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It’s also true that many of our patients are depressed or anxious, or have a diagnosed mental illness. During hospital rounds this morning, the first 3 patients presented by the resident complained of overwhelming stress. Add in patients with chronic fatigue, chronic pain, and somatization disorders, and it is clear that we are making daily use of the biopsychosocial model of illness.
That said, we are not card-carrying psychologists, psychiatrists, or social workers, and there is precious little time for us to address behavioral and psychological issues in depth while seeing 20 to 25 patients a day, even if we have the skills to do so. I often take the easy route—referral to someone else. For many patients, referral is a good option, but many others won’t go and want us to help them. And brief therapy from physicians can have a significant impact on patients’ unhealthy behaviors, as was demonstrated years ago in a smoking cessation trial, where brief advice from family physicians increased the quit rate by 5%.2
Now a large body of research can help guide us to effective brief interventions for behavior change. Raddock and colleagues summarize a number of effective techniques in their review, "7 tools to help patients adopt healthier behaviors." Another way to increase our effectiveness as behavior change agents is sharing the load with nurses and medical assistants who are trained in these techniques.
When I act as a health coach and advocate and meet my patients where they are, using either the 5 As model or motivational interviewing, I feel less stressed and more able to enjoy my patients as fellow travelers on this planet, with strengths and frailties just like me.
Please pass the cheesecake.
1. Centers for Disease Control and Prevention. Chronic diseases and health promotion. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/chronicdisease/overview/index.htm. Accessed January 19, 2015.
2. Russell MA, Wilson C, Taylor C, et al. Effect of general practitioners’ advice against smoking. Br Med J. 1979;2:231-235.
It’s also true that many of our patients are depressed or anxious, or have a diagnosed mental illness. During hospital rounds this morning, the first 3 patients presented by the resident complained of overwhelming stress. Add in patients with chronic fatigue, chronic pain, and somatization disorders, and it is clear that we are making daily use of the biopsychosocial model of illness.
That said, we are not card-carrying psychologists, psychiatrists, or social workers, and there is precious little time for us to address behavioral and psychological issues in depth while seeing 20 to 25 patients a day, even if we have the skills to do so. I often take the easy route—referral to someone else. For many patients, referral is a good option, but many others won’t go and want us to help them. And brief therapy from physicians can have a significant impact on patients’ unhealthy behaviors, as was demonstrated years ago in a smoking cessation trial, where brief advice from family physicians increased the quit rate by 5%.2
Now a large body of research can help guide us to effective brief interventions for behavior change. Raddock and colleagues summarize a number of effective techniques in their review, "7 tools to help patients adopt healthier behaviors." Another way to increase our effectiveness as behavior change agents is sharing the load with nurses and medical assistants who are trained in these techniques.
When I act as a health coach and advocate and meet my patients where they are, using either the 5 As model or motivational interviewing, I feel less stressed and more able to enjoy my patients as fellow travelers on this planet, with strengths and frailties just like me.
Please pass the cheesecake.
It’s also true that many of our patients are depressed or anxious, or have a diagnosed mental illness. During hospital rounds this morning, the first 3 patients presented by the resident complained of overwhelming stress. Add in patients with chronic fatigue, chronic pain, and somatization disorders, and it is clear that we are making daily use of the biopsychosocial model of illness.
That said, we are not card-carrying psychologists, psychiatrists, or social workers, and there is precious little time for us to address behavioral and psychological issues in depth while seeing 20 to 25 patients a day, even if we have the skills to do so. I often take the easy route—referral to someone else. For many patients, referral is a good option, but many others won’t go and want us to help them. And brief therapy from physicians can have a significant impact on patients’ unhealthy behaviors, as was demonstrated years ago in a smoking cessation trial, where brief advice from family physicians increased the quit rate by 5%.2
Now a large body of research can help guide us to effective brief interventions for behavior change. Raddock and colleagues summarize a number of effective techniques in their review, "7 tools to help patients adopt healthier behaviors." Another way to increase our effectiveness as behavior change agents is sharing the load with nurses and medical assistants who are trained in these techniques.
When I act as a health coach and advocate and meet my patients where they are, using either the 5 As model or motivational interviewing, I feel less stressed and more able to enjoy my patients as fellow travelers on this planet, with strengths and frailties just like me.
Please pass the cheesecake.
1. Centers for Disease Control and Prevention. Chronic diseases and health promotion. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/chronicdisease/overview/index.htm. Accessed January 19, 2015.
2. Russell MA, Wilson C, Taylor C, et al. Effect of general practitioners’ advice against smoking. Br Med J. 1979;2:231-235.
1. Centers for Disease Control and Prevention. Chronic diseases and health promotion. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/chronicdisease/overview/index.htm. Accessed January 19, 2015.
2. Russell MA, Wilson C, Taylor C, et al. Effect of general practitioners’ advice against smoking. Br Med J. 1979;2:231-235.
Would a cholesterol medication have made a difference? … More
Would a cholesterol medication have made a difference?
A WOMAN WITH A HISTORY OF HYPERTENSION and hyperlipidemia sought treatment from her family physician (FP) for a protracted, nonproductive cough. The FP diagnosed sinusitis and reactive airway disease and prescribed steroids and antibiotics. The patient returned to the FP 5 more times over the next 9 weeks. The patient’s symptoms waxed and waned, but her cough continued. She reported chest tightness and shortness of breath on exertion. A chest x-ray revealed moderate heart enlargement. An echocardiogram was scheduled.
During the patient’s last visit, her FP noted that she had shortness of breath on exertion, but no chest pain. Three days later she suffered a massive myocardial infarction (MI). Cardiac catheterization found 80% occlusion of the left anterior descending artery. She underwent angioplasty and stent placement; after this procedure her ejection fraction was 25% to 30%. One month later, the patient received a pacemaker/defibrillator. The patient’s cardiac symptoms returned 7 months later, and she underwent another angioplasty. She improved and her last echocardiogram showed near-normal heart function.
PLAINTIFF’S CLAIM Although the patient had persistently elevated cholesterol levels, the FP failed to order repeat cholesterol studies and arrange for drug therapy. If the patient’s hyperlipidemia had been medically managed, her coronary artery disease would not have progressed to unstable angina and MI. The FP also failed to obtain routine electrocardiograms or an urgent cardiac consult after a chest x-ray showed an enlarged heart. The FP also failed to send the patient to an emergency department when she complained of shortness of breath on exertion.
THE DEFENSE An urgent cardiac work-up was not indicated and the patient’s cholesterol levels were only mildly elevated and did not require medical management. Her MI was unavoidable since most infarctions are due to plaque rupture in coronary vessels that aren’t occluded enough to require treatment.
VERDICT $1.6 million Michigan verdict.
COMMENT I think the key issue in this difficult diagnostic case is not the lack of prescribing cholesterol medication, but the repeated office visits with no definite diagnosis. If the physician had escalated the evaluation more quickly, the MI might have been avoided.
Narcotic misstep has tragic consequences
A 47-YEAR-OLD MAN SOUGHT TREATMENT FOR DRUG ADDICTION. His physician prescribed methadone, despite not being licensed to do so. After 4 days of taking methadone, the patient went to the hospital because he felt dizzy and was having difficulty breathing. Two days after being examined and discharged, he died from methadone toxicity.
PLAINTIFF’S CLAIM The toxicity was caused by simultaneous use of methadone and alprazolam, which the patient also had been prescribed. The physician failed to recognize the potential toxicity and should have performed testing that could have revealed the simultaneous use of other drugs. In addition, the physician was not licensed to prescribe methadone.
THE DEFENSE The physician had recommended a licensed, qualified facility that could have treated the plaintiff, but the plaintiff preferred treatment in a setting that allowed him to remain anonymous.
VERDICT $1.15 million New York settlement.
COMMENT Don’t break the law, even if your patient asks you to. Know your state laws regarding narcotic prescribing. These are getting more stringent due to the rapid rise in prescription narcotic overdose deaths in the United States.
Would a cholesterol medication have made a difference?
