Changing Health Care Means Changing our Culture

Improving the quality of care and lowering costs will involve more than just an electronic medical record and improved data. It is people who go to doctors and hospitals and people's beliefs, expectations, and emotions drive the reasons more than facts and data. A study that looked at reasons parents took children to Pediatric Emergency Departments instead of a primary care physician for non-urgent conditions during daytime hours found that the parents believed that they would face long appointment waits in the physician office, that the staff in the ER would be more expert and more helpful and that the evaluation in the ER would be more complete and more expert. In other words they believed that more is better and that the knowledge that their regular physician had about their child was not as important as all the tests and resources available at the pediatric ER. This is a cultural issue and must be addressed as such. Until we find ways to educate people on the advantage of having a health professional who knows the patient over time and who can use their expertise and judgement to choose the right tests and treatments, the bias to "do something" will overwhelm other efforts to control costs and improve quality.

Electronic Medicine and How Doctors Practice

Electronic health records are being promoted as the answer to problems of health care quality and health care costs with electronic prescribing being the main example of improving care and lowering costs by automatically alerting doctors to safety issues and lower cost alternatives. It sounds great on paper but an article that was written in February in the Archives of Internal Medicine and more recently reported on in American Medical News shows that 90% of the time doctors get these alerts, they override them in order to order the medications that they feel are indicated. Even if these alerts are high severity, 89% of the time doctors override them. According to the authors, "existing alerts may provide little value to practitioners". They call for improvement in the alert systems and point out that the potential benefits of electronic prescribing may not be realized. In many ways, this is just an example of the danger of seeing automating a process as being a total answer. It may be one part of an answer but electronic records, electronic prescribing and other use of electronic media in the practice of medicine also has to take into account the people using that media and the training and cultural aspects of those people in order to be effective. Solutions must be real in practice and not just look exciting in a news sound bite.

Caring for the Patient

Francis Peabody in 1925, gave a lecture which was published in JAMA in 1927 called "The Care of the Patient". In it, he said,

"The good physician knows his patient through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satsifaction of the practice of medicine. One of the essential qualitites of the clinician is interest in humanity, for the secret of the care of the patient is caring for the patient."

I bold that last section as that quote is one of the most famous in medicine. An article in the April 22/29 issue of JAMA comments on that famous lecture and article and points to the scientific studies of neural networks which show the science behind Peabody's point. Another article in that same issue points out that with the changes in medicine, including the use of hospitalists the type of relationship that Peabody speaks of is being lost when people go into the hospital and out of the hospital. These patients have little to no continutity of care between the hospital and the outpatient arena. The use of electronic medical records (EMR) and the emphasis on data collection that accompanies its use is also changing the emphasis from care to data collection. As we move forward with implementation of EMR, hospitalists and other innovations that are designed to improve health care in our country while controlling costs, lets not forget that losing the personal relationships in the care of the patient is likely to hurt both care and finances and lead to a more depersonalized system that few will be happy with.

Play it Safe and Stick with a Doc who is Board Certified

It turns out that if you need an implantable cardioverter-defibrillator (ICD) you are more likely to get it for the right indications and less likely to have complications, if it is done by someone Board Certified in cardiac electrophysiology. If a cardiologist who is not an electrophysiologist or a thoracic surgeon does it, you complication rate is higher and you may have it done for questionable reasons. It may seem simple but stick with doctors who are board certified in the area that you need. Read the details in the April 22/29 issue of JAMA

My Back Pain

Yesterday, Friday, I had an epidural injection for my herniated disc. This entire episode over the past four weeks has been a wonderful learning experience although I often wish that learning could be less painful. (Learning is always a painful process but in this case the pain is quite literal.) For four weeks and 4 days, I have had pain in my leg which is classic for nerve root compression from a herniated disc at the L5 root. Thus I have learned the dermatome distribution of this nerve quite accurately and the history associated with nerve root pain. At the same time, as a patient, I have also learned that trying to figure out exactly where pain is and what makes it worse or better, where it radiates and any associated phenomena can truly drive you crazy. When you sit as a doctor and try to take a history, you somehow assume that the person feeling the symptoms (in this case pain) can perceive them in a straightforward way however that is not the case. Your mind does play tricks and you start to doubt your own feelings. You question whether you really feel what you think you feel or are you just imagining it. You struggle to maintain your center of reality and wonder if some psychological need is causing the pain rather than some physiologic condition. You start to doubt your own ability to think clearly on any matter.

