Health Care Reform With Out High Tech: Changing a Culture of Fatness to a Culture of Fitness

photo: flickr.com

 

President Obama has a stimulus package all ready to roll out.  Reportedly, it will include money ear marked to expand COBRA.  If this is true, there will be precious little left to fund the ‘everybody has to have an EMR’ mandate.

Good, I say.  Let’s work on some low tech solutions that will reap true benefits.  Yes, I admit that the low tech, grunt it out in the trenches approach is not nearly as sexy as an EMR with bells and whistles, but this time, I think low tech will trump high tech.  Here goes the PookieMD save the world through hard work approach:

First, focus on America’s growing middle.  Here are five low tech ways to cut the fat and increase activity.  (Literally and figuratively!)  I will work from the global to the micro.

1. Mandate the physical education be held every day from kindergarten through 12th grade.  Our plump kids are the diabetics  and cardiac stentees of tomorrow.   Making time for health now will pay off immensely later as we make physical movement a daily part of children’s day.  (By the way, cup stacking is not a sport!  Getting the heart rate up counts!  For a great look on what happens when schools institute a required daily physical education class read Spark, by John Ratey, MD.  Hint: test scores go up, learning improves and discipline problems go down.  Pretty good for having a bunch of kids run around a track!)
2. Offer tax benefits to companies that have in house exercise programs.  Tax benefits would be proportional to percentage of employees participating.  We need to change the culture of fatness into a culture of fitness.
3. Get your office workers in shape.  With all due respect, many times the office help are bigger than the patients.  One practice I know had a very successful biggest loser competition.  Why don’t YOU sponsor it, and include yourself? Consider a small prize (gift basket with soaps/lotions?) for the biggest loser.  Of course, absentee rates and sick days will go down as you and your staff get more fit.
4. Make fitness a part of your office culture.  Have info on health clubs, classes, rec centers available.  Consider a group visit for obese patients, focusing on exercise. Do group walks, enter a 3 k, host a weight watcher type group, do SOMETHING.  Getting your office in the news would be a nice side benefit.
5. Encourage patients to “chunk”.  (No we don’t want chunky patients!)  The surgeon general recommends 30 minutes of exercise daily.  Encourage the couch  potatoes to start by walking 15 minutes two times a day, or 10 minutes 3 times per day.  There is no law that says it should be all at once, although it’s a good goal.  For the  obese, a gym can be intimidating, so start simple: encourage walking, then jogging, and then maybe a trip to the gym.  It doesn’t get much easier than a walk around the block or up the stairs.  (You do take the stairs at the hospital don’t you?)  Additionally, the television is filled with exercise shows–for those who still can’t tear themselves away from the small screen.

These ideas aren’t new, definitely aren’t sexy, and won’t get your sponsorship from a drug company.  However, they will work and we, as physicians, hold the keys.  We need to start with legislation, and move on to what we as ‘health coaches’ can do.    We can have huge impact on the huge, and not so huge.  Please, please, let me know what WE can do together to move our country to health, starting TODAY in our medical officese and clinics.

10 Things Patients Love To Hate About Their Doctors

Patients have a love/hate relationship with their physicians.  They love some things and hate others.  Here is a list of things they hate, and actually take as a sign of incompetence, rather than just poor bed side skills.

