Thursday, October 8, 2009

Mindfulness Medicine

One of the challenges of practicing medicine, day after day, month after month, year after year is seeing each patient at each encounter as a new and unique experience.  For the patient, who has a problem that is unique to them at that particular appointment (that is why they are there seeing the physician), they expect nothing less however they often receive a quick response from the physician, who sees a common issue which is the same as he or she has seen thousands of times before.  The danger that lurks for both physician and patient (more for the patient) is that the difference between a common harmless problem and an unusual dangerous problem is often extremely small and the physician must be open to the possibility and be actively looking for the unusual to be a good physician.  Due to a number of factors, including the financial incentives and the insurance company and government requirements, the physician is often concerned with efficiency, productivity, and compliance with regulations rather than with thoughtful evaluation of the unique person and problem sitting before them.  That leaves the patient with a doctor “going through the motions” and a doctor often unhappy with their practice. 

Mindfulness Medicine

With physicians spending less than ten minutes with a patient, and payment systems pushing more doctors away from spending time with patients, how do we encourage thoughtful evaluation of every person in every encounter with a doctor.  A term, mindfulness medicine, has been coined to describe how we want a physician to act when he or she sees a patient. A recent article in the Journal of the American Medical Association defined that term as “a quality of awareness that includes the ability to pay attention in a particular way: on purpose, in the present moment, and non-judgmentally.  Mindfulness includes the capacity for lowering one's own reactivity to challenging experiences; the ability to notice, observe, and experience bodily sensations, thoughts, and feelings even though they may be unpleasant; acting with awareness and attention (not being on autopilot); and focusing on experience, not on the labels or judgments applied to them.”  In that article, the authors described a course of study for physicians to teach them mindfulness medicine and assessed the impact on the physicians’ satisfaction with practice and found that the doctors involved gained much more satisfaction following the course of study and were also more attentive and empathetic with patients.  But what about the patients?  Was the care improved?

Reflexive versus Cognitive Care

We do know that empathetic physicians tend to listen more effectively and that should improve care.  Care today is often reflexive, that is a doctor doesn’t really think about what is unusual concerning a patient but rather hears “runny nose” and reflexively thinks upper respiratory infection, and not leaking cerebral spinal fluid from the brain.  Usually that is fine (as a doctor can go through an entire career and never see a runny nose that isn’t just a runny nose).  However if the doctor misses the unusual aspect that can make that runny nose indicative of a brain problem, that could be a deadly mistake.  In my career of trying to influence medical care through managed care techniques, my goal has always been to build programs that foster thinking, or cognitive care and try to fight reflexive care.  Doctors tend to be smart and highly trained but they are human and often have to be shaken out of complacency that comes from routine.  The trick of reminding them of their intellectual roots can be challenging, especially in view of the many forces pushing them in the opposite direction.

Mindfulness, Health Economics and Reform

In the latest issue of the New England Journal of Medicine, there is a roundtable discussion with Drs. Atul Gawande and Elliot Fisher who are both physicians and Professors Jonathan Gruber and Meredith Rosenthal who are both health economists.  All are expert in areas of health policy and the effects of payment systems on physician practice as well as expert on the details of the various iterations of the proposed health reform packages.  At one point, Dr. Fisher says “Fee for service does not pay for us to have long conversations with our patients. When we're feeling constrained, it's much harder for us to have that long conversation with a patient with heart failure to see if we can safely manage them at home. The default position in many communities becomes, "Gosh, I'm too busy. I better send them to the emergency room."  Does any version of the current health reform bill address this?  While in the published article, which leaves out parts of the conversation, this issue is not addressed, the full transcript available on the NEJM website does reveal Professor Gruber addressing it by saying, “The problem is, we’re pretty far from legislative language. And there’s not that, quite frankly, can be in a bill by October 15th or by November 15th or probably even in the next couple of years. My feeling is, as we look to this round of reform, the science of coverage has gotten so far past the science of cost control that that’s why I feel like the President, on one level, did a bit of disservice holding up cost control as such a key feature of this round of reform.” 

