#patient-centered

I recently attended a discussion on proper lab ordering.  As it turns out, residents – and often attendings – tend to order patient labs with reckless abandon.  A patient in the hospital is likely to get a CBC and CMP every morning regardless of his or her clinical status.  Patients can even experience anemia from over zealous lab drawing (Thavendiranathan et al., 2005), a syndrome researchers have termed iatrogenic anemia.  Further, the act of needless labs is both cost and labor intensive (Malone, 2013), and it is not very fun for the patient who gets to be poked unnecessarily.

I have written before about the bias in healthcare to always do more. This is in part a cultural phenomenon.  It is easy for medical interventions and studies to occur when a patient is hospitalized, which in theory saves them the trouble of a lengthy outpatient workup.  There is also a sense that patients in the hospital need active intervention – why else would we keep them?  This leads to two problems: a bias towards invasive data collection and a bias towards procedures.  Unfortunately this can have a cascading effect, analogous to a positive feedback loop.  The problem with positive feedback loops is that they proceed until a step in the loop breaks.    

An example comes from one of my favorite serial journal articles, Teachable Moment, in JAMA Internal Medicine.  In a recent piece the authors tell the story of a gentleman with cellulitis, who developed a small murmur causing them to suspect endocarditis.  Though he quickly cleared his blood cultures, which only grow an atypical bug for endocarditis, and had a negative echo, he was schedule for a CT angiogram to rule out septic emboli to the brain.  Obviously this is a serious complication of bacterial endocarditis, but the savvy reader will note that he did not meet the criteria for an endocarditis diagnosis.  On CT angiogram he was noted to have an incidental finding, which again was asymptomatic.  This was further worked up with cerebral angiography, which led to a complication of embolic stroke (Chamberlin, 2015).  In essence, a bias towards invasive testing led to an intervention that eventually caused significant harm.  

So what happened here? Obviously there were some cognitive errors, but I believe that patients in the hospital are more likely to fall victim to this snowball effect than those who are worked up in an outpatient setting.  It is almost as if seeing a patient daily prompts physicians to act, creating a false sense of urgency.  There is also a mixing of incentives.  Ethical physicians wouldn’t knowingly push a procedure for their own financial gain, but it would be hard to deny the subconscious realization that to get paid, a physician must perform a service.  As I sat in the lecture on proper lab ordering, the lecturer continually referred to financial savings the hospital experienced from not performing excessive labs.  This is inaccurate.  Financial savings to patients are financial losses to hospitals, which is perhaps why it is hard to tease out the ultimate goals of hospital care.  

If I were to suggest a solution to this complex problem, it would center on price transparency and proper, shared decision-making.  Though we are far from the paternalistic medical care of the past, we often do not truly inform patients of their options. I think this is in part because we as physicians are poorly informed about how to interpret meaningful outcomes.  Too often we prescribe medications and treatments that offer a small amount of benefit in the face of significant harms (a great discussion of that can be found here and here).  Take for example antibiotics, which is obviously a low hanging fruit at this point.  Time and time again it is reported that antibiotics are given too frequently, and attendings readily cite these studies as they click through their lecture slides. However, on the wards and in clinic I witness the same attendings hypocritically hand out antibiotics unnecessarily.  When I protest, I am reprimanded about patient-centered care.  “What if this is strep pharyngitis?  What if that otitis becomes meningitis?  Why not give them a script so they don’t have to come back in 7 days?” 

Well, that is one argument. But what if that patient with acute bronchitis is the 1 in 24 who will experience an adverse effect with antibiotics (Smith et al., 2014)?  In a Cochrane review, patients with acute bronchitis treated with an antibiotic reported feeling better a half day before those that were treated with placebo. However, those that got antibiotics were more likely to experience effects such as nausea, vomiting, diarrhea, and rash (Smith et al., 2014).  Is that patient-centered medical care?

Physicians need to educate themselves and treat towards outcomes that matter, not outcomes that are statistically significant.  They need to weigh costs and benefits of investigations and interventions.  Returning to the possible endocarditis case above, that patient had an incidental finding with no symptoms and was subsequently put on the diagnostic train.  But you can’t really fix asymptomatic.  Diagnosing an asymptomatic patient seems a bit too academic.  

A number of years ago I read the House of God, which is perhaps the quintessential book on life as a medical intern.  I found the book horrifying, vulgar, and depressing in many ways, and yet it continues to haunt me as I make my way in the world of medicine.  The 13th law of the House of God is this: “The delivery of good medical care is to do as much nothing as possible.”  This rule plays in my head each time I watch futile and unnecessary care.  Obviously I don’t believe this rule to be true.  Perhaps it should be changed to: “The delivery of good medical care is to do as little harm as possible….”  Hmmm, that sounds strangely familiar doesn’t it?

