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Evidence Based Listening

I approve of evidence based medicine, but with one caveat. Evidence based medicine seems to forget that half of the job in primary care is listening.

I do think we should do research and clinical trials and studies where the people gathering the information are not biased by knowing who is getting which treatment and studies that are statistically large enough to have mathematical meaning.

However, NNT bothers me.

NNT is the Number Needed to Treat. For example, a treatment for bacterial ear infections for children goes through a clinical trial. In a large, radomized, double blinded clinical trial, the new treatment does better than the previous treatment. A little better. The Number Needed to Treat is 5 instead of 6 and this is statistically significant.

And what does that mean? That means that if 5 patients are treated with the new treatment course, one will get better more quickly or respond better.

My thought is always “What about the other four?” They are taking a medicine that is not better than the other medicine, may be more expensive, may not help. Why do we have to treat 5 people to make a difference to one?

Medicine is not exact. Diagnosis, treatment, course expected, side effects, response failure.

The hospital clinic where I worked for 9.5 years bought an electronic medical record in 2005, an EMR. It was purported to make us faster, more efficient, paperless, cutting edge and we could use templates! And build our own!

I hated it.

I particularly hated the templates. The template was a list of questions for a particular problem, such as ear pain. The computer listed the questions, I could ask the patient the question, check the little box and the computer would generate a narrative from the check.

The computer sentences were so dry, awful and boring that they were nearly unreadable. Each was the same. “The patient says that the quality of the ear pain was sharp. The patient says that the duration of the pain was 3 days. The patient says…”

One woman came in with ear pain. She said that the pain felt “like someone is kicking me over and over in the ear with the pointed toe of a cowboy boot.” That definitely got my attention. It was not on the list of computer choices. I stopped typing and looked at her ear immediately and called the Ear Nose and Throat specialist, who saw her that day.

Then I emailed our head computer geek doctor and suggested that they add that to the list of choices under “quality of pain” in the ear pain template. “feels like someone is kicking me over and over….” He said no.

The computer doctors and hospital told me that I could write my own templates. I said, “I have a template: Why are you here? After that, every patient is different.”

I said that if they wanted the computer to ask the questions, why was I in the room? Let the computer see the patient. There is a program where people can log on, fill out a template, email it to the doctor who then either treats, never seeing the person, or says, “No. Come in.” The person is charged if he treats them without seeing them, but no charge for reviewing the template if they are seen.

I do use the templates to make sure that I fill out the six things that the biller/coders are looking for. Once I was told that my note was down-coded for an 89 year old on a consult I’d done in the hospital. “You did not identify the quality or intensity of the pain.”

“Um,” I said, “Her hip was broken and she couldn’t walk. Are you telling me that I have to say hurts like shit and she can’t walk and 10/10 pain if she tries?”

“Yes,” said the coder primly.

Well, it’s stupid, but if I have to do it to take care of my medicare patients, whatever.

The forgotten piece in evidence based medicine and our current climate is listening. In medical school and residency we were told that half of primary care, family practice and internal medicine, is psychiatry. How can that be? My shcedule says back pain, hypertension, hospital followup, needs antidepressant, sinus infection, as the complaints that people are coming in for. I rarely see colds.

But the schedule doesn’t tell the whole story. I see someone for their fourth cold of the year. They didn’t come in for the other three. Why this one? They aren’t even surprised when I say that it is a virus and they don’t need an antibiotic.

Then they tell me that their daughter is back on methamphetamines and they are taking care of the grandchild.

And that is the real reason they are there. To tell me. To tell someone in a safe confidential place.

If I stuck to the upper respiratory template, I wouldn’t hear that. If I stuck to the template, they wouldn’t feel heard. If I stuck to the template, they wouldn’t get what they really need.

My ear.

With the economic downturn, there were more visits for anxiety or depression or “wonders if needs depression medicine.”

We talk and then sometimes a person starts crying and says that they’re losing their house, or they’ve lost their job, or they have to move.

I don’t have a pill for that.

More often than not, they decide not to go on a medicine.

They needed my shoulder and a place to weep.

I hope that Congress remembers that sometimes the most important job of a doctor is to listen. We need time to listen. There is nothing that can replace it.

Originally posted on Everything2.

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Mad as Hell Doctors

I am hitting the road September 8, 2009 with the Mad as Hell Doctors to fight for a single payer system. This is a roadtrip that will end on October 1, 2009 with a demonstration for a single payer on the White House lawn.

My “bio” for the program:

I am a Family Practitioner and chose rural medicine. I care for all ages, including pregnancy and delivering babies, for the 13 years since I finished residency and for the last 10 years in Port Townsend, Washington, population 9000. There has been steadily increasing pressure to “produce” with less time for patients, a minimum quota, templates that impede listening and pressure to see patients for “one thing per visit”. I chose family practice because I wanted to care for the whole patient, in the context of their family and their community. In May, the rural community hospital and I parted ways, because the direction of their guidelines felt unethical to me. I will be opening my own practice, but without the county hospital subsidizing me, I will no longer deliver babies nor take the state insurance. My mission is to treat all comers from my community, my patients ranged from newborns to pregnant mothers up to a 104 year old. I want a single payer system so that I can care for anyone in my community.

