CHF Readmission and CMS's Brain Damage

So, I'm sure a lot of you know Medicare's new idea about how to cut cost -- I mean enhance patient safety and quality of care.

To decide that once you have been admitted to the hospital for CHF that you shouldn't be seen back in a hospital for 30 days for any reason, even if said-reason-for-return-visit has NOTHING to do with CHF, Medicare just won't pay. Brilliant. So when granny has a fall and hip fracture 28 days after a 3 day hospitalization for CHF, Medicare calls foul and refuses to pay? The brazen ignorance is breathtaking.

Of course, I'd like to think that it isn't my problem if my hospital isn't getting paid for these things. I'm supposed to be immune to collections. Except in a healthcare system that has never valued primary care physicians, it suddenly finds itself without a way to get adequate follow up for our CHF discharges. I ask for a 1-2 week follow up with the PCP and they can't get them in for a month? Well damn. The solution must be to make the hospitalists do it. We'll call it something fancy ... like "bridging" clinics. It's like putting a band-aid on a spurting radial artery.

How many of you are being threatened with this?

This honestly makes me want to look into practicing medicine in New Zealand or Australia. Or to get out altogether. We have a healthcare system that has ensured (by virtue of its insuling primary care reimbursement) such a shortage of PCPs, that when we need them most, we don't have them. So let's make our hospitalists assume duties that make their job look more and more like the career they shunned. Then let the financial penalties roll downhill. If the hospital isn't getting paid, let's punish the hospitalists for their inability to make up for our shortsightedness.

Keep it up, CMS. When you punish our hospitals like this, they make our lives hell. Because they have shareholders to answer to. Less and less of us are going to put up with this abuse. As if you don't have enough doctors opting out of your insulting reimbursements... can you really afford to continue to piss us off?

Is GOMER The Driving Force Behind Emergency Department Efficiency Goals?

A reader sent me this scenario:

Happy,

I want your reaction to our new admit policy. When the ER doc sees a patient they do a "screening exam". If it looks like an admission" they send the patient immediately to the floor with out a diagnostic evaluation but with "holding orders" before we get to evaluate the patient who is, even so, put on "our service". The floor nurse is supposed to call us and we have to see the patient "immediately" (even  though we may be running a code at the time). When we see the patient, the eval begins. Are they doing this where you work?. If not, have you heard about it and what are the consequences to your knowledge?   Any suggestions to avoid disaster (other than quitting, of course)  This is called the THRU PUT policy. To PUT the patient THRU the ER.

Thanks,

Wow!  Who's running your hospital? That is one of the worst policies I have ever heard of.  First and foremost, how do you know where to send the patient.  ICU?  Cardiac unit?  The nursing home unit?  If all the ED is doing is vitals and a quick doorway rounds,this policy is full  with danger, the least of which is whether the patient is appropriately evaluated and stabilized in the ED.

In a field where time is life, sending a septic patient to the floor without their first set of blood work, fluid resuscitation, antibiotics etc is certainly going to back fire in terms of outcomes and length of stay on the back end, not to mention the time lag between finding a bed, sending the patient and eventually getting there to see them.

I might also add that many patients don't need to be admitted.  I send patients home from the ED all the time.  What happens when you see them on the floor and they don't need to be admitted? What happens then?

I would never practice in a hospital that dumped emergency room patients onto hospitalists so they could clear the ED with their GOMER policy.  This is horrible for patients, horrible for nurses and horrible for doctors.  Any savings they think they are making on the front end is certainly being wasted with longer lengths of stay due to delayed resuscitation efforts that happen much slower on the floor than it does in the ED.

Your administration is full of myopic bean counters who don't understand the big picture.  I just have one question for them.  If the people in charge making these decisions brought their mother in for evaluation, would they accept a direct transfer to the floor if pops looked like he needed to be admitted without starting an emergency room evaluation or resuscitation?  If the answer is yes, you work in a hospital that lacks any insight into quality.

If I was you I would make a phone call to the local television station (anonymous or not)  letting them know that their community emergency department has policies in place that risk patient safety all in the name of increasing through put of their emergency room.

And see how long that ridiculous policy lasts.

Opining on Truth and Quality

Opining on the Differential Diagnosis:

What does an Internist actually DO? … you ask.

Well, we coordinate care, provide first contact to the system, blah blah blah… but that just makes us glorified case managers.

