cheap, not always good and fast only for a select few. If we are to take our rightful place, where our patients want us to be, as the leaders of health care reform, we must begin by asking ourselves what we can do to bring about meaningful, timely and efficient medical care. I believe the solution lies in radically rethinking what constitutes a doctor visit. The electronic medical record can allow us to achieve that goal. It is a rare patient who has not had the unnerving experience of sitting for over an hour in a waiting room only to be rushed through a doctor visit. Studies show that, on average, doctors listen actively for about 18 seconds before interrupting a patient. Somehow, doctors and patients have come to accept the idea that interrupted visits, “overbooking” and long waiting room stays are a necessary price for quality care. In fact, we cheat our patients and ourselves out of the one chance to truly provide meaningful health care. Furthermore, at the end of these abbreviated visits, patients frequently leave the office remembering only half of what they were told during the visit, and half of this is remembered incorrectly. In the rush to create quality care out of limited time, we can easily succumb to the temptation to order tests, treatments and surgeries when similar outcomes could easily be achieved with listening, explaining and teaching. For example, several thorough studies of non-radiating low back pain have shown little to no overall gain to spine imaging, surgery or long term pain medicine use and yet these treatments represent the “standard of care” in modern treatment. The typical rejoinder to this criticism is that these are the things that patients insist on. My experience has taught me otherwise. In 17 years as a neurologist, I have come to believe that what most patients want from their doctor is understanding and education rather than pills and tests. They want to tell the story of their symptoms and they want us to appreciate its meaning to them. They want their symptoms explained back to them in a way that tells them what is going on with their body. Sometimes they want or need tests or medications or further referrals but many times, once they understand what is going on, they are more than happy to try simple time tested interventions first before resorting to pills and surgeries. When the necessary time to reach this understanding is not provided, patients (and their doctors) often use medicines and tests to fill that void. For example, a patient with a straightforward headache history with no worrisome signs or symptoms comes in asking for a brain MRI to ‘see what’s going on”. Admittedly, our medico-legal climate and the proliferation of “doc operas” on TV have created a climate of fear and expectation of the worst in both patient and doctor. However, many times, after a careful history, a thorough examination and a thoughtful explanation many patients will say, “That makes sense, why don’t we try a few simple things first and I will let you know if it helps or not?” This statement, I believe, is the holy grail of health care affordability. As a neurologist, I have a fairly large population of older patients, many of whom have limited ability to see or hear and, not uncommonly, to even comprehend. It became clear to me early on that I could not hope to provide good medical care for them without giving them a written summary of our discussion. This document explains their symptoms in plain language and outlines some simple interventions I would like them to try to find relief. Sometimes, there are further tests in addition to the treatment recommendations, but the simple recommendations are elevated in importance to the same level as the tests and medications and other interventions I might recommend. With the advent of digitized radiology imaging, I can often paste into this note a representative imaging study to reinforce the message. Any medicines I recommend will have a few lines about common side effects and a dosing schedule and range that starts low and builds slowly emphasizing taking the lowest dose that helps and coming off the medicine once symptoms are better. Any medicine I recommend comes with a printed patient information sheet as well. At the end of this note is a request to talk by phone or at a scheduled return visit to see how this plan has worked. I always type out my request to have the patient call me if he or she has questions or is clearly getting worse. While this may sound like an enormously time consuming endeavor, the truth is, many patients have similar symptoms making it possible to create a file of basic Care Plan building blocks that are customized for the individual patient. This is not, however, the same thing as a boilerplate handout that is too generic to have any meaning to an individual patient. The note I hand to the patient is pasted into our electronic medical record so that our medical support staff can see what I told our patient. This is a vital part of this process as it keeps everyone on the same page and helps our nurses and medical assistants encourage the patient to give the simple recommendations a good try. This extra documentation also serves to support levels of coding that support the time and work involved in the visit. For the most part, my patients have been very happy with this approach. The spouses, children and caregivers are even happier as they too are fully engaged in the process. I end up seeing a lot of their family members and friends. This work takes time. In fact, the note is only the end product of a very time intensive visit. I can only do this work because I have been able to use our electronic medical record to review the chart days in advance of the visit so that none of the visit time is spent pouring through the medical record. This pre-visit preparation allows me to arrange for necessary records and imaging studies to be forwarded prior to the visit. As a result of this preparation, I can begin the visit with a simple question to ask the patient to tell me the story in his or her own words. Then I sit quietly and listen. For most patients, the history unfolds in vignettes and disjointed fragments, usually