I will be on the Seattle to Denver leg, with nine town forums in 7 days. As follows:

9/08 Seattle, WA

9/09 Spokane, WA

9/09 Kennewick, WA

9/10 Helena, MT

9/11 Idaho Falls, ID

9/11 Pocatello, ID

9/12 Salt Lake City, UT

9/13 Fort Collins, CO

9/14 Denver, CO

The group is arranging places to stay, but I would be happy to hear from any noders along the way. I might not be coherent, since I haven’t actually met the others yet and I’m fairly introverted. But this is in line with everything I’ve been fighting with my ex-administrators about and I happen to not have opened my private practice yet.

How did I get on board? A friend sent an email to me and one of the madashelldoctors and said, “They need a woman and you should be it.” We started talking and things just happen sometimes. Another woman doctor will be joining them from Denver to Washington, DC. It is hard enough on the introverted thinker to leave her for a week on the first day of school, but three weeks doesn’t feel right.

I have been running around, boning up on all of the proposals and single payer, reading every website I can find, getting a picture and updating my CV and writing the “bio” above and so forth. And making arrangements for the introverted thinker oh, an I need to get the plane ticket back from Denver. I will miss the first rehearsal for the Mozart Requiem and I’ll miss the Wooden Boat Festival (http://woodenboat.org/festival/). Sacrifices must be made and nothing is perfect.

Normally I would be so busy in clinic and as a single mom that I would hardly be following all this. It is a confluence of forces. I am still surprised.

Originally published on Everything2.

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Death Panel

I am amazed over and over by the term “Death Panel”. I was at a cabin for two weeks with no electricity, newspaper, television or radio and I return to cries of “Death Panel” which seems to be a name for visits to a primary care doctor to discuss end of life issues.
I spoke at a church this summer: the title was “End of Life Issues: Death, Dying and Dementia”. I specialize in Family Practice; I have delivered babies for 18 years and my oldest patient is 104. I love to work with families in life’s transitions: birth, illness, family planning and yes, death.
Everyone dies. Everyone is born. We have prenatal care. Our nation is in continuous discussion about birth: how to make it safe and a welcome and we talk about bonding and reducing premature births. We try to make the gestation healthy; we take vitamins and exercise and see our doctors regularly.
Why don’t we do the same for death?
There is some effort. Hospice is care for the end of life, but to be in hospice, a doctor must say that a person would reasonably be expected to die within six months. Honestly, doctors are not very well trained in this. The truth is that we tend to refer people to hospice within days or a few weeks of death. I was not  well trained in approaching the subject of hospice. Some patients see this as a death sentence: the doctor is saying that I WILL die within six months. I now approach it as a challenge for them. “I could refer you to hospice now, because you might die within six months. They will pay for your medicines and you actually do not HAVE to die within six months. If you live for two years once you are referred, they may fire you from hospice.” Yes, I have had people who were in hospice and came back out. More than one. And I referred one woman because her cardiologist had said her cancer would kill her and her cancer doctor had said that her heart would kill her and she’d already outlived both their predictions and was complaining about an expensive medicine. I said that since they both had told me she’d be dead over a year ago, I was certainly able to refer her to hospice. She thought about it, accepted and then beat the six months. I miss her.
I like to discuss end of life issues. It is not easy, but I would much rather have a difficult discussion than the alternative.
A friend brought her mother, in her upper 80s, to see me in clinic. Her mother was already well past the age when she was likely to die of a sudden heart attack. I started talking about strokes and that it takes 2-3 days for the swelling in the brain to go down. We support people and wait to see if they will be able to swallow. If a person does not recover the ability to swallow, I was explaining why they would die.
“I don’t want to think about this.” she said firmly.
“Well,” I said, “You don’t have to. BUT, if you do not tell us what you want, you might not be able to talk or communicate. If you can’t communicate, your daughter and I will have to make the decisions, and we will err on the side of doing things, treating, rather than not treating. So it is your decision.”
She thought about it. “All right. I am willing to talk about it.”
She did talk about it and she listened to the information about strokes, heart attacks, and told us that if she were sick she would rather stay in Port Townsend. She did not want to be transferred to a big Seattle hospital in the event of a big heart attack or stroke. She wanted to stay in our small hospital, near her family, and use the more limited resources here. She seemed to understand what these were and what we could and couldn’t do. Sometimes transfer to a bigger hospital can slow death, but sometimes it is only by hours or days.
She did have a stroke, some months later. She was able to communicate and her swallowing was affected. She indicated clearly that she wanted to go home. She went home and had her children, grandchildren and a great grandchild present to say goodbye. Her family was very sad but also were prepared, I think, and able to care for her at home. I visited the day before she died. It  made me think of a Norman Rockwell painting, with the great grandchild playing happily in the room with a big bed and the family gathered around.
Every person’s response to the end of life is personal, no two are alike. My job as a family physician includes notifying people when I think the end is nearing; asking for their preferences and trying to help the dying person and their family through this sacred transition as best I can.
If that is what a “Death Panel” is, then I have already been on one.
Originally posted on Everyhing2.