What Internists do, and supposedly do better than anyone else is practice COGNITIVE adult medicine. That means, in a sense, we literally get paid… to be the smartest person in the room – no pressure.

But what does that mean!!??

For me - it means one thing in particular. We are expert diagnosticians. There.

In all seriousness though, to elaborate, once you know WHAT is happening to a patient there are any number of good evidence based resources to help you look up exactly what to DO about it. But, try as many have, to date there is no good electronic source or algorithmic guide to differential diagnosis sufficient to replace the mind of the practicing and talented internist. Sure, sure, Up-to-date will give you a flow sheet for the evaluation of say, syncope, or new onset seizure. And there is even a pretty good family medicine manual that will help you through the most common causes of pain here or there, swollen this or that etc. And there are one or two projects I have seen that come closer to automated generation of a differential based on symptoms, but none of these references are comprehensive, and they come nowhere near handling multiple interrelated issues concomitantly.

It is also unrealistic to think that any doctor can have SUCH a fund of knowledge that he / she will immediately recognize every rare disease and disorder instantly upon a brief description and examination (although I had some residency faculty who sure thought they could – they do the field a disservice).

As such, I believe good internists have a systematized PROCESS for approaching the differentiation of complex problems. I also believe that any truth that can be known, can be articulated in such a way that most people can understand it. In other words, there is no “mystery” here, per say. Honing the skill takes practice and experience like any other skill, but those who portray an austere sense of the unknowable (except to them) in medicine also do the field a disservice. There are times when you will encounter things that may not be initially clear, and using a systematized approach is a developed skill that can be taught. So, here is a look at the process I use.

I use several methods together, in a systematic way to cover the problem from different angles:

1

1. The Mnemonic: there are many, and they are varied, but I prefer the good old TIN CAN BED – it will walk you through the various systems and at least help ensure that you don’t skip over things.

2. A solid qualitative characterization – the PPQRST.

3. A timeline of events in cause and effect relationships.

4. An “through and through” anatomical approach where symptoms are localized, ie literally “in that location there is – skin, soft tissue, muscle, nerve, bone, parietal pleura, parenchyma, visceral pleura etc ect, until I come right out the other side like a bullet.

5. Semantics – by this I mean using correct and accurate terminology appropriately. A common example is “heart failure.” To simply say a patient has “CHF” should never be good enough. Dig through old records etc and call it ischemic or hypertrophic or dilated cardiomyopathy with an ejection fraction of X%, based on LVG/echo/muga dated such and such.

6. A good focused physical exam.

When you are finished running through this process for each presenting complaint or symptom, you should (sometimes with the help of an electronic resource) be able to generate a list of possible etiologies for each problem. THEN, you utilize epidemiologic data, or validated decision tools (for example the wells criteria, or the Ottawa ankle rules) to generate a “pre-test probability,” or the likelihood that the symptom or complaint is caused by X for each of the possible etiologies.

Next, based on those probabilities, you select a test or therapeutic trial (which is sometimes nothing more than watchful waiting), the outcome of which makes each possible diagnosis more or less likely. You initiate treatment when a diagnosis becomes “likely enough” to warrant it, or, when the possible diagnosis is so critical or when treatment delay would be harmful enough that you are comfortable enough with any potential risk to go ahead, and stop or decelerate once your potential diagnosis becomes less likely.

The fund of knowledge that helps guide one through the process is based both on openly available information (learned in medical school and residency) as well as the experience that comes with prolonged and repeated exposure. In other words, having run through this process for, say, chest pain 6000 times before, informs the six thousand and first time.

While I admit, this seems silly for routine complaints, it quickly becomes critical when things are not routine and when there are multiple, complex, concomitant issues.

Overall, my point here is not MY specific approach, so much as it is that there IS a specific approach that CAN be described and articulated.

What’s interesting to me is that it is the very attempt to quantify and codify this process that led to the development of E&M codes, but that the value assigned to those same codes so undervalued the process, that those same codes became the death of doing the process well. The thing is, this takes TIME, period. Cognitive medicine, when practiced well takes TIME, and we are not compensated based on time, but rather on documenting to justify a code, which incentivizes spending the minimum amount of time possible. This is a component of what has led, at least in my mind, to poorer quality. With discussion of healthcare reform, a re-focused attention on primary care must address the issue of time to facilitate a return to doing the MOST possible THINKING (which is cheap) and less expensive and unnecessary testing.