A WOMAN WITH A HISTORY OF HYPERTENSION and hyperlipidemia sought treatment from her family physician (FP) for a protracted, nonproductive cough. The FP diagnosed sinusitis and reactive airway disease and prescribed steroids and antibiotics. The patient returned to the FP 5 more times over the next 9 weeks. The patient’s symptoms waxed and waned, but her cough continued. She reported chest tightness and shortness of breath on exertion. A chest x-ray revealed moderate heart enlargement. An echocardiogram was scheduled.
During the patient’s last visit, her FP noted that she had shortness of breath on exertion, but no chest pain. Three days later she suffered a massive myocardial infarction (MI). Cardiac catheterization found 80% occlusion of the left anterior descending artery. She underwent angioplasty and stent placement; after this procedure her ejection fraction was 25% to 30%. One month later, the patient received a pacemaker/defibrillator. The patient’s cardiac symptoms returned 7 months later, and she underwent another angioplasty. She improved and her last echocardiogram showed near-normal heart function.
PLAINTIFF’S CLAIM Although the patient had persistently elevated cholesterol levels, the FP failed to order repeat cholesterol studies and arrange for drug therapy. If the patient’s hyperlipidemia had been medically managed, her coronary artery disease would not have progressed to unstable angina and MI. The FP also failed to obtain routine electrocardiograms or an urgent cardiac consult after a chest x-ray showed an enlarged heart. The FP also failed to send the patient to an emergency department when she complained of shortness of breath on exertion.
THE DEFENSE An urgent cardiac work-up was not indicated and the patient’s cholesterol levels were only mildly elevated and did not require medical management. Her MI was unavoidable since most infarctions are due to plaque rupture in coronary vessels that aren’t occluded enough to require treatment.
VERDICT $1.6 million Michigan verdict.
COMMENT I think the key issue in this difficult diagnostic case is not the lack of prescribing cholesterol medication, but the repeated office visits with no definite diagnosis. If the physician had escalated the evaluation more quickly, the MI might have been avoided.
Narcotic misstep has tragic consequences
A 47-YEAR-OLD MAN SOUGHT TREATMENT FOR DRUG ADDICTION. His physician prescribed methadone, despite not being licensed to do so. After 4 days of taking methadone, the patient went to the hospital because he felt dizzy and was having difficulty breathing. Two days after being examined and discharged, he died from methadone toxicity.
PLAINTIFF’S CLAIM The toxicity was caused by simultaneous use of methadone and alprazolam, which the patient also had been prescribed. The physician failed to recognize the potential toxicity and should have performed testing that could have revealed the simultaneous use of other drugs. In addition, the physician was not licensed to prescribe methadone.
THE DEFENSE The physician had recommended a licensed, qualified facility that could have treated the plaintiff, but the plaintiff preferred treatment in a setting that allowed him to remain anonymous.
VERDICT $1.15 million New York settlement.
COMMENT Don’t break the law, even if your patient asks you to. Know your state laws regarding narcotic prescribing. These are getting more stringent due to the rapid rise in prescription narcotic overdose deaths in the United States.
Would a cholesterol medication have made a difference?
A WOMAN WITH A HISTORY OF HYPERTENSION and hyperlipidemia sought treatment from her family physician (FP) for a protracted, nonproductive cough. The FP diagnosed sinusitis and reactive airway disease and prescribed steroids and antibiotics. The patient returned to the FP 5 more times over the next 9 weeks. The patient’s symptoms waxed and waned, but her cough continued. She reported chest tightness and shortness of breath on exertion. A chest x-ray revealed moderate heart enlargement. An echocardiogram was scheduled.
During the patient’s last visit, her FP noted that she had shortness of breath on exertion, but no chest pain. Three days later she suffered a massive myocardial infarction (MI). Cardiac catheterization found 80% occlusion of the left anterior descending artery. She underwent angioplasty and stent placement; after this procedure her ejection fraction was 25% to 30%. One month later, the patient received a pacemaker/defibrillator. The patient’s cardiac symptoms returned 7 months later, and she underwent another angioplasty. She improved and her last echocardiogram showed near-normal heart function.
PLAINTIFF’S CLAIM Although the patient had persistently elevated cholesterol levels, the FP failed to order repeat cholesterol studies and arrange for drug therapy. If the patient’s hyperlipidemia had been medically managed, her coronary artery disease would not have progressed to unstable angina and MI. The FP also failed to obtain routine electrocardiograms or an urgent cardiac consult after a chest x-ray showed an enlarged heart. The FP also failed to send the patient to an emergency department when she complained of shortness of breath on exertion.
THE DEFENSE An urgent cardiac work-up was not indicated and the patient’s cholesterol levels were only mildly elevated and did not require medical management. Her MI was unavoidable since most infarctions are due to plaque rupture in coronary vessels that aren’t occluded enough to require treatment.
VERDICT $1.6 million Michigan verdict.
COMMENT I think the key issue in this difficult diagnostic case is not the lack of prescribing cholesterol medication, but the repeated office visits with no definite diagnosis. If the physician had escalated the evaluation more quickly, the MI might have been avoided.
Narcotic misstep has tragic consequences
A 47-YEAR-OLD MAN SOUGHT TREATMENT FOR DRUG ADDICTION. His physician prescribed methadone, despite not being licensed to do so. After 4 days of taking methadone, the patient went to the hospital because he felt dizzy and was having difficulty breathing. Two days after being examined and discharged, he died from methadone toxicity.
PLAINTIFF’S CLAIM The toxicity was caused by simultaneous use of methadone and alprazolam, which the patient also had been prescribed. The physician failed to recognize the potential toxicity and should have performed testing that could have revealed the simultaneous use of other drugs. In addition, the physician was not licensed to prescribe methadone.
THE DEFENSE The physician had recommended a licensed, qualified facility that could have treated the plaintiff, but the plaintiff preferred treatment in a setting that allowed him to remain anonymous.
VERDICT $1.15 million New York settlement.
COMMENT Don’t break the law, even if your patient asks you to. Know your state laws regarding narcotic prescribing. These are getting more stringent due to the rapid rise in prescription narcotic overdose deaths in the United States.
Inadequate evaluation of a mole has costly consequences
Inadequate evaluation of a mole has costly consequences
A 53-year-old woman went to her physician for treatment of a mole on her upper right arm, which she stated had grown and changed color. The physician burned it off without conducting a biopsy or follow-up. Fifteen months later, the patient returned to her physician because the scar was raised with small bumps. He referred her to a surgeon, who diagnosed malignant melanoma (Clark’s level V), with a satellite lesion but negative lymph nodes. The patient underwent surgery and adjuvant interferon-alpha therapy, which caused significant adverse effects.
The patient now has anxiety related to fears of recurrence or death, and must undergo regular positron emission tomography and computed tomography scans to evaluate her for recurrence.
PLAINTIFF’S CLAIM The melanoma should have been diagnosed at the patient’s initial presentation. If it had been diagnosed at that time, the patient would have had an 85% to 90% chance of survival, but because it wasn’t, her survival rate dropped to 60%.
THE DEFENSE No information about the defense is available.
VERDICT $750,000 Virginia settlement.
COMMENT When there is any doubt—by patient or physician—cut it out and send it out (for biopsy).
A higher index of suspicion for PE could have been lifesaving
A 37-year-old morbidly obese man was recovering in a rehabilitation facility from spinal surgery performed 2 weeks earlier. On the day he was to be discharged, he was transported by ambulance to the emergency department (ED) complaining of “a syncopal episode” with weakness, lightheadedness, dizziness, and sweatiness. This was followed by a second episode with similar symptoms. The patient had no wheezes or rales and his heart rhythm was normal, with no murmurs or gallop. In the ED his pulse rose from 94 to 116 and his blood pressure (BP) rose from 106/82 to 145/102. An electrocardiogram (EKG) was abnormal.
The ED physician felt that the likelihood of pulmonary embolism (PE) was low; he suspected, instead, that it was “likely vagal syncope.” The patient returned to the rehab facility, stayed overnight, and was discharged the next day. Two days later, he became short of breath, passed out, and was taken by ambulance to the hospital, where resuscitation efforts were unsuccessful. Autopsy revealed the cause of death was pulmonary thromboemboli from deep vein thrombosis.