 Citations/Further Reading

Chamberlain E, Diveronica M, Segura R. When Medical Care Leads to Harm-Difficulty Finding Words: A Teachable Moment. JAMA Intern Med. 2015; DOI: 10.1001/jamainternmed.2015.2334

Malone, B. (2013, September). Our Daily Blood. In American Association for Clinical Chemistry. Retrieved June 9, 2015, from https://www.aacc.org/publications/cln/articles/2013/september/daily-blood

Shem S. The House of God. Berkley Publishing Group; reprint 2010 (original copyright 1978)

Smith  SM, Fahey  T, Smucny J, Becker  LA.  Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014;3(3):CD000245.

Rounding with a medical team at an academic institution can sometimes feel like a trip to the zoo. The patient, caged up in their room, is talked about as if they aren’t there.  They are then poked and prodded in their most intimate locations, often without explanation, by a gaggle of strangers.  And then everyone leaves the patient to endure his or her ailments alone. Even in non-academic centers, patients are often treated as objects rather than human beings.

There is an argument that objectiveness is what allows providers to make the best decisions; emotion muddles things.  But is this really true?  Doesn’t emotional connection also add something to patient interactions?  According to abundant research, it does.  A literature review, over a decade old now, sums up this idea nicely: “…one relatively consistent finding is that physicians who adopt a warm, friendly, and reassuring manner are more effective… (Di Biasi, et al., 2001).”  

I think to connect with patients you first have to know them beyond their diagnosis.  Hippocrates said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.”  I have learned the truth to statement during my time on the wards and I attempt to gather this information in my medical interviews.  I try to ask myself, “Who is this man?” “What did this woman do before being sick?”  To me these are vital questions.

However, anyone who has participated in medical rounds realizes how little this type of personal information is captured, and further, how little this type of curiosity about patients is rewarded.  In the equations of efficiency, productivity, and profits there is little room for questioning the patient experience.  Further, modern medicine places a lot of emphasis on evidence-based care, which seems to preclude personal relationships.  Because we are awash in data points and expert guidelines, the patient’s chart gets magnificent care.  The patient, however, is left as a placeholder – a physical representation of those digital numbers.  As one patient stated, "you cease being a person and become 'the carcinoma in Room B-2,' (Carey, 2005)."

“But wait,” you might say, “hasn’t that been fixed with the ACA, MACRA, and the new emphasis on patient satisfaction metrics?”  

Theoretically.  

In my experience the result of such efforts has been the creation of entire departments that focus on appeasing patients, not improving the overall experience.  Plastered on many hospital walls are new signs that say, “If you cannot give us top marks in satisfaction, please call 1-800-LETUSKISSYOURASS.”  Some data suggests the problem gets worse as hospitals consolidate into ever-larger organizations, a persistent trend in modern U.S. health care.  The larger a hospital is, the lower it’s satisfaction scores are (Mcfarland et al., 2015).  Obviously correlation is not causation, but it does beg some interesting questions.    

The upside of these realizations is that many hospitals are attempting to re-engineer the provider-patient relationship.  For example, Johns Hopkins and other institutions are now collecting personal patient data with the belief that truly knowing the patient improves the patient experience and creates a more responsible attitude on the part of the provider (Sun, 2015).  This is wonderful and extremely sad – why do we have to create a workflow for caring about someone on a personal level?  Shouldn’t that be part of the job?

Regardless of how we accomplish it, proper patient care has a strong evidence base for improving outcomes. Take for instance a recent Consumer Reports’ study, which reported that patients who felt rarely respected by medical staff were 2.5 times as likely to experience a medical error (2014).  As care becomes more complex, we cannot afford to let attitudes become a malignancy that prevents positive outcomes.    

Many physicians lament the use of patient satisfaction metrics.  But here is a telling quote from a nurse turned patient and her experience: "There's this overwhelming sense being a patient of having no boundaries, no privacy, no control over anything, and you feel so awful you can't do anything about it. (Carey, 2005)."  Is it any wonder that patients who feel cared for do better?  Whether you argue physiology (stress hormones and their impact on healing) or psychological factors (patient’s motivation to get better), it seems obvious why patients might do better in a supportive environment.  

Obviously there are barriers to being able to spend adequate time with each patient and their story. Hospitals are often over census and understaffed.  Administrators favor profits and efficiency over quality and satisfaction.  But each provider can make small changes.  Try to lead with empathy in each interaction.  Imagine how you would treat each patient if they were your mom, dad, sister, or brother.  This can change your entire interaction, even with the curmudgeonliest patients.  Realize that patients are at their most vulnerable when they are in your care. In true Maslow fashion, they are looking to have their most basic needs of security and safety fulfilled. Finally, call patients by their name. Just remembering they are a human being and not an illness is perhaps the easiest way to restore some dignity.

To summarize, I will end with another quote from a giant of our field.

The good physician treats the disease; the great physician treats the patient who has the disease.

-Sir William Osler

Citations/Further Reading

Carey, B. (2005, August 16). In the Hospital, a Degrading Shift From Person to Patient. The New York Times. Retrieved from http://www.nytimes.com/2005/08/16/health/in-the-hospital-a-degrading-shift-from-person-to-patient.html

Di blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet. 2001;357(9258):757-62.

