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Many of the patients that I treat have brain injuries. Whether caused by a stroke, car accident, fall, or drug overdose, their rehab course has taught me one thing: nobody likes to be forced to do things against their will. Even the most devastated brains seem to remain dimly aware of their loss of independence and buck against it. Sadly, the hospital environment is designed for staff convenience, not patient autonomy.
In the course of one of my recent days, I witnessed a few patient-staff exchanges that sent me a clear message. First was a young man with a severe brain injury who was admitted from an outside hospital. EMS had placed him in a straight jacket to control his behavior on his trip and by the time I met him, he was in a total panic. Sweating, thrashing, at risk for self harm. He didn’t have the ability to understand fully what was happening but one thing he knew – he was being restrained against his will. The staff rushed to give him a large dose of intramuscular Ativan, but I had a feeling that he would calm down naturally if we got him into a quiet room with dim lights and a mattress with wall padding set up on the floor. As it turned out, the environmental intervention was much more successful than the medicine. Within minutes of being freed to move as he liked, he stopped moving much at all.
Later I was speaking with one of my patients in the shared dining room. An aide arrived with a terry cloth bib to tie around his neck so that he didn’t spill anything during lunch. I saw a flash of anger in my patient’s eyes as he pulled the bib away from his neck with his good arm and placed the towel on his lap instead. I could tell that he found the bib infantalizing, though none of us had thought twice about it before. Here again, a patient did not appreciate having everything determined for him, right down to napkin placement.
Towards the end of the day, I was bidding farewell to a patient whose care would be provided by another attending physician going forward. I was summarizing my view of his progress and expectations for the future, and stopped to ask if he had any questions. What he asked completely flummoxed me. Instead of probing for details about his medical condition and treatment options, he asked, “Will the new doctor be a good listener? Will she pay attention to what I’m saying and be easy to talk to?”
It is unfortunate that healthcare providers and patients are often on very different wavelengths. In Atul Gawande’s recent book, Being Mortal, he argues that nursing homes have often failed to provide healthy environments for patients because they have focused exclusively on safety and meeting basic needs (eating, dressing, bathing, etc.) on their terms. The removal of patient independence unwittingly results in devastating loneliness, helplessness, and depression. It seems to me that hospitals end up doing the same thing to patients – if only for a shorter period of time.
I was moved by Gawande’s book (and I consider it required reading for anyone facing a life-limiting illness or caring for someone who is). It renewed my conviction about the importance of rehabilitation – helping people to become as functionally independent as possible after a devastating injury or disease. Even as we age, we all become less able to do the things we hold dear. Preserving dignity by prolonging independence, and respecting patient autonomy, are often overlooked goals of good health care. It’s time to think about what our actions – even as small as placing a bib around someone’s neck – are doing to our patients’ morale. Maybe it starts with asking the right questions… Or better yet, just watching and listening.
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In my last blog post I discussed how harmful physician “thought leaders” can be when they are dismissive of the value of other specialists’ care. I must have touched a nerve, because a passionate discussion followed in the comments section. It seems that physicians (who spend most of their time involved in clinical work) are growing tired of the leadership decisions of those who engage in little to no patient care. Clinicians urge lawmakers to turn to practicing physicians for counsel, because those who are out of touch with patients lack real credibility as advisers.
Interestingly, the credibility question was raised in a different light when I was recently contacted by a prestigious medical organization that was seeking expansion of its board membership. I presumed that this was a personal invitation to join the cause, but soon realized that the caller wanted to use my influence to locate “more credible” candidates with academic gravitas.
When I asked what sort of candidate they wanted my help to find, the response was:
“A physician with an academic appointment at a name brand medical school. Someone who isn’t crazy – you know, they have to be respected by their peers. Someone at Harvard or Columbia would be great. You must know someone from your training program at least.”
While I appreciated the honesty, I began thinking about the age-old “town versus gown” hostilities inspired by academic elitism. In medicine, as with many other professions, it is more prestigious to hold an academic position than to serve in a rural community. But why do we insist on equating credibility with academics?
Another facet of credibility lies in physicians’ tendencies to admire only those at the top of their specific specialty. Dr. Lucy Hornstein described this phenomenon in her powerful essay on “How To Drive Doctors To Suicide:”
“Practice that condescending look and use it at hospital staff events. Make it a point to ignore newcomers. Concentrate on talking just with your friends and laughing at inside jokes, especially when others are around. Don’t return their calls, and don’t take their calls if you can possibly help it. If you accidentally wind up on the phone with the patient’s primary physician, just tell them you’ve got it all under control, and that he (and the patient) are so lucky you got involved when you did.”