PLAINTIFF’S CLAIM The ED physician failed to rule out PE, which should have been considered because of the patient’s obesity, recent back surgery, immobilization, syncope, tachycardia, elevated BP, and abnormal EKG.
THE DEFENSE No information about the defense is available.
VERDICT $1.25 million Massachusetts settlement.
COMMENT Why the physician decided that this patient, who died of a PE, was at low risk for one is puzzling. I count at least 4 risk factors for PE: obesity, postoperative status, abnormal EKG, and tachycardia.
Inadequate evaluation of a mole has costly consequences
A 53-year-old woman went to her physician for treatment of a mole on her upper right arm, which she stated had grown and changed color. The physician burned it off without conducting a biopsy or follow-up. Fifteen months later, the patient returned to her physician because the scar was raised with small bumps. He referred her to a surgeon, who diagnosed malignant melanoma (Clark’s level V), with a satellite lesion but negative lymph nodes. The patient underwent surgery and adjuvant interferon-alpha therapy, which caused significant adverse effects.
The patient now has anxiety related to fears of recurrence or death, and must undergo regular positron emission tomography and computed tomography scans to evaluate her for recurrence.
PLAINTIFF’S CLAIM The melanoma should have been diagnosed at the patient’s initial presentation. If it had been diagnosed at that time, the patient would have had an 85% to 90% chance of survival, but because it wasn’t, her survival rate dropped to 60%.
THE DEFENSE No information about the defense is available.
VERDICT $750,000 Virginia settlement.
COMMENT When there is any doubt—by patient or physician—cut it out and send it out (for biopsy).
A higher index of suspicion for PE could have been lifesaving
A 37-year-old morbidly obese man was recovering in a rehabilitation facility from spinal surgery performed 2 weeks earlier. On the day he was to be discharged, he was transported by ambulance to the emergency department (ED) complaining of “a syncopal episode” with weakness, lightheadedness, dizziness, and sweatiness. This was followed by a second episode with similar symptoms. The patient had no wheezes or rales and his heart rhythm was normal, with no murmurs or gallop. In the ED his pulse rose from 94 to 116 and his blood pressure (BP) rose from 106/82 to 145/102. An electrocardiogram (EKG) was abnormal.
The ED physician felt that the likelihood of pulmonary embolism (PE) was low; he suspected, instead, that it was “likely vagal syncope.” The patient returned to the rehab facility, stayed overnight, and was discharged the next day. Two days later, he became short of breath, passed out, and was taken by ambulance to the hospital, where resuscitation efforts were unsuccessful. Autopsy revealed the cause of death was pulmonary thromboemboli from deep vein thrombosis.
PLAINTIFF’S CLAIM The ED physician failed to rule out PE, which should have been considered because of the patient’s obesity, recent back surgery, immobilization, syncope, tachycardia, elevated BP, and abnormal EKG.
THE DEFENSE No information about the defense is available.
VERDICT $1.25 million Massachusetts settlement.
COMMENT Why the physician decided that this patient, who died of a PE, was at low risk for one is puzzling. I count at least 4 risk factors for PE: obesity, postoperative status, abnormal EKG, and tachycardia.
Inadequate evaluation of a mole has costly consequences
A 53-year-old woman went to her physician for treatment of a mole on her upper right arm, which she stated had grown and changed color. The physician burned it off without conducting a biopsy or follow-up. Fifteen months later, the patient returned to her physician because the scar was raised with small bumps. He referred her to a surgeon, who diagnosed malignant melanoma (Clark’s level V), with a satellite lesion but negative lymph nodes. The patient underwent surgery and adjuvant interferon-alpha therapy, which caused significant adverse effects.
The patient now has anxiety related to fears of recurrence or death, and must undergo regular positron emission tomography and computed tomography scans to evaluate her for recurrence.
PLAINTIFF’S CLAIM The melanoma should have been diagnosed at the patient’s initial presentation. If it had been diagnosed at that time, the patient would have had an 85% to 90% chance of survival, but because it wasn’t, her survival rate dropped to 60%.
THE DEFENSE No information about the defense is available.
VERDICT $750,000 Virginia settlement.
COMMENT When there is any doubt—by patient or physician—cut it out and send it out (for biopsy).
A higher index of suspicion for PE could have been lifesaving
A 37-year-old morbidly obese man was recovering in a rehabilitation facility from spinal surgery performed 2 weeks earlier. On the day he was to be discharged, he was transported by ambulance to the emergency department (ED) complaining of “a syncopal episode” with weakness, lightheadedness, dizziness, and sweatiness. This was followed by a second episode with similar symptoms. The patient had no wheezes or rales and his heart rhythm was normal, with no murmurs or gallop. In the ED his pulse rose from 94 to 116 and his blood pressure (BP) rose from 106/82 to 145/102. An electrocardiogram (EKG) was abnormal.
The ED physician felt that the likelihood of pulmonary embolism (PE) was low; he suspected, instead, that it was “likely vagal syncope.” The patient returned to the rehab facility, stayed overnight, and was discharged the next day. Two days later, he became short of breath, passed out, and was taken by ambulance to the hospital, where resuscitation efforts were unsuccessful. Autopsy revealed the cause of death was pulmonary thromboemboli from deep vein thrombosis.
PLAINTIFF’S CLAIM The ED physician failed to rule out PE, which should have been considered because of the patient’s obesity, recent back surgery, immobilization, syncope, tachycardia, elevated BP, and abnormal EKG.
THE DEFENSE No information about the defense is available.
VERDICT $1.25 million Massachusetts settlement.
COMMENT Why the physician decided that this patient, who died of a PE, was at low risk for one is puzzling. I count at least 4 risk factors for PE: obesity, postoperative status, abnormal EKG, and tachycardia.
A disease that strikes close to home
Besides caring for these patients, many of us also have a parent, spouse, or a close relative with dementia. My 90-year-old mother has multi-infarct dementia from her diabetes and vascular disease, but is still able to live in an apartment with my 91-year-old father, with assistance from wonderful home aides. Despite her profound dementia, she can still play the piano and read music.
Menchola and Weiss are to be congratulated for their excellent, evidence-based review of the diagnosis, treatment, and prevention of Alzheimer’s disease (AD). (See "Addressing Alzheimer’s: A pragmatic approach.") They do not get caught up in unjustified enthusiasm for screening and drug treatment. Some of their important recommendations bear repeating here:
Do not routinely screen for AD. This may seem like heresy in these days of early detection and prevention. But for screening to be useful, there must be effective early interventions, and so far, early treatments for AD have been disappointing. Cholinesterase inhibitors and N-methyl-D-aspartate glutamate receptor blockers provide very small improvements in cognitive function and have significant adverse effects. Some behavioral interventions to delay onset of cognitive decline show promise—but are unproven.
Although routine screening is not recommended, “case finding” remains important. We need to be alert to signs and symptoms that suggest early dementia in our patients, and we need to evaluate these patients carefully or refer them for neurologic testing if the diagnosis is in doubt.
Use drugs sparingly, especially when treating behavioral problems. They have serious adverse effects, and behavioral interventions should always be used first. Encourage caregivers to seek out social support. My father attends an Alzheimer’s support group each month, and this has lifted some of the burden.
Address prognosis and end-of-life care, and avoid unnecessary and aggressive treatments that are likely to cause more harm than benefit. Hospice care is suitable and beneficial for those with late-stage Alzheimer’s, but feeding tubes are not.
With many new advances in research techniques, it is likely that investigators will develop better methods of diagnosis and treatment of AD. In the meantime, there is already much we can do to alleviate the suffering of these patients and support their caregivers. This knowledge will likely serve us at home, as well.
Besides caring for these patients, many of us also have a parent, spouse, or a close relative with dementia. My 90-year-old mother has multi-infarct dementia from her diabetes and vascular disease, but is still able to live in an apartment with my 91-year-old father, with assistance from wonderful home aides. Despite her profound dementia, she can still play the piano and read music.