L. P. Casalino, M. F. Pesko, A. M. Ryan et al., “Small Primary Care Physician Practices Have Low Rates of Preventable Hospital Admissions,” Health Affairs Web First, published online Aug. 13, 2014.

Mcfarland DC, Ornstein KA, Holcombe RF. Demographic factors and hospital size predict patient satisfaction variance-implications for hospital value-based purchasing. J Hosp Med. 2015; Epub ahead of print: 4 May 2015. DOI: 10.1002/jhm.2371

Sun, L. H. (2015, April 8). Meet the cancer patient in Room 52: His name is Joseph, but call him Joe. The Washington Post. Retrieved from http://www.washingtonpost.com/national/health-science/effort-to-reduce-harm-in-hospitals-centers-on-seeing-patient-as-a-person/2015/04/08/13c7a814-da16-11e4-b3f2-607bd612aeac_story.html

As I sat typing my note, I heard an alarm go off.  I glanced around, looking for its source.  It was an IV machine, somewhere in a patient room, announcing to all that could hear that it had finished its infusion.  There was no nurse in sight.  We are discouraged from turning off the IVs without their permission, so the alarm continued, and continued, and continued.  Shortly thereafter an ECG alarm went off, signaling an abnormal rhythm. I glanced in the room and saw a respiratory therapist had been adjusting the patient’s electrical leads.  Behind me, somewhere down the hall, a third alarm went off signaling God knows what. 

If you are not used to being in the hospital, it can be a noisy place.  Alarms ring out in the halls.  Carts are wheeled around to bring food, supplies, and often life-sustaining medication.  The chatting between coworkers ensures that at all hours there is a constant din. And this, of all places, is where we send people to rest.  Hospitals are not designed with the patient in mind.  But they could be.

Let’s reimagine some of the above scenarios in a patient centered manner.  First, there must be a decision about what requires an alarm.  The term alarm fatigue, which has recently gained popularity in describing this conundrum, describes situations in which the ubiquity of alarms detracts from their usefulness.  Anyone who grew up with small siblings understands you can eventually grow accustomed to the most annoying of noises.  Indeed, patient deaths have been ascribed to healthcare works ignoring alarms (Kowalczyk, 2011).

Second, there needs to be a discussion about how alarms (or alerts) should be delivered.  For example, does an alarm need to signify the completion of an infusion?  What if a text page went to a nurse’s mobile device (many hospitals now use nursing communication systems that can send and receive text pages and calls)?  The alert could then be placed in the queue from which it can only be removed by addressing it manually at the actual infusion pump.  This allows non-emergent alarms to cease being alarms.  By making them less invasive alerts, actual audible alarms become more meaningful.  

At the other end of this spectrum, are there alarms that should be set off without need for human intervention?  Typically, a hospital staff member has to send out certain codes, which increases the amount of time to dispatch the appropriate response.  Some responses are delayed dramatically by the above mentioned alarm fatigue.  What if an alert about falling oxygen saturations combined with heart and respiratory rate changes automatically signaled a code blue across the hospital’s PA system?  This takes out the guesswork and increases the sensitivity of the code system.  It would likely create more false positives, however I find that more comforting than false negatives from ignored alarms.  

These ideas are not the resolution; they are an attempt at a conversation.  I am astounded that solutions to these well-documented problems have not permeated the healthcare field.  The cessation of needless noises in the hospitals – the beeps and boops of non-urgent alarms – would go a long way in making it a more peaceful place where patients can get rest, which can improve healing (Gumustekin, Seven, Karabulut, et al., 2004).  Wasn’t that the whole point of a hospital to begin with, a place of rest and healing? Hold that thought – somewhere I hear an alarm going off, and I intend to stop it.    

 Citations/Further Reading

Chopra V, Mcmahon LF. Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. JAMA. 2014;311(12):1199-200.

Cvach M. Monitor alarm fatigue: an integrative review. Biomed Instrum Technol. 2012;46(4):268-77.

Gumustekin K, Seven B, Karabulut N, et al.  Effects of Sleep Deprivation, Nicotine, and Selenium on Wound Healing in Rats. International Journal of Neuroscience.  2004, Vol. 114, No. 11 , Pages 1433-1442 (doi:10.1080/00207450490509168)

Kowalczyk, L. (2011, September 21). ‘Alarm fatigue’ a factor in 2nd death. The Boston Globe. Retrieved from http://www.boston.com/lifestyle/health/articles/2011/09/21/umass_hospital_has_second_death_involving_alarm_fatigue/

Krachman SL, Criner JG, D’Alonzo GE. Sleep in the Intensive Care Unit. Chest. 1995;107(6):1713-1720. doi:10.1378/chest.107.6.1713

When the Pickup Truck Meets the 18 Wheeler

Let’s take a quick look at what we know or at least what we may have read or heard.  A Rand Corporation study, presented in JAMA in 2014, compared a group of practices that had achieved patient-centered medical home (PCMH) recognition from the National Committee for Quality Assurance (NCQA) with a similar number of control practices that did not receive…