A reader notes:
“And perhaps those of us who do see patients should get some self esteem and stop fawning all over [physician thought leaders] at conferences like needy interns.”
And finally, there seems to be an unspoken pecking order among physicians regarding the relative prestige of various specialties. How this order came about must be fairly complicated, as dermatology and neurosurgery seem to by vying for top spots these days. I find the juxtaposition almost amusing. Nevertheless, it’s common to find physicians in the more popular specialties looking down upon the worker bees (e.g. hospitalists and family physicians) and oddballs (e.g. physiatrists and pathologists).
While I try very hard not to take offense at my peers’ dismissiveness of my career’s value, it becomes much more concerning when funding follows prejudicial lines in the medical hierarchy. As a sympathetic family physician writes:
“I have observed the inequitable distribution of resources from the less glamorous to the sexy sub specialties despite obvious patient needs. Unfortunately, the administridiots who usually lack any medical training, opt to place resources where they are most likely to attract headlines.”
Yes, caring for the disabled (PM&R) is “less glamorous” than wielding a colonoscope (GI) (again, not sure who made that decision?) but it should not be less credible, or become a target for budget cuts simply because people aren’t informed about how rehab works.
It is time to stop specialty prejudice and honor those who demonstrate passion for patients, regardless of which patient population, body part, or organ system they serve. Excellent patient care may be provided by academics, generalists, or specialists, by those who practice in rural areas or in urban centers. The best “thought leaders” are those who bring unity and an attitude of peer respect to the medical profession. With more of them, we may yet save ourselves from mutually assured destruction.
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Electronic medical records (EMRs) now play a part in the daily documentation routine for most physicians. While improvements in access to patient data, legibility of notes, and ease of order entry are welcome enhancements, there is a significant downside to EMRs as well. Although I’ve blogged about my frustrations with nonsensical, auto-populated notes and error carry-forward, there is a more insidious problem with reliance on EMRs: digital dependency.
The idea of digital dependency first occurred to me during a conversation with a young medical resident at a hospital where we share patients. I was bemoaning the fact that I was being forced to use hospital-designed templates for admission notes, rather than a dictation system or carefully crafted note of my own choosing. She looked at me, wide-eyed and said:
“You’ve worked without templates? How do you even know where to begin? Can you really dictate an entire note off the top of your head? I couldn’t live without templates.”
As I stared back at her with an equal amount of bewilderment, I slowly realized that her thinking had been honed for drop-down menus and check boxes. Over time, she had lost the ability to construct narratives, create a cohesive case for her diagnostic impressions, and justify her patient plan of action. To this bright, highly trained mind, clinical reasoning was an exercise in multiple choice selection. Her brain had been optimized for the demands of an EMR template, and mine was a relic of the pre-EMR era. I was witnessing a fundamental cognitive shift in the way that medicine was practiced.
The problem with “drop-down medicine” is that the advantages of the human mind are muted in favor of data entry. Physicians in this model essentially provide little benefit over a computer algorithm. Intuition, clinical experience, sensory input (the smell of pseudomonas, the sound of pulmonary edema, the pulsatile mass of an aneurysm) are largely untapped. We lose our need for team communication because “refer to my EMR note” is the way of the future. Verbal sign-outs are a thing of the past it seems, as those caring for the same patient rely on their digital documentation to serve in place of human interaction.
My advice to the next generation of physicians is to limit your dependency on digital data. Like alcohol, a little is harmless or possibly healthy, but a lot can ruin you. Leverage the convenience of the EMR but do not let it take over your brain or your patient relationships. Pay attention to what your senses tell you during your physical exam, take a careful history, listen to family members, discuss diagnostic conundrums with your peers, and always take the time for verbal sign outs. Otherwise, what advantage do you provide to patients over a computer algorithm?
Am I a curmudgeon who is bristling against forward progress, or do I have a reasonable point? Judging from the fact that my young peers copy and paste my assessment and plans into their progress notes with impressive regularity, I’d say that templatized medicine still can’t hold a candle to thoughtful prose. Even the digitally dependent know this.