Menchola and Weiss are to be congratulated for their excellent, evidence-based review of the diagnosis, treatment, and prevention of Alzheimer’s disease (AD). (See "Addressing Alzheimer’s: A pragmatic approach.") They do not get caught up in unjustified enthusiasm for screening and drug treatment. Some of their important recommendations bear repeating here:
Do not routinely screen for AD. This may seem like heresy in these days of early detection and prevention. But for screening to be useful, there must be effective early interventions, and so far, early treatments for AD have been disappointing. Cholinesterase inhibitors and N-methyl-D-aspartate glutamate receptor blockers provide very small improvements in cognitive function and have significant adverse effects. Some behavioral interventions to delay onset of cognitive decline show promise—but are unproven.
Although routine screening is not recommended, “case finding” remains important. We need to be alert to signs and symptoms that suggest early dementia in our patients, and we need to evaluate these patients carefully or refer them for neurologic testing if the diagnosis is in doubt.
Use drugs sparingly, especially when treating behavioral problems. They have serious adverse effects, and behavioral interventions should always be used first. Encourage caregivers to seek out social support. My father attends an Alzheimer’s support group each month, and this has lifted some of the burden.
Address prognosis and end-of-life care, and avoid unnecessary and aggressive treatments that are likely to cause more harm than benefit. Hospice care is suitable and beneficial for those with late-stage Alzheimer’s, but feeding tubes are not.
With many new advances in research techniques, it is likely that investigators will develop better methods of diagnosis and treatment of AD. In the meantime, there is already much we can do to alleviate the suffering of these patients and support their caregivers. This knowledge will likely serve us at home, as well.
Besides caring for these patients, many of us also have a parent, spouse, or a close relative with dementia. My 90-year-old mother has multi-infarct dementia from her diabetes and vascular disease, but is still able to live in an apartment with my 91-year-old father, with assistance from wonderful home aides. Despite her profound dementia, she can still play the piano and read music.
Menchola and Weiss are to be congratulated for their excellent, evidence-based review of the diagnosis, treatment, and prevention of Alzheimer’s disease (AD). (See "Addressing Alzheimer’s: A pragmatic approach.") They do not get caught up in unjustified enthusiasm for screening and drug treatment. Some of their important recommendations bear repeating here:
Do not routinely screen for AD. This may seem like heresy in these days of early detection and prevention. But for screening to be useful, there must be effective early interventions, and so far, early treatments for AD have been disappointing. Cholinesterase inhibitors and N-methyl-D-aspartate glutamate receptor blockers provide very small improvements in cognitive function and have significant adverse effects. Some behavioral interventions to delay onset of cognitive decline show promise—but are unproven.
Although routine screening is not recommended, “case finding” remains important. We need to be alert to signs and symptoms that suggest early dementia in our patients, and we need to evaluate these patients carefully or refer them for neurologic testing if the diagnosis is in doubt.
Use drugs sparingly, especially when treating behavioral problems. They have serious adverse effects, and behavioral interventions should always be used first. Encourage caregivers to seek out social support. My father attends an Alzheimer’s support group each month, and this has lifted some of the burden.
Address prognosis and end-of-life care, and avoid unnecessary and aggressive treatments that are likely to cause more harm than benefit. Hospice care is suitable and beneficial for those with late-stage Alzheimer’s, but feeding tubes are not.
With many new advances in research techniques, it is likely that investigators will develop better methods of diagnosis and treatment of AD. In the meantime, there is already much we can do to alleviate the suffering of these patients and support their caregivers. This knowledge will likely serve us at home, as well.
We need to step up to the plate (again)
What brought this report to mind was the October launch of the “Family Medicine for America’s Health” initiative at the American Academy of Family Physicians Assembly. The initiative, led by a collaboration of 8 family medicine organizations, seeks to organize and reinvigorate family medicine to respond to today’s health care challenges.
As detailed in an article in Annals of Family Medicine,2 the goals of Family Medicine for America’s Health are “... to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim.”2 The Triple Aim is an effort to create better health, better health care, and lower cost for patients and communities. Family Medicine for America’s Health “... is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.”2 Teams will develop initiatives in 6 areas—technology, practice, payment, workforce education, research, and engagement—to bring family medicine to the center stage of health care reform.
To quote the famous American philosopher Yogi Berra, “It’s déjà vu all over again.” Although we have clearly made significant progress over the past half century, family medicine has a long way to go. The landscape of health care in the United States has changed markedly, but the principles of family medicine remain the same. The implementation of these principles, however, is what is so difficult for us today.
That is why each of us needs to step up to the plate and work with our family medicine organizations to improve primary care delivery in the United States. Doing so will ensure that it is not “déjà vu all over again” 50 years from now.
1. Meeting the Challenge of Family Practice: The Report of the Ad Hoc Committee on Education for Family Practice of the Council on Medical Education. Chicago, IL: American Medical Association; 1966.
2. Phillips RL Jr, Pugno PA, Saultz JW, et al. Health is primary: Family Medicine for America’s Health. Ann Fam Med. 2014;12 suppl 1:S1-S12.
What brought this report to mind was the October launch of the “Family Medicine for America’s Health” initiative at the American Academy of Family Physicians Assembly. The initiative, led by a collaboration of 8 family medicine organizations, seeks to organize and reinvigorate family medicine to respond to today’s health care challenges.
As detailed in an article in Annals of Family Medicine,2 the goals of Family Medicine for America’s Health are “... to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim.”2 The Triple Aim is an effort to create better health, better health care, and lower cost for patients and communities. Family Medicine for America’s Health “... is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.”2 Teams will develop initiatives in 6 areas—technology, practice, payment, workforce education, research, and engagement—to bring family medicine to the center stage of health care reform.
To quote the famous American philosopher Yogi Berra, “It’s déjà vu all over again.” Although we have clearly made significant progress over the past half century, family medicine has a long way to go. The landscape of health care in the United States has changed markedly, but the principles of family medicine remain the same. The implementation of these principles, however, is what is so difficult for us today.
That is why each of us needs to step up to the plate and work with our family medicine organizations to improve primary care delivery in the United States. Doing so will ensure that it is not “déjà vu all over again” 50 years from now.
What brought this report to mind was the October launch of the “Family Medicine for America’s Health” initiative at the American Academy of Family Physicians Assembly. The initiative, led by a collaboration of 8 family medicine organizations, seeks to organize and reinvigorate family medicine to respond to today’s health care challenges.
As detailed in an article in Annals of Family Medicine,2 the goals of Family Medicine for America’s Health are “... to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim.”2 The Triple Aim is an effort to create better health, better health care, and lower cost for patients and communities. Family Medicine for America’s Health “... is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.”2 Teams will develop initiatives in 6 areas—technology, practice, payment, workforce education, research, and engagement—to bring family medicine to the center stage of health care reform.
To quote the famous American philosopher Yogi Berra, “It’s déjà vu all over again.” Although we have clearly made significant progress over the past half century, family medicine has a long way to go. The landscape of health care in the United States has changed markedly, but the principles of family medicine remain the same. The implementation of these principles, however, is what is so difficult for us today.
That is why each of us needs to step up to the plate and work with our family medicine organizations to improve primary care delivery in the United States. Doing so will ensure that it is not “déjà vu all over again” 50 years from now.
1. Meeting the Challenge of Family Practice: The Report of the Ad Hoc Committee on Education for Family Practice of the Council on Medical Education. Chicago, IL: American Medical Association; 1966.
2. Phillips RL Jr, Pugno PA, Saultz JW, et al. Health is primary: Family Medicine for America’s Health. Ann Fam Med. 2014;12 suppl 1:S1-S12.
1. Meeting the Challenge of Family Practice: The Report of the Ad Hoc Committee on Education for Family Practice of the Council on Medical Education. Chicago, IL: American Medical Association; 1966.
2. Phillips RL Jr, Pugno PA, Saultz JW, et al. Health is primary: Family Medicine for America’s Health. Ann Fam Med. 2014;12 suppl 1:S1-S12.