1. Being a slouch.  Patients take the lack of eye contact, hands in pockets and crossed arms as a signal your aren’t listening.  Lack of eye contact finishes it off. ( If your kid did this, would you feel they were listening?)  Lack of eye contact is the NUMBER ONE behavior that patients hate the most.
2. Standing when the patient is sitting (or laying.) Sit down and look at the patient. 
3. Standing far from the exam table/bed.  Patients are apt to think that YOU think they smell!  Seriously!
4. Not being available.  When calls aren’t returned, patients hold it against you.  This also goes for being available while you are in the exam room.  I try to delay answering pages while I’m examining a patient, as I need to BE present for the patient I am examining,
5. Giving the perception that you are rushing,  Please notice the word perception.  You may be hurried (harried?) but sit down, smile, and use humor if appropriate.
6. Using technical terms.  Patients are intimidated by the words we throw about.  Speak simply. I don’t know anything about car engines and my eyes glaze over when the mechanic mentions words like “catalytic converter” or “repack the wheel bearings”.  Patients feel similarly about words like “congestive heart failure” and “synovial fluid.”
7. Not answering questions.  If you don’t know the answer, tell the patient you will get back to them, or ask Dr. Bigg Bux, the orthopod, to explain exactly how the hip will be replaced.
8. Don’t automatically say no, especially with out a reason.  I am ashamed to admit that I reflexively said no to a family request this past week, thought about the request, and then came back to tell them I could do what they asked.  Why was I so quick to say no?  Arrogance, time pressure, all of the above.  It took more time to change my mind then to do what they asked!
9. Talking down to patients.  It is difficult to hit the sweet spot.  You want your conversations to be easy to understand but not juvenile.  You never know how patients will take what you say, but being flexible is helpful. 
10. Mistrusting the patient/type casting the patient.  The book, How Physicians Think, by Jerome Groopman, has an excellent chapter on how physicians make mistakes when they stereotype patients.

Patients will also be less likely to trust you if you are of a different ethnicity, sex or culture.  These are harder to over come, and patients perceptions can be tough to change in these areas.  I still haven’t found a way around the fact that some patients prefer a male physician.  I happen to be female, and that’s one thing that ‘s not likely to change!

Resources: How Doctors Think, and Trust and Distrust in Organizations

Enter to win a Amazon gift card–list a goal for your practice this year and a plan to achieve it!

See the December 29 post and enter your practice’s goals for 2009.  Include a plan by which your will achieve the goals.  The best plan wins a $15 gift card from Amazon.

Power to the Punctual! How Physicians can be on Time!

Patients have a pet peeve: they hate waiting for the doctor.  I hate waiting for the doctor, and hate it when patients wait for me!  It’s very funny, but in my personal life I tend to run late, but at work, I’m usually on time.  Reflecting on what helps me be on time, I came up with some tips:

1. Don’t check voice mail or email first thing.  Get to the clinic (or hospital, as is my case), and get started.  Checking emails/voice mails will likely take up more time than you have.  Remember, the beauty of email/voice mail is that you can respond when you are able.
2. Give yourself extra time to get to the office/hospital.  Don’t fall in to the “well, I have three extra minutes so I will check my emails, start my latest article, read up on transplants…”  trap.  Get to work first!
3. Set your clock or watch ahead by an uneven amount.  (It’s harder to subtract, although my fiendish little brain has become adept at subtracting odd numbers.)  Set different clocks ahead by different amounts.  (Take that, smart brain!)
4. Estimate accurately how long something will take, then add 15 minutes.  When a nurse calls me and asks when will I see a patient, I estimate how long it will be, and then add the extra 15 minutes.  The patients and families love it because I am on time, and I really look good if I arrive in the room early!
5. Don’t schedule meetings during peak times.  At one hospital I worked at, they wanted us to meet with the case managers at 9:00 am.  I am hitting my rounding stride around then, and having a meeting in the middle of the morning would really slow me down, (not to mention slowing discharges down!)  My group was able to get a different meeting time set up.
6. Set a goal for what you want to accomplish ahead of time.  I try to break my day up when I’m rounding into segments.  I will set a goal of seeing 2/3rds of my patients by 1:00 pm for example.  I know I am much slower in the afternoon, so I try to have the bulk of my work done before lunch.
7. Set up your day so you can use your peaks effectively.  I try to see my ICU patients first, when I am sharpest, and leave phone calls for late in the day, when I can sit down with a cup of tea and really listen to what the families say.
8. Don’t dwaddle on the Internet.  There is so much to read and learn, but getting sucked into the Internet black hole is a guaranteed time drain.  Be strong!
9. Cut the optimism.  We all have ideas that we can get “just one more thing” done.  Try doing less, and you will probably be able to do more, because  you are less stressed because you are on time!
10. Lastly, why are you late?  Is it a rebelliousness toward the system?  Are we physicians late because we can get away with it? Better book some time on the shrink rap couch!