Health Care Reform: Time to Get Real

Reading health care reform proposals should be required for anyone wishing to rant on the subject. Listening to the talking heads and the chatter from concerned citizens, I can understand why people are demanding some type of reform. The number of children, disabled citizens, pregnant women and others unable to get timely health care is mind boggling—or so you might be lead to believe.

Here is the eye opener, people:

Despite everything being said, and in regard to US citizens:

1) There are no children that do not currently have access to health care thanks to provisions already existing in Medicaid and CHIPS.***
2) There is no disabled person or anyone over the age of 65 that does not have access to healthcare right now.***
3) There are no pregnant women without access to health care.***

(*** not to say their access is not very poor in regions because of a lack of providers accepting government insurance***)

It is the 18-65, non-disabled, non-pregnant person who is at risk. Of these we’re talking about able bodied/able minded:

1) Legal citizens.
2) Those that can’t afford private insurance (ie under employed).
3) Those that have lost their insurance because of changed jobs or dropped insurance.
4) Those that insurance will not cover for preexisting disease.
5) Those that chose to self-insure or take their chances without insurance.

SO, IF THIS IS THE CASE, WHY ARE WE CONSIDERING A COMPLETE OVERHAUL OF THE HEALTH CARE SYSTEM INSTEAD OF:

1) ADDRESSING THESE SPECIFIC AREAS (ie focused insurance reform to make insurance more affordable, eliminate drops and denials, a more affordable safety net than COBRA, expanding Medicare alone…).
2) FOCUSING ON WASTES IN THE CURRENT SYSTEM (ie tighter regulation/oversight to prevent large scale criminal abuse, initiatives to decrease defensive medical practices, astronomical excesses in end of life care. )
3) IMPROVING PHYSICIAN PARTICIPATION IN EXISTING GOVERNMENT PROGRAMS for the elderly, disabled, children, pregnant women, veterans. (Because of high overhead, MOST physicians tend to avoid or significantly limit patients with Medicare, Medicaid, Tricare (I don’t know about CHIPS) because the reimbursement hardly covers overhead—either increase reimbursement or decrease overhead-ie health related taxes, costs for medical malpractice… NO HEALTH CARE PROPOSAL HAS ADDRESSED THIS and making more Medicaid-like programs ain’t gonna guarantee anyone access to a doctor—just ask anyone with Medicaid now.)
In the end, it has become incredibly obvious to me that current efforts to reform health care are agenda driven and fail to focus on real problems thereby putting at risk the provision of high quality care, increasing the insult to our economy which will have repercussions for generations to come, adding new layers of government bureaucracy which in itself is a burden to our economy and established way of life.

IN MY OPINION, NO REFORM IS BETTER THAN ANYTHING BEING PROPOSED AT THIS TIME.

Yes, the emergency rooms and hospitals will continue taking up the slack for those without other access to care and while this is expensive and endangers care to others, I’ve been doing it for years and so have doctors and hospitals across the country. Neither the tax payer nor the government takes it in the shorts for this kind of care—we providers do in the form of unreimbursed labor, risk and resources, and we’ll continue to do it, if need be, until the government, the media, the trial lawyers, and the Kool-Aid drinkers on both sides of the fence decide to cut the crap and GET REAL!

HR3200: pages 205-301

HEY!

Thanks to Happy and others involved in allowing me to share my raves and rants at Hospitalist with a View--and I've got a few. At www. Pissydoc.com things get a little absurd at times but I'll try and keep my nose clean here (the Tabasco is back in the pantry). What I hope to share with you are retative political and ethical views involving health care that affect us all. Recently I've started reading the text of HR3200 and what follows is my review of pages 205-301 (except for my highlighting which did not survive the cut and paste). Thanks for having me and I hope you find the post interesting.

Pissydoc (Well, not so pissy today anyway)

*******************************************************************************

Alright, I got the through to page 301. This portion of HR3200 contains a lot of provisions directed at durable equipment, use of xrays and other forms of medical imaging, physician, nursing home and hospital providers as well as Medicare in general. If you saw may last post (the fake outtake of the bill) many changes regarding Medicare are presented this way: references and amendments to text in the Medicare legislation without discussion of the context. This makes things difficult to review without actually having the Medicare legislation in front of me, In this regard, my review of pages 205-301 may be incomplete. As always, I’ll stick to the areas I feel are relevant to the public and medical community.

227. Provision for providing payment for inpatient psychiatric care. This is a nice change as focusing on mental wellbeing can improve quality of life in the face of medical issues that are unlikely to improve significantly regardless of therapy.