How to avoid diagnostic errors
As a generalist specialty, family medicine faces more diagnostic challenges than any other specialty because we see so many undifferentiated problems. However, only 2 family physicians attended this meeting: I was one, because of my research interests in proper use of lab testing, and John Ely, MD, from the University of Iowa, was the other. He has been researching diagnostic errors for most of his career. Dr. Ely has been testing an idea borrowed from aviation: using a diagnostic checklist. He developed a packet of note cards that lists the top 10 to 20 diagnoses for complaints commonly seen in family medicine, such as headache and abdominal pain. Before the patient leaves the exam room, he pulls out the appropriate checklist and goes through it out loud, just like a pilot before takeoff. He says for most patients, this process is pretty quick and it reassures both them and him that he has not missed an important diagnosis. (You can download Dr. Ely’s checklists from http://www.improvediagnosis.org/resource/resmgr/docs/diffdx.doc.)
How are the rest of us avoiding diagnostic errors? Some day IBM’s Watson or another diagnostic software program embedded in the electronic health record will guide us to the right diagnosis. In the meantime, I have developed a list of 7 low-tech ways to arrive at the correct diagnosis (and to rapidly correct a diagnostic error, should one occur):
2. Find out what dreaded diagnosis the patient believes he or she has so you can rule it in or out.
3. Don’t forget the pertinent past history. It makes a big difference if this is the patient’s first bad headache or the latest in a string of them.
4. Don’t skip the physical exam; even a negative exam, if documented properly, may keep you out of court.
5. Negotiate the diagnosis and treatment plan with the patient. This often brings out new information and new concerns.
6. Follow up, follow up, follow up, and do so in a timely manner.
7. Quickly reconsider your diagnosis and/or get a consultation if things are not going as expected.
As a generalist specialty, family medicine faces more diagnostic challenges than any other specialty because we see so many undifferentiated problems. However, only 2 family physicians attended this meeting: I was one, because of my research interests in proper use of lab testing, and John Ely, MD, from the University of Iowa, was the other. He has been researching diagnostic errors for most of his career. Dr. Ely has been testing an idea borrowed from aviation: using a diagnostic checklist. He developed a packet of note cards that lists the top 10 to 20 diagnoses for complaints commonly seen in family medicine, such as headache and abdominal pain. Before the patient leaves the exam room, he pulls out the appropriate checklist and goes through it out loud, just like a pilot before takeoff. He says for most patients, this process is pretty quick and it reassures both them and him that he has not missed an important diagnosis. (You can download Dr. Ely’s checklists from http://www.improvediagnosis.org/resource/resmgr/docs/diffdx.doc.)
How are the rest of us avoiding diagnostic errors? Some day IBM’s Watson or another diagnostic software program embedded in the electronic health record will guide us to the right diagnosis. In the meantime, I have developed a list of 7 low-tech ways to arrive at the correct diagnosis (and to rapidly correct a diagnostic error, should one occur):
2. Find out what dreaded diagnosis the patient believes he or she has so you can rule it in or out.
3. Don’t forget the pertinent past history. It makes a big difference if this is the patient’s first bad headache or the latest in a string of them.
4. Don’t skip the physical exam; even a negative exam, if documented properly, may keep you out of court.
5. Negotiate the diagnosis and treatment plan with the patient. This often brings out new information and new concerns.
6. Follow up, follow up, follow up, and do so in a timely manner.
7. Quickly reconsider your diagnosis and/or get a consultation if things are not going as expected.
As a generalist specialty, family medicine faces more diagnostic challenges than any other specialty because we see so many undifferentiated problems. However, only 2 family physicians attended this meeting: I was one, because of my research interests in proper use of lab testing, and John Ely, MD, from the University of Iowa, was the other. He has been researching diagnostic errors for most of his career. Dr. Ely has been testing an idea borrowed from aviation: using a diagnostic checklist. He developed a packet of note cards that lists the top 10 to 20 diagnoses for complaints commonly seen in family medicine, such as headache and abdominal pain. Before the patient leaves the exam room, he pulls out the appropriate checklist and goes through it out loud, just like a pilot before takeoff. He says for most patients, this process is pretty quick and it reassures both them and him that he has not missed an important diagnosis. (You can download Dr. Ely’s checklists from http://www.improvediagnosis.org/resource/resmgr/docs/diffdx.doc.)
How are the rest of us avoiding diagnostic errors? Some day IBM’s Watson or another diagnostic software program embedded in the electronic health record will guide us to the right diagnosis. In the meantime, I have developed a list of 7 low-tech ways to arrive at the correct diagnosis (and to rapidly correct a diagnostic error, should one occur):
2. Find out what dreaded diagnosis the patient believes he or she has so you can rule it in or out.
3. Don’t forget the pertinent past history. It makes a big difference if this is the patient’s first bad headache or the latest in a string of them.
4. Don’t skip the physical exam; even a negative exam, if documented properly, may keep you out of court.
5. Negotiate the diagnosis and treatment plan with the patient. This often brings out new information and new concerns.
6. Follow up, follow up, follow up, and do so in a timely manner.
7. Quickly reconsider your diagnosis and/or get a consultation if things are not going as expected.
Failure to properly manage a patient’s hypertension
Failure to properly manage a patient’s hypertension
A 44-YEAR-OLD MAN WHO WEIGHED >450 POUNDS went to his internist for treatment of hypertension. At a work-related physical the previous day, his blood pressure had been 160/110 mm Hg. After examination, the internist wrote a 30-day prescription for amlodipine, 5 mg/d, with 3 refills. The patient saw the physician 2 weeks later but not again until 3 months later. At that visit, the internist prescribed amlodipine, 5 mg/d, for 90 days with 2 refills. The patient missed his next appointment, which was set for 4 months later, but when his medication was about to run out, he was able to get a prescription for 10 months’ worth of amlodipine by phone. The patient died 2 months before the prescription ran out.
PLAINTIFF’S CLAIM The physician failed to properly manage and monitor the patient’s hypertension. The dosage of amlodipine was insufficient.
THE DEFENSE The patient was noncompliant and failed to show for follow-up appointments. The dosage of amlodipine was sufficient. The cause of death was unknown because no autopsy was performed.
VERDICT $136,000 New Jersey verdict.
COMMENT If we accept a patient into our practice, we need to have reasonable policies for patients to show up for follow-up, and to consider having them find another physician if they do not.
Did the patient’s age discourage proper evaluation?
THREE MONTHS AFTER NOTICING BLOOD IN HER STOOL, a 19-year-old woman went to see her physician. Without ordering a flexible sigmoidoscopy or colonoscopy, the physician diagnosed a healing anal fissure. Approximately 4 years later, the patient developed bloody diarrhea and went to a gastroenterologist, who found a 2.6 cm lesion in her rectum during a flexible sigmoidoscopy. Biopsy confirmed a low-grade adenocarcinoma. Imaging studies revealed that the cancer had spread to her lungs and liver, and she was diagnosed with Stage IV rectal cancer. After 2 years of extensive treatment that included surgical resection, conventional and experimental chemotherapy, and radiation therapy, the patient died.
PLAINTIFF’S CLAIM If the physician had ordered endoscopy exams when the patient first presented for treatment, testing could have identified a polyp or early-stage cancer.
THE DEFENSE No information about the defense is available.
VERDICT $2.5 million Maryland verdict.
COMMENT Colon cancer in a 19-year-old is extraordinarily rare. I doubt that the patient didn’t experience any more rectal bleeding until 4 years after she first sought treatment. A lesson in this tragic case is to be sure to document when you tell patients to “come back to see me right away if this happens again.”
23-year-old dies when myocarditis is mistaken for bronchitis
A 23-YEAR-OLD MAN PRESENTED TO THE EMERGENCY DEPARTMENT (ED) with chest tightness, cough, and fever. After a chest x-ray, the ED physician diagnosed bronchitis and sent the patient home with prescriptions for hydrocodone/acetaminophen and antibiotics. He was found dead in his bed less than 24 hours later. An autopsy determined the cause of death was myocarditis.
PLAINTIFF’S CLAIM The physician didn’t perform an electrocardiogram (EKG), which is a routine evaluation for a patient with chest pain. The EKG would have detected myocarditis.
THE DEFENSE The patient was evaluated properly. An EKG was not necessary.
VERDICT $2.9 million Massachusetts verdict.
COMMENT I think the jury got this one wrong. I don’t think an EKG is necessary for every case of acute bronchitis. However, I do wonder if the chest x-ray showed a large heart shadow.