punctuated by reading from the back of an envelope where notes have been scribbled. Sometimes they bring in a three paged single spaced summary and ask me to read it. I gently encourage them to read it to me, so they can add color and context. This history comes out like a torrent at first but eventually tapers off to, “That’s about it doc”. The drop in the tension in the room is palpable and we can all feel that the stage has been set for healing. I then ask questions from my prior reading and notes I have taken to gather the threads into some narrative. At the end of the history, I ask, “Is there anything else you think is important that we haven’t discussed yet?” Since the advent of Google and WebMD and the like, I have also started asking, “Is there a specific diagnosis you have been concerned about that you want to make sure we think of today?” I never cease to be amazed at the things people come up with that I would never have thought of. But if that question is not asked, it remains the 500 lb. gorilla in the room. In addition to previewing charts ahead of time, I do not “double book” patients or allow my clinic to run late. A patient sitting in a waiting room after the beginning of their scheduled visit is a failure on my part to properly manage my time. If a patient arrives and my staff is busy, I get them myself. The whole of the visit time is simply that important. I am fortunate enough to work at an organization that recognizes the time it takes to do good work and gives me that time. We encourage our patients to be here 20 minutes before their visit so that any paperwork or other details that might cut into our visit time are taken care of. If the patient arrives late, I give them my full attention for the remainder of the time we have and then schedule a make up visit. To do otherwise is to cheat every other patient on the schedule that day. The electronic medical record has also created the opportunity to make every kind of patient encounter more meaningful. For example, I typically call my patients with most test results. This allows me to update the narrative arc of the issue I saw them for in a section of the note called the “Problem List”. Here, a concise summary of their symptom or diagnosis is available for any provider to review without having to plow through the chart in search or an initial note and subsequent phone or office visits. The story of the issue I saw them for is readily available and updated as test results and treatment responses are reported. Our urgent care, emergency doctors and hospitalist find this particularly valuable. These phone visits also allow me to check in on how the simple treatment strategies are working, suggest minor adjustments and provide encouragement. For some patients, their preference is for this to occur through a virtual visit through our secure email system. For others, a return visit works best. What the electronic medical record affords is the ability to provide seamless care to far more patients that the traditional check back visit allows for. Here again is another way to increase the efficiency of health care while sacrificing none of the quality. As for me, this approach has enhanced rather than detracted from my work satisfaction. I can see the appreciation in the faces of patients and their loved ones that they have finally gotten an explanation. I feel that the reasoning skills that led me to this profession are honored and appreciated, rather than my ability to order tests and medicines. And I can see the subtle ripple effect of these teaching notes in the care plans of my colleagues. This administration has touted the electronic medical record as a vital tool in reforming our system of care. Like any tool, it is only as good as the skill and dedication of the user. We must always remember that


  1. Tim, this is an excellent post, and I quite agree with you for all of the reasons you share here and a few others that I have encountered. To your point about working with older patients, I am now helping my mother navigate her healthcare. My father has died and when she was recently diagnosed with hypertension, she was nervous about the medication her doctor wanted to prescribe. Luckily the blood pressure monitor that she uses to monitor her daily vital signs has an app that allows her to download the reading into a personal health record that I created in Microsoft HealthVault. When doctors and patients can share that kind of data, it saves trips to the doctor's office, can reassure the patient that the medication is working as needed, and even enables family members to better understand the care their parent or family member is receiving (especially with so many of us not living in the same town as our parents). Electronic medical records, and personal health records, improve the dialogue between patient and physician and can make the relationship more of a partnership, which I also believe is so important. On another note, I'm excited to hear that you won the lottery; that's a big event. Running through the lava fields is going to be a hot experience, to say the least! Best of luck!!

  2. Tim,
    Fantastic message on improving the quality of health care. You do such a wonderful job of helping your patients understand what is happening to them in ways they can comprehend. This is especially important when the information may feel overwhelming to the patient at the time.
    I want to tell you a story about how one doctor did this for me and I will never forget it. As Dave and I sat in an exam room waiting to meet the surgeon who would remove my tumor, a million thoughts were racing through my head. Finally, the door opened and without introducing himself, the surgeon took one look at me and must have seen the terror in my eyes. He walked over and gave me a hug and said "We're going to take care of you". That moment of caring was more healing to me than all the information in the world ever written about cancer. With advancing technology available, electronic records, diagnostics and tests we MUST keep medicine as a healing profession with real human interaction and caring. Once again, thank you for all your efforts and compassion.