So what are my top reasons for being late:

1. Exuberant optimism about how much I can get done.
2. Perfectionism, for example trying to get my computerized note to look “just so.”  (I am desperately trying to break this habit!)
3. My kid/family/dog.
4. Reading when I should be in the car driving.
5. Complaining.  (Seriously, the way we docs carry on!  I am working HARD on breaking this habit, and will post on my ‘no complaining’ bracelet later.)

And you?  What’s keeping you from your patients?  Make 2009 the year when physicians are on time!  Power to the punctual!!!

Resources:  See posts on Lifehack and MedicineNet.

Enter the YOUR plan to improve your practice and win an Amazon Gift Card!

See the December 29 post and enter your practice’s goals for 2009.  Include a plan by which your will achieve the goals.  The best plan wins a $15 gift card from Amazon.

Don’t Write Off E-prescribing

I may appear to be somewhat of a troglodyte, but I actually have  committed myself to learning to love technology.  I am the proud owner of a smart phone, have mastered my email, and actually use two different EMRs.  So, you see, this qualified me as an expert on EMRs and e-prescribing (wipe that smirk off your face!)

It was with interest that I read “Effect of Electronic Prescribing With Formulary decision Support On Medication Use and Cost” in the December 8/22 2008 issu3e of Archives Of Internal Medicineby Michael Fischer, MD, MS et al.  The authors describe a study in which physicians using e-prescribing with formulary decision support were compared with physicians using traditional paper prescriptions with respect to prescribing tier 1 medications.  When prescribing electronically, the physicians were more likely to choose the lower cost generic tier 1 medication.  There was a 3.3% increase in tier 1 prescribing, with a decrease in tier 2 and 3 prescriptions.  Fischer et al estimate that this would result in an $845,000 savings per 100,000 patients, based on the assumption that each patient filled one prescription per month.

I love saving money, but what was the cost of saving money?  According to the authors, “government estimates of approximate first year costs were $3000 per prescriber.”  In the study, Blue Cross Blue Shield supplied the software to the physicians, along with a free wireless device, access to a secure Web portal, licensing and wireless carrier.  So, the cost was not borne by the participating physicians.

I think as a first step toward an EMR, e-prescribing makes sense.  I do not think that every insurance company should provide physicians with it’s wireless device.  Can you imagine, five different devices for five different insurance companies?!

So what is to be done?  The federal government must mandate one SINGLE e-prescription system that we all should use, and insurance companies should bear the cost, based on percentage of patients enrolled in each plan.  Why should health insurance plans pay?  Because they are the ones that will enjoy the savings!  I think this would be an effective way to usher in the beginnings of an EMR.  Mr. Obama and Mr. Daschle, are you listening?

As physicians, we must look for ways that we can use e-prescribing efficiently and effectively.  We must commit to learning all the bells and whistles, and using it to our advantage.  So, stop hiding behind your prescription pad, and make way for what is inevitable.  Get out there and lobby for what should be done, rather than whining when we get handed the bill for something that will most benefit the health insurance industry!

Win an Amazon Gift Card: What Are Your Goals for Your Practice in 2009?

As a way to encourage goal setting and planning for medical practices, I am hosting a contest.  I will email a $15 Amazon gift card to the person who sends in the best plan for improving their medical practice in 2009.

Here are the rules:

1. Under the comments section for this post, list the goal your practice will achieve in the year 2009.
2. Write out the  step by step plan as to how your practice will reach this goal.
3. Have a time line accompanying each step.
4. Assign a person  (don’t use their name, but rather “office manager” or “me”  or “book keeper”) who will be responsible for each action.
5. All goals/plans must be submitted by January 16, 2009 by 12:00 midnight.
6. I will pick the best goal/plan/action list, and post it on the blog by January 23rd.
7. I will email the winning entry a $15 Amazon gift card.