Failure to properly manage a patient’s hypertension
A 44-YEAR-OLD MAN WHO WEIGHED >450 POUNDS went to his internist for treatment of hypertension. At a work-related physical the previous day, his blood pressure had been 160/110 mm Hg. After examination, the internist wrote a 30-day prescription for amlodipine, 5 mg/d, with 3 refills. The patient saw the physician 2 weeks later but not again until 3 months later. At that visit, the internist prescribed amlodipine, 5 mg/d, for 90 days with 2 refills. The patient missed his next appointment, which was set for 4 months later, but when his medication was about to run out, he was able to get a prescription for 10 months’ worth of amlodipine by phone. The patient died 2 months before the prescription ran out.
PLAINTIFF’S CLAIM The physician failed to properly manage and monitor the patient’s hypertension. The dosage of amlodipine was insufficient.
THE DEFENSE The patient was noncompliant and failed to show for follow-up appointments. The dosage of amlodipine was sufficient. The cause of death was unknown because no autopsy was performed.
VERDICT $136,000 New Jersey verdict.
COMMENT If we accept a patient into our practice, we need to have reasonable policies for patients to show up for follow-up, and to consider having them find another physician if they do not.
Did the patient’s age discourage proper evaluation?
THREE MONTHS AFTER NOTICING BLOOD IN HER STOOL, a 19-year-old woman went to see her physician. Without ordering a flexible sigmoidoscopy or colonoscopy, the physician diagnosed a healing anal fissure. Approximately 4 years later, the patient developed bloody diarrhea and went to a gastroenterologist, who found a 2.6 cm lesion in her rectum during a flexible sigmoidoscopy. Biopsy confirmed a low-grade adenocarcinoma. Imaging studies revealed that the cancer had spread to her lungs and liver, and she was diagnosed with Stage IV rectal cancer. After 2 years of extensive treatment that included surgical resection, conventional and experimental chemotherapy, and radiation therapy, the patient died.
PLAINTIFF’S CLAIM If the physician had ordered endoscopy exams when the patient first presented for treatment, testing could have identified a polyp or early-stage cancer.
THE DEFENSE No information about the defense is available.
VERDICT $2.5 million Maryland verdict.
COMMENT Colon cancer in a 19-year-old is extraordinarily rare. I doubt that the patient didn’t experience any more rectal bleeding until 4 years after she first sought treatment. A lesson in this tragic case is to be sure to document when you tell patients to “come back to see me right away if this happens again.”
23-year-old dies when myocarditis is mistaken for bronchitis
A 23-YEAR-OLD MAN PRESENTED TO THE EMERGENCY DEPARTMENT (ED) with chest tightness, cough, and fever. After a chest x-ray, the ED physician diagnosed bronchitis and sent the patient home with prescriptions for hydrocodone/acetaminophen and antibiotics. He was found dead in his bed less than 24 hours later. An autopsy determined the cause of death was myocarditis.
PLAINTIFF’S CLAIM The physician didn’t perform an electrocardiogram (EKG), which is a routine evaluation for a patient with chest pain. The EKG would have detected myocarditis.
THE DEFENSE The patient was evaluated properly. An EKG was not necessary.
VERDICT $2.9 million Massachusetts verdict.
COMMENT I think the jury got this one wrong. I don’t think an EKG is necessary for every case of acute bronchitis. However, I do wonder if the chest x-ray showed a large heart shadow.
Failure to properly manage a patient’s hypertension
A 44-YEAR-OLD MAN WHO WEIGHED >450 POUNDS went to his internist for treatment of hypertension. At a work-related physical the previous day, his blood pressure had been 160/110 mm Hg. After examination, the internist wrote a 30-day prescription for amlodipine, 5 mg/d, with 3 refills. The patient saw the physician 2 weeks later but not again until 3 months later. At that visit, the internist prescribed amlodipine, 5 mg/d, for 90 days with 2 refills. The patient missed his next appointment, which was set for 4 months later, but when his medication was about to run out, he was able to get a prescription for 10 months’ worth of amlodipine by phone. The patient died 2 months before the prescription ran out.
PLAINTIFF’S CLAIM The physician failed to properly manage and monitor the patient’s hypertension. The dosage of amlodipine was insufficient.
THE DEFENSE The patient was noncompliant and failed to show for follow-up appointments. The dosage of amlodipine was sufficient. The cause of death was unknown because no autopsy was performed.
VERDICT $136,000 New Jersey verdict.
COMMENT If we accept a patient into our practice, we need to have reasonable policies for patients to show up for follow-up, and to consider having them find another physician if they do not.
Did the patient’s age discourage proper evaluation?
THREE MONTHS AFTER NOTICING BLOOD IN HER STOOL, a 19-year-old woman went to see her physician. Without ordering a flexible sigmoidoscopy or colonoscopy, the physician diagnosed a healing anal fissure. Approximately 4 years later, the patient developed bloody diarrhea and went to a gastroenterologist, who found a 2.6 cm lesion in her rectum during a flexible sigmoidoscopy. Biopsy confirmed a low-grade adenocarcinoma. Imaging studies revealed that the cancer had spread to her lungs and liver, and she was diagnosed with Stage IV rectal cancer. After 2 years of extensive treatment that included surgical resection, conventional and experimental chemotherapy, and radiation therapy, the patient died.
PLAINTIFF’S CLAIM If the physician had ordered endoscopy exams when the patient first presented for treatment, testing could have identified a polyp or early-stage cancer.
THE DEFENSE No information about the defense is available.
VERDICT $2.5 million Maryland verdict.
COMMENT Colon cancer in a 19-year-old is extraordinarily rare. I doubt that the patient didn’t experience any more rectal bleeding until 4 years after she first sought treatment. A lesson in this tragic case is to be sure to document when you tell patients to “come back to see me right away if this happens again.”
23-year-old dies when myocarditis is mistaken for bronchitis
A 23-YEAR-OLD MAN PRESENTED TO THE EMERGENCY DEPARTMENT (ED) with chest tightness, cough, and fever. After a chest x-ray, the ED physician diagnosed bronchitis and sent the patient home with prescriptions for hydrocodone/acetaminophen and antibiotics. He was found dead in his bed less than 24 hours later. An autopsy determined the cause of death was myocarditis.
PLAINTIFF’S CLAIM The physician didn’t perform an electrocardiogram (EKG), which is a routine evaluation for a patient with chest pain. The EKG would have detected myocarditis.
THE DEFENSE The patient was evaluated properly. An EKG was not necessary.
VERDICT $2.9 million Massachusetts verdict.
COMMENT I think the jury got this one wrong. I don’t think an EKG is necessary for every case of acute bronchitis. However, I do wonder if the chest x-ray showed a large heart shadow.
EHRs: Something’s gotta give
Clicking on a checklist of symptoms seldom provides sufficient information about the patient’s illness. “Hypertension” and “type 2 diabetes” are not assessments; they are diagnoses that do not tell the person reading the electronic health record (EHR) how the patient is doing. A diagnosis of “abdominal pain” without a prioritized differential is inadequate, especially in court.
Why is visit documentation too often inadequate? I am convinced it is rarely due to clinician incompetence, laziness, or lack of knowledge, but nearly always due to a combination of inadequate EHR formats and billing documentation requirements that encourage quantity rather than quality. Documentation is no longer driven by the essential need to record the care provided.
I’m sure a lot of you are nodding your heads in agreement. You all know what those EHR notes look like—cluttered with cut-and-pasted information drawn from prior encounters that document no end of details regarding medical, family, and social histories, facts that are often completely irrelevant to the reason the patient is in the office today. And unless one meticulously updates those other elements of the patient’s record, this information pulled into the note may be inaccurate.
I am not the only one complaining. The American Medical Association just published Improving Care: Priorities to Improve Electronic Health Record Usability,1 which outlines 8 priorities for EHR improvement. The first is to “Enhance physicians’ ability to provide high-quality patient care.” I could not agree more. I think today’s EHRs are like an old-fashioned crank phone and what we really need is an iPhone.
Something has got to change.