I did have an MRI which shows the herniation, as well as a more minor herniation at the S1 level, and does show the nerve root being compressed by the herniation at L5 looking as though there was a foot stepping on the nerve root stretching it. That would seem to suggest going in surgically and just shaving off the piece of the disc that is pressing on the nerve. However it turns out that some people with this MRI finding have no pain, some do get better without surgery and some people who have the surgery don’t get better. So I enter the findings on the MRI into my mind as one more data point as I try to figure out what I am feeling and what I should do.

In my case, I always tend to intellectualize the problem and try to gain some foothold in my battle to keep reality based and rational in my approach to my own symptoms. It is a struggle. I do this by reading the medical texts and journals about the condition and by speaking to people who are expert in this area and who I trust, either through personal knowledge or by reputation, experience and accomplishments. Of course, since my pain (as is everyone’s pain) is a bit unique, one never finds a pure description of findings and expectations in this way. You can, however and I did, discover certain nuances that you do not appreciate before going to the literature. In my case, I discovered the difference between mechanical back pain and radicular pain. Mechanical back pain is what most people write about and it is really pain in the back. Radicular pain, which is what I have, is pain in the leg (or legs) which originates from a problem in the nerve root which is in the back. Got it? It turns outs to be important because expectations and treatments can differ. For example, you almost never want to operate on a mechanical back because it does not usually help. On the other hand, surgery for radicular pain may help but then again it may not. If that seems clear as mud, don’t forget that these insights have only come after hours of reading and discussing and capturing the top minds in the country on these topics.

So what were and are my options. They are staying on bed rest. The best minds in medicine say that bed rest is the best thing for the pain, bed rest is the worst thing for the pain and bed rest makes no difference in the pain. How about physical therapy and exercise? The best minds in medicine say that physical therapy and exercise is the best thing for the pain, is the worst thing for the pain and makes no difference. Chiropractic, massage therapy, acupuncture? I have similar findings from my research to report. Total confusion! What about surgery? Well here I am confident that surgery may or may not help. There are facts about surgery. One is if I get worse, I will need it. Another is that if I stay the same, I should not really consider surgery until I have lived and managed the pain for about 12 weeks. But at that point I should consider surgery but not necessarily pursue it. So my choices now seem to be to try and live with it with narcotics and exercise (or not) or perhaps try an epidural injection. An epidural injection has a 50% chance or decreasing the pain by up to 75%. Yes, that is a real statistic from the medical literature.

This led me to the hands of a skilled physiatrist who specializes in epidural injections of the back for various pain syndromes. His practice is an excellent example of the type of “focused factories” that Regina Herzlinger has written about as being the best at providing services in their area. Of course any focused factory such as this, also suffers from the challenge of having physicians who bring to life the old saying “if your only tool is a hammer everything looks like a nail”. For those of you looking for wisdom in these ramblings, the wisdom here is only go to a focused factory after you know exactly what you want and need done and after getting advice from people who are broader in their outlooks.

The physiatrist performed the injection skillfully and quickly and today I still have pain but it does seem to be somewhat less intense than before the procedure. So I may be part of the 50% who get some, but not total relief. It does not feel like 75% relief but the medical journals say up to 75%. I would give it a 25% improvement.

So what do I do next? I think that the next step is that I do have to exercise in the swimming pool although I find almost no enjoyment in that. I will keep taking pain meds, although I take them infrequently and with great mental anguish as I worry that I will become dependent in some minor way. I hate my focus on my pain but I also know that I cannot ignore it, as much as I try to while I am working and doing other things. This may be educational but it is clearly no fun.