That’s it.  No  bull, just good ideas on how to improve medical practices!  I will post my goals for my company, ExtraMD,  by January 8th.

Here’s to some great ideas!

State CME Guidelines

State	MD/DO	CME Credits Required	Term (years)	AMA PRA Category 1 Credit(s)TM required	Required Topics
Alabama	MD/DO	12	1	12
Alaska	MD/DO	50	2	50
Arizona	MD	40	2
	DO	40	2	24(AOA 1-A)
Arkansas	MD/DO	20	1	Not specified
California	MD	100	4	100	1 time requirement of 12 hrs. pain mgmt. and end of life care; If >20% of patients are over 65, 20 hrs. in Geriatric medicine required
	DO	150	3	60 (AOA 1-A or B	1 time requirement of 12 hrs. pain mgmt. and end of life care; If >20% of patients are over 65, 20 hrs. in Geriatric medicine required
Colorado	MD/DO	none
Connecticut	MD/DO	50	2		1 hr. infectious disease, risk mgmt., sexual assault, domestic violence
Delaware	MD/DO	40	2	40
D. of Columbia	MD/DO	50	2	50
Florida	MD	40	2	40	1st time renewal: 1 hr. HIV/AIDS, 2 hrs. medical error prevention; Subsequent renewals: 2 hrs. medical errors prevention; Every 3rd renewal: 2 hrs. medical errors prevention, 2 hrs. domestic violence
	DO	40	2	20 (AOA 1-A)	1st renewal: 1 hr. HIV/AIDS, risk mgmt., FL laws & rules, controlled substances; 2 hrs. domestic violence & medical errors prevention; Subsequent renewals: 1 hr. each risk mgmt., FL laws and controlled substances, 2 hrs. each domestic violence and medical error prevention; Every 3rd renewal: 2 hrs. domestic violence. All other hours can be either AOA 1A or AMA PRA Cat. 1. Risk Mgmt, FL laws, controlled substances and medical errors courses must be live, participatory attendance.
Georgia	MD/DO	40	2	40
Hawaii	MD	40	2	40
	DO	none
Idaho	MD/DO	40	2	40
Illinois	MD/DO	150	3	60
Indiana	MD/DO	none
Iowa	MD/DO	40	2	40	Child/dependent adult abuse (identifying and reporting) required every 5 yrs.
Kansas	MD/DO	50	1	20
Kentucky	MD/DO	60	3	30	1 time Domestic Violence; 2 hrs. KY approved HIV/AIDS every 10 yrs.
Louisiana	MD/DO	20	1	20
Maine	MD	100	2	40
	DO	100	2	40 (AOA 1-A or B)
Maryland	MD/DO	50	2	50	Partial credit for ABMS
Massachusetts	MD/DO	100	2	40	Study board reqs; risk mgmt; (40 AOA 1-A for DOs)
Michigan	MD	150	3	75
	DO	150	3	60 (AOA 1-A or B)
Minnesota	MD/DO	75	3	75	ABMS cert/recert accepted
Mississippi	MD/DO	40	2	40	For initial certification only: DO credit must be AOA 1-A
Missouri	MD/DO	50	2	50	50 hrs. AMA PRA Cat. 1, AOA 1-A or AAFP; or 40 hrs. of AMA PRA Cat. 1 or AOA 1-A if activity includes post-test; or specialty board certification; or ACGME or AOA approved internship / residency
Montana	MD/DO	none
Nebraska	MD/DO	50	2	50
Nevada	MD	40	2	40	2 hrs. ethics; 20 hrs. in specialty; 18 hrs. any AMA Cat. 1. New applicants: 4 credits WMD/bioterrorism
	DO	35	1	10 (AOA 1-A)
New Hampshire	MD/DO	150	3	60	Credits reported to NH Med Soc; CME reporting cycle changing to 2 yrs.
New Jersey	MD/DO	100	2	40	6 hrs. Cultural competence in addition to 100 for physicians licensed prior to 3/24/05. These credits may be included in 100 if licensed after 3/24/05
New Mexico	MD/DO	75	3	75	DO may substitute active membership in AOA
New York	MD/DO	none
North Carolina	MD/DO	150	3	60
North Dakota	MD/DO	60	3	60
Ohio	MD/DO	100	2	40	For DO: AOA 1-A or B
Oklahoma	MD	60	3	60
	DO	16	1	16 (AOA 1-A or B)	1 hr. prescribing controlled substances every 2 yrs.
Oregon	MD/DO	7 (by 2009)			Pain Mgmt. and end of life care completed by 1/2/09
Pennsylvania	MD/DO	100	2	20	12 hrs. Patient safety or risk mgmt (For DO: AOA 1-A)
Rhode Island	MD/DO	40	2	40	2 hrs. universal precautions, bioterrorism, end of life, OSHA, ethics or pain mgmt.
South Carolina	MD/DO	40	2	40	75% specialty education (30 hrs. every 2 yrs.)
South Dakota	MD/DO	none
Tennessee	MD/DO	40	2	40	1 hr. appropriate prescribing (For DO: AOA 1-A or 2-A)
Texas	MD/DO	24	1	12	Min. 1 hr. ethics and/or professional responsibility; (For DO: 12 AOA 1-A)
Utah	MD/DO	40	2	20
Vermont	MD	none
	DO	30	2		Min. 12 hrs. osteopathic medicine
Virginia	MD/DO	60	2	30
Washington	MD	200	4
	DO	150	3	60
West Virginia	MD	50	2	50	One time requirement: 2 hrs. end of life care including pain mgmt and 30 hrs. related to specialty
	DO	32	2	16	One time requirement: 2 hrs. end of life care including pain mgmt and 30 hrs. related to specialty
Wisconsin	MD/DO	30	2	30
Wyoming	MD/DO	60	3	60