So tell me: Have any of you figured out how to use your EHR to enhance the quality of your documentation?
Reference
1. American Medical Association. Improving Care: Priorities to Improve Electronic Health Record Usability. American Medical Association Web site. Available at: https://download.ama-assn.org/resources/doc/ps2/x-pub/ehr-priorities.pdf. Accessed September 18, 2014.
Clicking on a checklist of symptoms seldom provides sufficient information about the patient’s illness. “Hypertension” and “type 2 diabetes” are not assessments; they are diagnoses that do not tell the person reading the electronic health record (EHR) how the patient is doing. A diagnosis of “abdominal pain” without a prioritized differential is inadequate, especially in court.
Why is visit documentation too often inadequate? I am convinced it is rarely due to clinician incompetence, laziness, or lack of knowledge, but nearly always due to a combination of inadequate EHR formats and billing documentation requirements that encourage quantity rather than quality. Documentation is no longer driven by the essential need to record the care provided.
I’m sure a lot of you are nodding your heads in agreement. You all know what those EHR notes look like—cluttered with cut-and-pasted information drawn from prior encounters that document no end of details regarding medical, family, and social histories, facts that are often completely irrelevant to the reason the patient is in the office today. And unless one meticulously updates those other elements of the patient’s record, this information pulled into the note may be inaccurate.
I am not the only one complaining. The American Medical Association just published Improving Care: Priorities to Improve Electronic Health Record Usability,1 which outlines 8 priorities for EHR improvement. The first is to “Enhance physicians’ ability to provide high-quality patient care.” I could not agree more. I think today’s EHRs are like an old-fashioned crank phone and what we really need is an iPhone.
Something has got to change.
So tell me: Have any of you figured out how to use your EHR to enhance the quality of your documentation?
Clicking on a checklist of symptoms seldom provides sufficient information about the patient’s illness. “Hypertension” and “type 2 diabetes” are not assessments; they are diagnoses that do not tell the person reading the electronic health record (EHR) how the patient is doing. A diagnosis of “abdominal pain” without a prioritized differential is inadequate, especially in court.
Why is visit documentation too often inadequate? I am convinced it is rarely due to clinician incompetence, laziness, or lack of knowledge, but nearly always due to a combination of inadequate EHR formats and billing documentation requirements that encourage quantity rather than quality. Documentation is no longer driven by the essential need to record the care provided.
I’m sure a lot of you are nodding your heads in agreement. You all know what those EHR notes look like—cluttered with cut-and-pasted information drawn from prior encounters that document no end of details regarding medical, family, and social histories, facts that are often completely irrelevant to the reason the patient is in the office today. And unless one meticulously updates those other elements of the patient’s record, this information pulled into the note may be inaccurate.
I am not the only one complaining. The American Medical Association just published Improving Care: Priorities to Improve Electronic Health Record Usability,1 which outlines 8 priorities for EHR improvement. The first is to “Enhance physicians’ ability to provide high-quality patient care.” I could not agree more. I think today’s EHRs are like an old-fashioned crank phone and what we really need is an iPhone.
Something has got to change.
So tell me: Have any of you figured out how to use your EHR to enhance the quality of your documentation?
Reference
1. American Medical Association. Improving Care: Priorities to Improve Electronic Health Record Usability. American Medical Association Web site. Available at: https://download.ama-assn.org/resources/doc/ps2/x-pub/ehr-priorities.pdf. Accessed September 18, 2014.
Reference
1. American Medical Association. Improving Care: Priorities to Improve Electronic Health Record Usability. American Medical Association Web site. Available at: https://download.ama-assn.org/resources/doc/ps2/x-pub/ehr-priorities.pdf. Accessed September 18, 2014.
Can a plant-based diet really reverse CAD?
We can all agree that this study is not the definitive study of this highly restrictive vegetarian diet. It is a case series of highly motivated patients, and we do not know how these findings would apply to others. Dr. Esselstyn and his colleagues admit that “(w)ithout a control group, it is challenging to establish causality and assess how much of the observed changes are specifically due to the diet.”
I think we can agree, too, that case series can lead us astray. A good example is the randomized trials of knee arthroscopy for relief of knee pain from meniscal tears that found lack of benefit compared to earlier case series that showed significant improvement (see “Surgery for persistent knee pain? Not so fast”). In a case series, it is not possible to answer the important question: compared to what? Without a control group and randomization, we cannot know if outcomes are due to the treatment, another factor, or the natural course of the disease.
On the other hand, case series can be the first step in medical breakthroughs. The first known successful trial of penicillin was a case series of 5 patients with eye infections performed in 1930,2 and the first published description of acquired immunodeficiency syndrome involved case reports of 5 patients with pneumocystis carinii pneumonia.3
In the present case, I was intrigued by Dr. Esselstyn’s findings and believe the methods and biological plausibility were good enough to get the word out, mostly to stimulate others’ thinking and actions. That is why, after the manuscript underwent peer review, we decided to publish it.
In a separate letter to me, Dr. Silverstein wrote, “Sometimes if something seems too good to be true, it isn’t [true].” I could not agree more. But the flip side of that statement is that sometimes something that seems too good to be true, actually is true.
We do not yet know which of these statements applies to Dr. Esselstyn’s work. I do, however, agree with Dr. Esselstyn and his colleagues that “...the time is right for a controlled trial.”
1. Esselstyn CB, Gendy G, Doyle J, et al. A way to reverse CAD? J Fam Pract. 2014;63:356-364,364a,364b.
2. Wainwright M, Swan HT. C.G. Paine and the earliest surviving clinical records of penicillin therapy. Med Hist. 1986;30:42-56.
3. Centers for Disease Control (CDC). Pneumocystis pneumonia—Los Angeles. MMWR Morb Mortal Wkly Rep. 1981;30:250-252.
We can all agree that this study is not the definitive study of this highly restrictive vegetarian diet. It is a case series of highly motivated patients, and we do not know how these findings would apply to others. Dr. Esselstyn and his colleagues admit that “(w)ithout a control group, it is challenging to establish causality and assess how much of the observed changes are specifically due to the diet.”
I think we can agree, too, that case series can lead us astray. A good example is the randomized trials of knee arthroscopy for relief of knee pain from meniscal tears that found lack of benefit compared to earlier case series that showed significant improvement (see “Surgery for persistent knee pain? Not so fast”). In a case series, it is not possible to answer the important question: compared to what? Without a control group and randomization, we cannot know if outcomes are due to the treatment, another factor, or the natural course of the disease.
On the other hand, case series can be the first step in medical breakthroughs. The first known successful trial of penicillin was a case series of 5 patients with eye infections performed in 1930,2 and the first published description of acquired immunodeficiency syndrome involved case reports of 5 patients with pneumocystis carinii pneumonia.3
In the present case, I was intrigued by Dr. Esselstyn’s findings and believe the methods and biological plausibility were good enough to get the word out, mostly to stimulate others’ thinking and actions. That is why, after the manuscript underwent peer review, we decided to publish it.
In a separate letter to me, Dr. Silverstein wrote, “Sometimes if something seems too good to be true, it isn’t [true].” I could not agree more. But the flip side of that statement is that sometimes something that seems too good to be true, actually is true.
We do not yet know which of these statements applies to Dr. Esselstyn’s work. I do, however, agree with Dr. Esselstyn and his colleagues that “...the time is right for a controlled trial.”
We can all agree that this study is not the definitive study of this highly restrictive vegetarian diet. It is a case series of highly motivated patients, and we do not know how these findings would apply to others. Dr. Esselstyn and his colleagues admit that “(w)ithout a control group, it is challenging to establish causality and assess how much of the observed changes are specifically due to the diet.”
I think we can agree, too, that case series can lead us astray. A good example is the randomized trials of knee arthroscopy for relief of knee pain from meniscal tears that found lack of benefit compared to earlier case series that showed significant improvement (see “Surgery for persistent knee pain? Not so fast”). In a case series, it is not possible to answer the important question: compared to what? Without a control group and randomization, we cannot know if outcomes are due to the treatment, another factor, or the natural course of the disease.