The Short Term Answer

Until payment systems can encourage doctors to spend time and think, rather than encourage them to act reflexively, we will need to hope that more educational programs to teach mindfulness like the one described above are put into place.  As patients (and all of us are patients at some point) we also need to demand that from our doctors every time we are at an appointment.  That means going in to an appointment prepared to ask questions and to find ways to get the doctor to think about us differently even if only for the ten minutes he or she is with us.

Monday, October 5, 2009

The Dog That Didn’t Bark

It is often pointed out that Arthur Conan Doyle’s model for the great detective Sherlock Holmes was based on the methods used by physicians to determine diagnoses.  While patients are invariably most concerned with the treatments, as the treatments will make them better, most physicians, especially family practice physicians, internists, pediatricians and ER doctors, all of whom are on the front line of medical treatment, are usually much more concerned with making a proper diagnosis as the treatment often follows the diagnosis in a very straightforward way.  Missed and incorrect diagnoses can lead to disaster and it can be a true mystery to determine the cause of an ailment or a symptom. I think about this while reading a wonderful book Every Patient Tells a Story by Lisa Sanders.  Dr. Lisa Sanders describes the challenges of making diagnoses through stories of real situations between doctors and patients.

Finding what Doesn’t Fit

I admit that I enjoy watching formulaic detective shows on television.  Give me a good episode of NCIS or Monk (prior to this season in which the writing has gone downhill) and I am happy.  As you watch these shows, you often see that the trick in finding the killer and solving the mystery, is finding the fact that does not fit with the others and persisting until a different answer can be found that does explain all the findings.  In many ways, a good diagnosis follows this approach.  You tend to start with a number of possibilities in your mind and you then test these possibilities with the patient’s history, physical exam and lab tests.  You have to know quite a bit from just the history and physical to select the right lab tests.  This is the most important part of the science and art of making a diagnosis.  One patient story comes to mind.  A young physician with severe abdominal pain comes into the Emergency Room saying that he has right sided abdominal pain that is excruciating and also has a low grade fever.  He tells the ER doctor that he thinks he has appendicitis and a surgeon comes and starts to take him straight to the Operating Room.  No one notices that he is squirming on the gurney and cannot get comfortable.  That doesn’t fit.  People with appendicitis have to hold very still to minimize their pain.  The appendicitis turns out to be a kidney stone, luckily discovered before the incision is made to operate. (I was the patient in that story some thirty years ago when I was an intern)

Solving the Mystery

It turns out that, for a physician, making a diagnosis often requires thinking about each patient in a new way and not allowing yourself to become complacent about every person having the typical illness.  Dr. Jerry Groopman has written about this in articles in the New Yorker and in a book How Doctors Think.  Dr. Groopman talks about doctor’s use of heuristics, or rules of thumb, and how it makes the physician more efficient but also may make a physician less thoughtful and therefore less accurate in making difficult diagnoses.  It takes time to carefully take a history and perform a physical examination in such a way to get to a potential list of diagnoses.  It also takes some strong presence of mind not to see twenty cases of constipation  due to poor diet and perform just as careful a history and physical on the twenty-first to discover that colon cancer while it is still treatable.  Good medicine takes time.  Yet our payment systems do not reward for this time.  Rather the payments encourage large numbers of patients seen briefly with little true “thinking” about each person seen.

The Best Diagnostician

The most impressive diagnostician that I know is my wife who sees newborns who may have rare genetic diseases.  The history that she takes can go back for generations in a family.  Her physical examination will often cause her to precisely measure the distance between the eyes and carefully describe the ear folds.  She will routinely take two hours or more to see and evaluate a new patient.  That may be why, despite her many years of training, first as a pediatrician, then as a Clinical Geneticist, and her many years of experience including running statewide programs in genetic diseases, her income is below that of a general pediatrician. 

Paying for the Best

I think about all this as we continue the health reform debate in this country.  While we debate the public option and the mandated coverage while also talking about cutting Medicare payments and eliminating a popular Medicare program (Medicare Advantage), we avoid talking about the payment reform that will actually encourage physicians to perform careful, thoughtful histories and physical exams and likely save money on procedures, tests and surgeries.  Right now, Medicare and Medicaid have the market power to initiate payment reform and encourage the type of payment system that would improve quality of care by improving the solving of medical mysteries that is the heart of diagnostics.  I only hope that someone in government wakes up to this basic need in reform.