 

From Medscape.

Walk the Talk: the Patient Encounter

I am fascinated by how we physicians communicate (or not) with each other and with our patients.  As a medical student and resident NO ONE ever thought about how physicians communicated with patients.  We were always so focused on nailing the disease process and treatment that the patient was nearly ignored.  I don’t think I had a single attending that excelled in talking and listening to patients.  I have tried to self educate (isn’t that what most of medicine is?) and found a thoughtful curriculum for residents on line, from the University of Washington.  I will reproduce the salient points here:

1. Have an opening introduction: “Hi, Mrs. Marlboro, I’m Dr. Pookie.”  (Hand shake, sit down, look at patient.)
2. Allow the patient to complete their opening statement.
3. Attempt to get the patients full agenda: “Mrs. Marlboro, what is the most important thing we need to work on today?” At this point, prioritizing the patients concerns is key.
4. Set the ground rules: “Mrs. Marlboro, it sounds like stopping smoking is what we should focus on today.  Is that right?”
5. Gather information, with a  mixture of open and closed ended questions.  Summarize and clarify with out interrupting.
6. Actively listen, using non verbal cues as well as verbal cues.  (“Uh huh, ah…”)
7. Explore their beliefs about the illness.  (Yes it’s hard to keep your mouth shut when a patient insists that smoking isn’t bad “because, Doc, I know you’ve heard it before, but I don’t inhale.”  Just heard this from a diabetic as he went on his way to the cardiac cath lab…  But try!)
8. Acknowledge the patients feelings/values.  (“Yes, quitting smoking is really hard, even our President Elect thinks so.”)
9. Share information in terms that patients understand.  (Save the free radical talk, two gene promotor theory of cancer for some one who cares.)
10. Encourage questions: “what questions or concerns do you have?”
11. Reach agreement on the treatment plan, actively encouraging patients to participate in the plan. 
12.  IMPORTANT: TRY TO GAUGE THE PATIENTS WILLINGNESS  AND ABILITY ENGAGE IN THE TREATMENT PLAN!  The best plan in the world is worthless if the patient can’t/won’t follow it!
13. Provide resources (hand outs, referrals etc.)
14. Realize you can NOT cover every item at every visit. 
15. Close the encounter by summarizing the treatment plan and setting up the follow up plan.