On the other hand, case series can be the first step in medical breakthroughs. The first known successful trial of penicillin was a case series of 5 patients with eye infections performed in 1930,2 and the first published description of acquired immunodeficiency syndrome involved case reports of 5 patients with pneumocystis carinii pneumonia.3
In the present case, I was intrigued by Dr. Esselstyn’s findings and believe the methods and biological plausibility were good enough to get the word out, mostly to stimulate others’ thinking and actions. That is why, after the manuscript underwent peer review, we decided to publish it.
In a separate letter to me, Dr. Silverstein wrote, “Sometimes if something seems too good to be true, it isn’t [true].” I could not agree more. But the flip side of that statement is that sometimes something that seems too good to be true, actually is true.
We do not yet know which of these statements applies to Dr. Esselstyn’s work. I do, however, agree with Dr. Esselstyn and his colleagues that “...the time is right for a controlled trial.”
1. Esselstyn CB, Gendy G, Doyle J, et al. A way to reverse CAD? J Fam Pract. 2014;63:356-364,364a,364b.
2. Wainwright M, Swan HT. C.G. Paine and the earliest surviving clinical records of penicillin therapy. Med Hist. 1986;30:42-56.
3. Centers for Disease Control (CDC). Pneumocystis pneumonia—Los Angeles. MMWR Morb Mortal Wkly Rep. 1981;30:250-252.
1. Esselstyn CB, Gendy G, Doyle J, et al. A way to reverse CAD? J Fam Pract. 2014;63:356-364,364a,364b.
2. Wainwright M, Swan HT. C.G. Paine and the earliest surviving clinical records of penicillin therapy. Med Hist. 1986;30:42-56.
3. Centers for Disease Control (CDC). Pneumocystis pneumonia—Los Angeles. MMWR Morb Mortal Wkly Rep. 1981;30:250-252.
Diabetes care: Whose goals are they?
Words are important, and the language of medicine is changing. Two words that have taken on great importance in health care are “goals” and “targets.” A portion of primary care physicians’ compensation for caring for patients with diabetes, hypertension, and hyperlipidemia depends on our patients achieving certain goals and targets for blood sugar, blood pressure (BP), and lipids, as summarized for type 2 diabetes in “Is your patient on target? Optimizing diabetes management” by Harmes and Cigolle. Based on randomized trials published during the past several years, the “official” US goal for glucose control should be customized to fit patients’ individual risk profiles, although 7% is still recommended for younger and healthier patients with diabetes. Based on randomized trial data, the BP target is less stringent than in the past—now 140/90 mm Hg for all patients with hypertension, including those with diabetes, although not all experts agree with this newer recommendation.
We have entered a confusing time regarding lipid control because of the new and controversial guidelines to treat patients based on risk of cardiovascular disease rather than treating to a specific low-density lipoprotein cholesterol target.
Whose goals and targets are these? We know they are goals for insurance companies and health plans because they send us reports and pay us incentives when enough of our patients hit the targets (or penalize us if they don’t).
They are our goals, too, because we know that, to some extent, our patient’s likelihood of bad things happening to them is linked to their blood sugar, BP, and lipid control.
Ultimately, these have to be our patients’ goals, because they are the ones who have to buy into taking medications, which have costs, risks, and side effects, and altering their lifestyles, which is difficult for most.
Goal setting is an effective method for helping people increase physical activity and improve their diets.1 This requires negotiating with patients about what they believe is achievable. In addition, these goals need not be the same as the targets proposed by the experts. Even the American Diabetes Association has come around to the idea that patients should have some flexibility and that one hemoglobin A1c target does not fit all. I like the idea of sharing a simple “report card” with patients at each visit that lists the A (A1c), B (BP), and C (cholesterol) targets and the patient’s most recent values. Point-of-care testing allows for immediate feedback and medication adjustment.
What tools do you use to help your patients achieve their diabetes goals?
REFERENCE
1. Greaves CJ, Sheppard KE, Abraham C, et al; IMAGE Study Group. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health. 2011;11:119.
Words are important, and the language of medicine is changing. Two words that have taken on great importance in health care are “goals” and “targets.” A portion of primary care physicians’ compensation for caring for patients with diabetes, hypertension, and hyperlipidemia depends on our patients achieving certain goals and targets for blood sugar, blood pressure (BP), and lipids, as summarized for type 2 diabetes in “Is your patient on target? Optimizing diabetes management” by Harmes and Cigolle. Based on randomized trials published during the past several years, the “official” US goal for glucose control should be customized to fit patients’ individual risk profiles, although 7% is still recommended for younger and healthier patients with diabetes. Based on randomized trial data, the BP target is less stringent than in the past—now 140/90 mm Hg for all patients with hypertension, including those with diabetes, although not all experts agree with this newer recommendation.
We have entered a confusing time regarding lipid control because of the new and controversial guidelines to treat patients based on risk of cardiovascular disease rather than treating to a specific low-density lipoprotein cholesterol target.
Whose goals and targets are these? We know they are goals for insurance companies and health plans because they send us reports and pay us incentives when enough of our patients hit the targets (or penalize us if they don’t).
They are our goals, too, because we know that, to some extent, our patient’s likelihood of bad things happening to them is linked to their blood sugar, BP, and lipid control.
Ultimately, these have to be our patients’ goals, because they are the ones who have to buy into taking medications, which have costs, risks, and side effects, and altering their lifestyles, which is difficult for most.
Goal setting is an effective method for helping people increase physical activity and improve their diets.1 This requires negotiating with patients about what they believe is achievable. In addition, these goals need not be the same as the targets proposed by the experts. Even the American Diabetes Association has come around to the idea that patients should have some flexibility and that one hemoglobin A1c target does not fit all. I like the idea of sharing a simple “report card” with patients at each visit that lists the A (A1c), B (BP), and C (cholesterol) targets and the patient’s most recent values. Point-of-care testing allows for immediate feedback and medication adjustment.
What tools do you use to help your patients achieve their diabetes goals?
Words are important, and the language of medicine is changing. Two words that have taken on great importance in health care are “goals” and “targets.” A portion of primary care physicians’ compensation for caring for patients with diabetes, hypertension, and hyperlipidemia depends on our patients achieving certain goals and targets for blood sugar, blood pressure (BP), and lipids, as summarized for type 2 diabetes in “Is your patient on target? Optimizing diabetes management” by Harmes and Cigolle. Based on randomized trials published during the past several years, the “official” US goal for glucose control should be customized to fit patients’ individual risk profiles, although 7% is still recommended for younger and healthier patients with diabetes. Based on randomized trial data, the BP target is less stringent than in the past—now 140/90 mm Hg for all patients with hypertension, including those with diabetes, although not all experts agree with this newer recommendation.
We have entered a confusing time regarding lipid control because of the new and controversial guidelines to treat patients based on risk of cardiovascular disease rather than treating to a specific low-density lipoprotein cholesterol target.
Whose goals and targets are these? We know they are goals for insurance companies and health plans because they send us reports and pay us incentives when enough of our patients hit the targets (or penalize us if they don’t).
They are our goals, too, because we know that, to some extent, our patient’s likelihood of bad things happening to them is linked to their blood sugar, BP, and lipid control.
Ultimately, these have to be our patients’ goals, because they are the ones who have to buy into taking medications, which have costs, risks, and side effects, and altering their lifestyles, which is difficult for most.
Goal setting is an effective method for helping people increase physical activity and improve their diets.1 This requires negotiating with patients about what they believe is achievable. In addition, these goals need not be the same as the targets proposed by the experts. Even the American Diabetes Association has come around to the idea that patients should have some flexibility and that one hemoglobin A1c target does not fit all. I like the idea of sharing a simple “report card” with patients at each visit that lists the A (A1c), B (BP), and C (cholesterol) targets and the patient’s most recent values. Point-of-care testing allows for immediate feedback and medication adjustment.
What tools do you use to help your patients achieve their diabetes goals?
REFERENCE
1. Greaves CJ, Sheppard KE, Abraham C, et al; IMAGE Study Group. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health. 2011;11:119.
REFERENCE
1. Greaves CJ, Sheppard KE, Abraham C, et al; IMAGE Study Group. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health. 2011;11:119.