229. Provision to increase reimbursement of non-therapeutic nursing home costs (room & board?) and to decrease payment for therapeutic care. In my experience, our older NH patients get in more trouble when they are, in effect, thrown out of the NH when their benefits expire. So much of what we do for many of these individuals slows the progression of debility but often not in a meaningful way. Allowing patients to stay longer in a facility when they require total support is likely to be more beneficial for many patients than an extra week of physical therapy. I also suspect the cost of paying out of pocket to stay in a nursing home is greater than that of adding physical therapy… which loved ones may still choose to do on their own.

230: The Secretary of HHS will determine what services in NHs will be paid for and which will not. He or she will take into consideration age and functional status of individual patients when making these determinations. This is no doubt the mechanism of assigning rationed care and while this needs to be watched closely for abuse, consider how you would feel if your mentally intact mother, who after a stroke has potential for walking again, but could not qualify for more than 2 weeks of physical therapy because Medicare was paying for continued physical therapy for non-independent individuals with advanced dementia and no reasonable prospect for resuming a normal life style. This is not saying that individuals such as these should not have access to those treatment options but should Medicare be responsible for paying for them? We can’t afford to provide everything to everybody. Medicare should be focused on investing in situations where there is at least a reasonable likelihood for return on that investment. Beyond that, if family want it anyway, they should pay for it.

232 Budget Neutrality. I really like this term; a shell game by any other name is still a shell game. I would hope that physicians, especially gerontologists, will have the opportunity to review the specific recommendations for services to be covered or cut. There are no specifics provided here. The secretary will of course seek endorsement of the proposed changes but he/she is not bound by endorsement and can in effect do what ever they want.

235-7. Medicare payments (esp to SNFs/NHs?) will be adjusted upward if the national rate of uninsured individuals decreases by 8% secondary to this reform. There is no mention as to what happens if this does not happen.

239-248. Limitation of Physicians’ Services: This has to be the worse written portion of this section. I have no fricken idea what they’re talking about here—and that’s scary. I think this section refers to the use of target growth rates in service utilization to determine correction factors to be applied to standard Evaluation and Management codes (what the physicians use to bill for services) & do away with specific specialty billing codes. I can not tell what the effect on specialty reimbursement will be because of this (I can tell you the specialist physicians I know are pretty worried).

250. More bundling of service E&M codes (which will pay the provider less than if the services were billed separately). 252. Again, the Secretary is in total control of this and does not apparently need to answer to anyone. It is worth noting that all of this reanalysis of billing codes and fee adjustment, and bundling of services has been going on for a long time and is not new; it just has the potential of getting worse now.

254 20 million is appropriated for Medicare funding in 2010 but additional funds as necessary may be obtained from unappropriated treasury funds—you know that bottomless pit from which everything is being paid (the treasury is funded by taxes, income from penalties, savings from other programs, and, of course, loans from other countries if needed).

256. Services (physicians, hospitals, nursing homes…) functioning in regions determined to be most efficient in utilization of medical resources will receive quarterly bonus reimbursements as incentive/rewards. This worries me in that often areas of higher utilization are areas with sicker patients and incentives such as these may influence whether new services move into these regions thereby potentially worsening care for those already behind the 8 ball. An example would be the inner city which typically already suffers relative to the burbs. I’m not going to work at St. Elsewhere when I can earn an additional 5 % outside the city limits. (recurrent theme here: the Secretary will decide what counties get bonuses and there is no provision for judicial or administrative review of his/her decision.)

272. Provision to address potential excess costs by cancer hospitals relative to receiving similar treatments elsewhere. Medicare (and so the Exchange program) should have to pay no more for the same treatment just because it’s provided at specialty facilities.

