Beyond The Doctor's Bag

The Pathophysiology of Bad Doctors

When I was in training, I worked under senior physicians who provided compassionate care to their patients. They were great role models. But I also witnessed supervising doctors who were not so nice. They made fun of our patients when we were on hospital rounds or in the operating room (after patients were sedated with anesthesia) and bullied medical students, residents, and nurses. 

 As I observe the behavior of attending physicians and doctors-in-training, I find unprofessionalism in medical culture to continue. But we make up excuses to justify our bad behavior. We work long hours, face extraordinary stressful situations, and endure a long period of training that at times resembles the hazing period of rushing for a fraternity. In order to curb our bad behavior, medical educators have attempted to teach professionalism in medical schools. I took some of these professionalism and ethics classes when I was in training. While I found them interesting, I’m unsure if they really helped.  

Why do we doctors become bad? It’s complicated but I think the answer may lie in this medical student’s observation:

The chief barrier to medical professionalism education is unprofessional conduct by medical educators.

Those of us who teach residents and medical students have a profound impact on the professionalism of doctors because we set the boundaries for both appropriate and inappropriate behavior. Theresa Brown, an oncology nurse, wrote an article in the NY Times in which she states:

Because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

There is no vaccine to prevent unprofessionalism in medicine. But the disease of bad behavior can spread like a virulent virus. Even a small number of attending physicians behaving badly can negatively influence a future generation of doctors. 

Architects can save lives.  

Last week at a Global Health Conference I listened to a talk given by Michael Murphy who runs the organization MASS Design Group. MASS designed the Butaro Hospital in Rwanda in collaboration with Partners in Health. In order to reduce the transmission of Tuberculosis-an airborne pathogen-within the hospital, they designed the buildings to allow for natural ventilation and left out hallways (an unventilated area where patients are often boarded, even in US hospitals). Keeping sustainability in mind, MASS made use of local materials (like nearby volcanic rock) and hired Rwandan laborers. On top of that, the hospital looks amazing. 

I’m a big fan of MASS and I wish that more hospitals in the US could be put as much innovation and thought into the design of their healthcare facilities. 

The Billion Dollar Urinary Tract Infection

As an Independent, I am no fan of many (most!) stances taken by the current Republican House leadership - particularly with regards to the provision of healthcare and ensuring healthcare coverage (see previous post regarding cost advantages of single-payer and check out Physicians for a National Health Program or National Physicians Alliance) on importance of universal access to healthcare rather than universal insurance). Nonetheless, I appreciated the willingness and courage of Wisconsin Representative Paul Ryan to bring up the need to reform the Medicaid and Medicare programs.

As a primary care physician (PCP) at an academic practice, I see a large number of patients with Medicaid (~45%) and Medicare (~15%). The numbers also illustrate that Bon - and other ED physicians - will see and evaluate a large number of Medicaid patients. However, many physicians (both specialists and PCPs) have been opting-out of the Medicaid system due to low payments (at times <50% of the reimbursement provided by private insurers). This makes access a challenge for the individuals living in poverty who qualify for Medicaid. Moreover, evidence demonstrates that the lack of a regular source of care is associated with increased utilization of the emergency department . This increase in utilization may be appropriate in some cases due for example to the need for emergent stabilization of an acute exacerbation of a poorly managed chronic problem (e.g., an asthma attack or diabetic ketoacidosis). However, in many cases, care could (and should!) be provided in other (less expensive) venues. Indeed, we know that high-quality primary care delivered by empathetic physicians can lead to improved management of chronic conditions and that follow-up with PCPs can prevent rehospitalizations and reduce costs. Therefore, by recommending cuts to Medicaid, Representative Ryan’s efforts to control our future healthcare costs may instead actually lead to *increased* costs due to less efficient use of the healthcare system.

As individuals - patients and physicians - we absolutely have the power to potentially “bend” the cost curve, but to do so, we need to closely evaluate our actions. Physicians should prescribe generics when possible, and should encourage the efforts of medical extenders such as physician assistants and advance practice nurses (APNs) such as specialty-certified registered nurse practitioners (CRNPs) to provide care to the limits of their training and capacity (and provide appropriate back-up and support to these colleagues). We should also handle what medical issues we can for established patients through telemedicine (check out the model promulgated by Jay Parkinson. Patients for their part must not be shy about reporting symptoms, side-effects or barriers that may be preventing them from complying with treatment recommendations or follow-up schedule.

A perfect example of how significant costs could be saved while preserving access, quality of care, and patient satisfaction is with urinary tract infections (UTIs). Approximatley 50% of women will have a UTI in their lifetime, and about 20% of those who have one UTI will have another. According to the CDC and other sources, UTIs account for some 4-5 million outpatient visits per year (1% of total) and 1 million ED visits. Like many things, however, just because something happens frequently, doesn’t make it either necessary or right.