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Physicians looking for part-time jobs to supplement their income may have run across advertisements for “lucrative” Medicare Advantage evaluation opportunities at CenseoHealth. Here’s a typical ad:
CenseoHealth is the leading Risk Adjustment provider for Medicare Advantage plans – with a network of more than 1,800 credentialed providers conducting over 20,000 member health evaluations a month. Due to our continued growth, we are currently looking to hire in-home physician evaluators to work in these states.
As a CenseoHealth physician, you will meet with Medicare Advantage members in their homes to conduct their annual medical history and physical evaluation.
Conduct evaluations when it’s convenient for you
Ongoing physicians can make $3,500 to $4,000 per week
Physicians who work 1-3 days per week can make $800 – $2,000
Travel and lodging expenses are covered, plus we provide a per diem reimbursement
Malpractice insurance is included
This position does not require you to prescribe medicine, order lab tests, do blood work, or alter the member’s current treatment regimen
Please contact us, for more information.
Director of Physician Recruiting
Sounds pretty good, right? Well here’s what they won’t tell you:
1. Low Hourly Pay. Compensation is $100 per completed evaluation – but you have to drive to each member’s house (sometimes an hour each way) to complete a 31 page history and physical exam. Members are often medically complex, cognitively impaired, and/or non-English speaking. In the end (after counting travel time, cancellations, scheduling snafus, and long hours completing paperwork and FedEx shipping) the hourly wage works out to be about $30.
2. Poor Logistics. Members are scheduled back-to-back without regard to distance between their locations. That means you are chronically late, and some members cancel their meeting with you. No-show and cancellation rates (in my experience) are about 20%. You are not compensated for any of the time associated with driving to their location, talking to them on the phone, or otherwise trying to locate them when they are not home upon your arrival. Once a member cancels, you cannot fill their slot with someone else on the same day.
3. Threat of harm. Members mostly come from low to middle class income levels. Some of them live in truly horrific living situations (no electricity, a home overrun with cockroaches, no food or running water), and others are psychologically unstable. As a female physician driving alone into a very rural area to conduct a physical exam on a male patient who is actively psychotic… this can be dangerous. You never know what or who you will face. I have had to call social services on numerous occasions and have narrowly escaped inappropriate sexual advances.
4. Limited Support. There is no guarantee that anyone from the parent company will be available via phone when you call during an emergency. I have called on several occasions during critical situations where I had to leave a voice message and was assured that “my call was very important” and someone from provider services “would get back to me within 1/2 a business day.”
5. Questionable ethics. Schedulers do not explain to the members why you are coming to their home to evaluate them. Because the schedulers seem to work on commission, they often use questionable tactics to get the members to agree to the evaluation – such as telling them that the meeting is “mandatory” and will “take 20 minutes” or is “just a wellness visit.” For this reason, many members receive you with suspicion, wondering if you’re there to try to “throw them off the Medicare plan” or are angry that they were mandated to meet with you. Lengthy conversations and apologies to set the stage for your evaluation are commonplace.
6. Payment denials and exaggerated pay potential. Evaluations must be completed meticulously or the quality assurrance reviewers will reject your forms and you will not be compensated for your work (if you, for example, forget to check a box or use a non-approved abbreviation). Although the advertisements state that some physicians complete 35-45 evaluations per week, that is nearly impossible in areas where clients are not clustered together tightly. It is an extremely misleading statement, in my experience. Apparently online reviewers agree.
7. Glitchy and costly technology. In order to save on costs, electronic evaluations can be completed via an iPad rather than paper forms. Unfortunately, the software often crashes, resulting in a return to paper in the middle of an evaluation. This ends up increasing the amount of time required to complete evaluations as your evenings are spent copying paper records into the iPad program. In addition, you are required to purchase your own stylus for data entry, as well as all the equipment required during your physical exam (e.g. blood pressure cuff, bathroom scale, ophthalmoscope, stethoscope, and more).
8. Low-budget travel and accommodations. While the agency boasts that they will pay for your accommodations and rental car, that typically translates into a room at a low-budget hotel and a Toyota Yaris with roll-down windows and no GPS.
9. The truth is hidden. The real reason for the evaluations is to help health insurers obtain larger reimbursements from the government. A physician (or NP) is required to verify all of the patient’s current medical conditions to justify their “risk score.” Medicare Advantage plans get paid more to manage patients with higher risk scores, so they are very motivated to document the complete list of diseases and conditions per at-risk senior. Patients may benefit from having an objective third party review their health record, but this is not the main goal. Also, it is unclear if the higher risk scores ultimately translate to more benefits and services for the patients.