280. Much of the next ~20 pages deal with reducing readmissions to the hospitals. This is a difficult subject in so much that punitive measures can actually cause harm to patients.Example: Once I am not doing anything different for a patient that can be done at home I discharge that patient with instructions that his/her condition has the potential for getting worse in which case they need to return. I do this to minimize the patient’s risk of hospital born infections (ie MRSA) and hospital related errors (i.e. getting someone else’s medication)—which will always exist as long as humans are in charge of administering care. When someone returns to the hospital in compliance with my instructions I say “the system works”, though, of course, everyone would have preferred that he would not have needed to return. If this provision goes through, I, and physicians like me, will be inclined to hold on to patients longer in the hospital. The patients, for the before mentioned reasons, will potentially suffer for this. The hospitals will suffer too; they are often paid a single fee for a patient’s hospitalization no mater how long the patient stays. If a patient stays an extra day, the cost for that day comes out of the hospital’s pocket. That means less money for improving services provided by the hospital to the community. Certainly, hospitals push to get patients out quickly, and maybe too quickly sometimes but a blanket proposal here throws the baby out with the bathwater. The only reason hospitals push for discharges anyway is because of the bundling of services that Medicare has already imposed on them which encourages early discharges. This proposal pushes providers from both sides when possibly the safest thing for the patient is to leave such matters to the hospitals and physicians.
I agree with need to address excessive costs from non-compliance by patients in regard to their health care instructions but I don’t agree with initiatives to ensure they comply. This is simply throwing good money after bad. We should do everything possible to make sure patients understand their instructions but beyond that, if they do otherwise and their condition worsens further insurance coverage for that particular medical problem should be denied. I think patients will be more inclined to behave or at least ask more questions if they know there is a significance consequence to bad behavior.
(Don’t remember page). There is a provision to decrease reimbursement of frequently used imaging (xray) tests and this is another difficult call. I’ve often had to order double studies (ie MRI and CT scan) to arrive at a diagnosis. I’ve also had to repeat studies (ie ct scan) within 24 hours to catch a medical problem worsening. I am afraid that over regulation here might save Medicare money but will cost hospitals, which again will lead to decreased services, or increase in charges for other services. The other side of the coin is this, I’ve been bitching about our tendency to over order tests for a long time but the resultant mantra usually involves physicians wanting to cover their butts from potential law suits. Unfortunately, we will not see this trend decrease until there is some level of protection from lawyers, who not only cater to those seeking to file suits but actively encourage such things. President Obama, impress me and do something about this (right). Once again, the hospitals will pay the cost for this utilization trend after the government refuses to reimburse for certain imaging studies and end result will be less hospital initiated/funded community service.

Thats it for this episode, and you’ll have to pardon me if it takes a while to get out the next installment: This thing is giving me brain pain.

Is "numerous drug allergies" a marker for psychiatric disease?

Happy at "A Happy Hospitalist" blog recently wrote about a colleague who thinks the presence of four or more drug allergies is a good indicator of fibromyalgia.

I'm reminded of an ER doc and I who were marvelling about a patient he was seeing who had a full page of drug allergies, about 40 drugs. Patients like that are extremely time-consuming and difficult to treat.

Entirely separate from the fibromyalgia issue, I've long thought that having numerous drug allergies or sensitivities is a marker for psychiatric disease. The more allergies, the more severe the psychiatric disease.

I'm not sure which psychiatric diagnoses would most likely be present in a patient with too many drug allergies. Hypochondriasis? Histrionic personality disorder? Somatiform disorder? Somatization disorder? Obsessive-compulsive disorder? [This is more than just anxiety or depression.]

Undoubtedly, there are exceptions. People with extremely poor health (who go to doctors) or history of serious disease (e.g., cancer) are exposed to many more drugs than fortunate people who rarely go to the doctor. They WILL have more legitimate drug allergies than the general population. And some people just have odd immune systems.

[Remember the old "multiple chemical sensitivity sydrome" from 20 years ago? Is it still around?]

I spent five minutes at PubMed looking for data to back me up, and found none. With more time, I bet I'd find it. If not, there's an opportunity here for someone to do the research and have a clinical sign named after himself.

Do you agree with me that having too many drug allergies raises a flag for possible psychiatric issues?

And what's "too many"? Four's not enough. Forty's too many. I suggest six.

And which psychiatric diagnoses are associated with numerous drug allergies?

[Whoever earns naming rights for the syndrome will have to determine sensitivity and specificity limits, as well as specify what constitutes a "drug allergy." It's probably easiest to simply ask the question (or put it on a form), "Are you allergic to any medications? Which ones?" Boom, there's your answer.]

-Steve Parker, M.D.

PS: For any patients reading this, continue to share all your drug allergies and sensitivities with your doctors. Your life could depend on it.

What Do Your Patients Believe?

Misinformation about cancer can cause patients to delay or reject treatment or others to blame them for having cancer. Misinformation can kill. One study suggests that a high number of patients would not have lung surgery for cancer because of their belief that surgery would spread the cancer.