As any woman who has suffered a UTI can tell you, their onset is not typically particularly subtle. Women often report increased urinary frequency, dysuria (painful urination), and/or change in urine odor, and are quite capable of accurately identifying these symptoms when they recur. Since high-quality evidence also supports empiric treatment of uncomplicated UTIs with 3 days of antibiotics, it seems evident that not only should fewer women require ED evaluation for UTIs, but also that fewer women should require in-person evaluation of UTIs in their PCP’s offices either. The majority of adult women with UTI symptoms should be able to contact their PCP’s office and receive appropriate antibiotic therapy after a few quick questions to rule-out pyelonephritis (kidney infection) and sepsis and a review of precautions to call back or come in for a visit should their symptoms fail to resolve on treatment. Given the high prevalence of yeast infections following treatment with antibiotics, prescriptions for safe and well-tested medications to treat this common and well-understood side-effect (e.g., oral fluconazole, miconazole cream, etc.) should also be provided at the same time for use on an as-needed basis.

Unfortunately, the current reimbursement system does *not* incentivize me to provide this kind of evidence-based, rapid, responsive, and patient-centered care. I am not allowed to charge for telephone consultation under Medicaid (most providers in most States). Thus, each time I save the system money - and more importantly, save my patients from delays in treatment and the time and monetary costs of an appointment with me - by doing the “right” thing, I am undercutting the viability of my practice, not to mention giving my wife another reason to glare at me and my pager. Importantly, by pre-empting an unnecessary office visit by these patients, access is improved for those patients with challenging chronic issues that we mentioned above.

For those interested in the bottom line, some quick “back-of-the-envelope” calculations demonstrate that if we (very) conservatively assume that 50% of the 1 million women who are seen in the ED (avg cost ~$500) could be seen instead in their PCP’s office (avg cost ~$65), and that 40% of the 5 million women evaluated for UTIs in their PCP’s office could be safely managed by phone/email (currently $0 to system), almost $350 million would be saved on an annual basis without even taking into consideration reductions in lab costs, prevention of lost productivity, and improved quality of life. Although not a large number in relation to total healthcare costs, that’s still $3.5 billion over 10 years which could be invested. So is this idea just pie in the sky? I don’t believe so, because guidelines that allow for this type of treatment are in existence and have worked well. One might ask why similar guidelines haven’t been promulgated everywhere.

As always, I would love to hear your thoughts and any recommendations you might have for better aligning physician incentives with more efficient and appropriate patient care.

Full disclosure: Please note that I am a member of both NPA and PNHP. I have elected to join and support these organizations rather than the AMA precisely because in my opinion they more clearly emphasize the primacy of the well-being of our patients and our nation above that of physicians.

This weekend, I was able to attend a small local student-run conference on Global Health.  For those out there who are cynical about our nation’s youth - and the medical establishment! - this experience was a great elixir.  Faculty (including Dr. Asgary - featured recently in NY Times), students, and refugees spoke of their experiences with the healthcare system, and more importantly identified specific, obtainable goals to improve the transition of refugees during the resettlement process.  Some of the projects include - development and expansion of community gardens in Philadelphia to maintain connection with traditional foods and to enhance nutrition, assisting in the development of health education programs and English as a Second Language (ESL) classes both at a local resettlement agency and at a refugee camp in Thailand for the Karen Burmese, developing an interprofessional program involving physicians and pharmacists, community leaders and NGOs, to enhance understanding of medication regimens (dosing, refills, etc.) among refugees, and pursuing additional training to enhance practitioners’ ability to identify and characterize signs or symptoms of torture.
 
For those who may be unaware, approximately 80,000 refugees are *legally* admitted to the US each year due to an inability to safely return home.  They are all screened prior to departure from their refugee camps, and none are permitted to travel with Class A conditions.  Once they arrive in the US, they are provided with medical care (typically through State Medicaid programs) for 8 months, after which they are expected to obtain insurance through their employers (or in the case of children, through State Children’s Health Insurance Programs (SCHIPs)).  During that time, they are screened (again) for infectious disease, receive vaccinations, and - hopefully! - provided with preventative care and care for chronic conditions such as hypertension and diabetes (Note: Cardiovascular Disease has become the #1 cause of death in the developing world).
 
Obviously, in an environment where access to care - and caring healthcare providers - is a challenge for many, this begs the question of where our efforts and limited should best be targetted.  Personally, I believe that any cause which can inspire the level of passion and excitement that I saw this week (and have witnessed working with colleagues, residents, and students from across the spectrum of healthcare) is a worthwhile cause in that it will ultimately benefit society as a whole by “hooking” future providers as advocates for and with vulnerable communities.  Not everyone will work with Doctors Without Borders, but many more who remain in the US may end up working in public health and primary care, working with marginalized populations, and being better prepared to identify systemic barriers to care.  I’d love to hear your thoughts and comments!

My father-in-law died in the operating room 6 years ago during an elective open heart surgery.  This article highlights that the use of statistics when making important medical decisions can be complicated.  Informed medical decision making is hard—even when you’re a doctor.