10. Treated like a number. Sadly, my experience with my recruiter (the person who matches your availability with evaluation needs in various states where you hold a medical license) has been underwhelming. I took the time to make suggestions about how to improve the process for evaluators, but my recommendations fell on deaf ears. Not only were my phone calls and emails not returned, but when I suggested that it didn’t make sense for me to continue seeing members when I had a 66% no-show rate he simply replied, “I took you off the schedule – we have an abundance of FL doctors so it is not an issue.”
Take a look at the lovely marketing promotional images for the job:
And this video of what it’s like to do a home evaluation:
Now take a look at some photos that I took while on assignment (note: these are not actual patient homes, but are very similar to ones I encountered):
Taking a job as a Medicare Advantage evaluator was a real eye-opener. Poverty and chronic illness in America takes on a whole new light when you experience patients’ actual home environments. It’s like being a medical missionary in your own country. I’ve met patients who hadn’t seen a physician in decades, diagnosed life-threatening illnesses, and made sure that care (or case management) was initiated for countless people living on the fringes of society.
I’m glad for the experience – but think that my peers considering similar work should be told the truth about what they will be doing. Being a Medicare Advantage evaluator is not like the shiny “care anywhere” ad suggests – and “lucrative” is not exactly the right adjective for $30/hour for an MD’s time. But if you don’t mind being treated poorly by your employer, investing a lot of your own money in equipment costs, and putting your life at risk in dangerous home environments – you may actually do some good for the forgotten, frail elderly of this nation, (while helping middle men like Censeo Health to profit from health insurance behemoths, alas). Now you know the truth behind the advertising and can make an informed decision about whether or not you’d like to sign up for this work.
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I recently treated a patient who was hospitalized with paraplegia. During some routine lab testing I noticed that his liver function tests were elevated, and so I began looking for a cause. I discussed the patient’s drinking habits (he rarely drank alcohol), risks for viral hepatitis (no IV drug use or exposure to those with known hepatitis), and general medical history (nothing relevant to liver disease). I reviewed his current medication list, and found little to explain a potential drug-induced hepatitis. He denied any history of acetaminophen use.
Next I ordered a hepatitis panel – all normal. And finally a liver ultrasound (which showed some non-descript “fatty liver” changes). My next best guess was that the patient was a heavy drinker who was simply not telling me the whole story about his history. I hated to have to press for more information, and worried that the patient would be annoyed that I didn’t seem to believe his vehement denials of regular alcohol use.
So I asked him again. “Are you SURE you don’t drink ANY alcohol? Nothing that could have alcohol in it that you might not realize?”
“Well, maybe there is alcohol in the cold medicine that I drink?” he said.
“Why are you drinking cold medicine? Do you have cold symptoms?” I asked.
“I use it to get to sleep at night.” He responded.
“How much do you use?”
“I use it every night. I just drink it out of the bottle.”
“So you don’t use the measuring cup?”
“No. I just drink it out of the bottle.”
Suddenly, I had my answer. There is a significant amount of acetaminophen in many different cold syrup formulations, which is why it is so important to use the dosing cup and not exceed the recommended daily amount.
“So is there alcohol in the cold medicine?” The patient asked.
I explained to him that it was very likely that he was over-dosing himself on cold medicine and that his liver was being harmed as a result of the acetaminophen (not alcohol) it contained. It was a good thing that we had caught the damage in the rehab unit – just an incidental finding on a blood test that could have saved him from eventual liver failure (and even death) if we hadn’t course-corrected.
This experience was a cautionary tale for us both – I realized how easy it was for patients taking liquid drug formulations to overdose themselves, and not be aware of the active ingredients that they contained. My patient didn’t believe he was taking any acetaminophen when I originally interviewed him, and it was my persistent nagging on the alcohol front that finally revealed the cause (again quite accidentally).
Acetaminophen toxicity is the most common cause of acute liver failure in the United States. Better education is needed regarding over-the-counter medications and their potential harms if used incorrectly. I will certainly spend more time asking my patients about their OTC medication use, including sleep aids and liquid formulations. Perhaps I’ll be able to avoid ordering unnecessary liver ultrasounds with better history taking in the future!
For more information on safe use of acetaminophen, see my article at OTCSafety.com.