The patient encounter needs to be a balance between “patient centered skills” and “agenda setting skills.”  Interestingly, when a patient is dissatisfied, they underestimate by 8% how much time the physician spent with them, while if they are satisfied, they overestimate the time the physician spent with them by 20%!

Please see link from Society of General Internal Medicine below.   First author is Matthew F. Hollon, M.D., M.P.H., from the University of Washington. 

http://sgim.org/userfiles/file/AMHandouts/AM08/WC01%20Matthew%20Hollon.pdf

Allow Natural Death v. Do Not Resuscitate

“Allow Natural Death”

There is a movement afoot to replace DNR with “AND” or Allow Natural Death.  The idea is that patients and families are put off by the verbiage of DNR–that agreeing to a DNR is a death sentence.  Families and patients do not want to sign such an order committing them to what appears to be certain death.  However, Allow Natural Death puts distance between the final moments where the heart and lungs stop, and focuses on events leading up to death.  It is more than a change in semantics, it is a change in the way we talk about death.

AND appears more humane and, forgive me, natural.  Patients and families think that CPR/Code Blue results in saving most of the patients, most of the time, if TV’s ER is to believed.  But the sad fact is, resuscitation is frequently an invasive end of life maneuver that ignores dignity and natural progression.  Moving toward AND will require a shift in thinking whose time has come.  Patients and families want a peaceful, dignified death.  In order for patients to understand that death is a part of  life that can’t be denied, we as physicians will have to do what we aren’t particularly good at.  We will have to talk to patients and families about death.

We need to educate families (and ourselves) that death is part of living, and that sometimes it is best to let God and nature take their course, with out our highly invasive, technological, expensive interventions.  I think the place to start occurs when a patient that is  approaching the end of life.  That is the time  to get a grasp of what a patient wants/doesn’t want.  We shouldn’t wait until a patient is at death’s door to talk about the end of life.   Many patients want to die at home.  (Most, actually want to die at home, and sadly, most die in the hospital.)  The idea then is to address these desires when beforethe patient deteriorates so significantly that death is imminent.  For instance, is it appropriate to treat every infection?  Back in the day, pneumonia used to be called “the old man’s friend.”  Does the patient and family want to treat the pneumonia?  Do they want to go on toward intubation?  Does the 95 year old wheel chair bound patient WANT her fractured hip replaced–or would she be more comfortable at home with a decent pain regimen?  (Yes, just saw this last week when the orthopod called asking for “medical clearance” to replace the patient’s hip.  No one had thought about AND in this case.)   Just as important, does the patient and family want the new mass on chest Xray to be worked up in the 85  year old patient with COPD? 

These are excellent examples of when AND would be a well placed directive.   I think that AND is more than a directive, it is a direction to guide treatment.  Much discussion should go into WHAT treatments families and patients want.  I don’t think we can fore go DNR as it is a clear directive of what to do when a patient has a cardiopulmonary arrest.  However, I think “AND” should be a primary topic of discussion way before we ever get to DNR.

Currently, AND is not a legal replacement for DNR.  I don’t think it should be, but rather would use it as an adjunct to guide diagnosis, management and treatment.  I think it is the responsible way to help patients face the end of  life with dignity.  We need to get good at these discussions, and help our patients in realizing their ultimate decision: the manner in which they wish to die.

Just to be very clear:  this is in NO way a piece advocating that we help patients end their lives.   I am advocating that patients choose how much medical treatment they want as they near the end of their lives, and that we help them explore various options to make this decision.