Cross-posted from my own blog:
Last week I received the email at the bottom of this post by someone who was pretty upset about it. There are a few, but not many, facts, and those that do exist are skewed to support illogical conclusions.

Unfortunately, the text of this email has been reproduced all over the alternative medicine web as fact. The "facts" in it are laughable; distilled water is perfect at a 7.0 pH--it is not acidic! This is very basic science. It's funny that someone concerned about dioxin in plastic bottles would recommend covering microwaved food with paper towels--plastic doesn't contain dioxins, but paper towels are bleached with dioxins. There is truly bad science and lack of logic in every numbered item in this email. But again, it's reproduced all over the web. People believe it.

This kind of misinformation below harms, however; it is not at all innocuous and can lead patients to very bad decisions that can take their lives. According to one study, many people believe that surgery will spread cancer (a misunderstanding of metastasis or recurrence) and would not have lung surgery even if a doctor dispelled the myths (http://caonline.amcancersoc.org/cgi/content/full/54/1/2). While chemotherapy is toxic, your chance of surviving breast cancer, for example, is 92% with it but very small without.

The email seems to ignore the ever-increasing survival rates of cancers that result from surgeries, chemo, and other therapies. I have been told that my pre-cancerous uterus was caused by eating sugar and not eliminating it absolutely 100% without exception. Anyone who's taken biology and thinks about it remembers that food is broken down into lipids, proteins, sugars, etc. Sucrose is not different from other carbohydrates that are metabolized into glucose (milk sugar becomes lactose and fruit sugar fructose), though unrefined carbohydrates and a balanced diet are best for a number of reasons. If food is to blame, and we can't know for sure, it is far more likely that I was harmed by drinking soy formula and then soy milk daily until I was 11 because of milk allergy (excessive soy causes cancer, though it's recommended below) and other hormonal therapies to try to control my bleeding for many years.

Increasingly, people encourage an "alkaline" rather than "acidic" diet. This is nonsense. While vegetables are good for you, so are fruits. Quick fact-checking suggests that the normal pH of the blood is 7.3-7.5 and should not go over or under this much (dire circumstances can occur). There is little most people can do to change their blood pH, however; blood pH is an example of homeostasis--the body maintains it.

Both Johns Hopkins and Snopes dispel this email, though I am a bit disappointed they do not address more details, such as the nutritional ones; brevity perhaps helps people to read through all of it. http://www.hopkinskimmelcancercenter.org/index.cfm/cID/1684/mpage/item.cfm/itemID/1016 http://www.snopes.com/medical/disease/cancerupdate.asp

While I don't think anyone would make their decisions on a single email, hearing this kind of material over and over (as with the acidic/alkaline garbage, or that chemo directly causes recurrences) can lead people to poor decisions not based in fact, to alternatives that have little effect or that can even harm. I am not opposed to alternative and complementary medicine that has evidence to support its claims, but this kind of nonsense is harmful.
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FW: JOHN [sic] HOPKINS MEDICAL - Good Article!

Don't know how true it is but sure makes sense....

Health Info that I think we can all use.

Subject: JOHN HOPKINS MEDICAL
Very informative !!!

John Hopkins Update - Good article
AFTER YEARS OF TELLING PEOPLE CHEMOTHERAPY IS THE ONLY WAY TO TRY ('TRY', BEING THE KEY WORD) TO ELIMINATE CANCER, JOHNS HOPKINS IS FINALLY STARTING TO TELL YOU THERE IS AN ALTERNATIVE WAY.

Cancer Update from Johns Hopkins :
1. Every person has cancer cells in the body. These cancer cells do not show up in the standard tests until they have multiplied to a few billion. When doctors tell cancer patients that there are no more cancer cells in their bodies after treatment, it just means the tests are unable to detect the cancer cells because they have not reached the detectable size.
2. Cancer cells occur between 6 to more than 10 times in a person's lifetime.
3. When the person's immune system is strong the cancer cells will be destroyed and prevented from multiplying and forming tumors.
4.. When a person has cancer it indicates the person has multiple nutritional deficiencies. These could be due to genetic, environmental, food and lifestyle factors
5. To overcome the multiple nutritional deficiencies, changing diet and including supplements will strengthen the immune system.
6. Chemotherapy involves poisoning the rapidly-growing cancer cells and also destroys rapidly-growing healthy cells in the bone marrow, gastrointestinal tract etc, and can cause organ damage, like liver, kidneys, heart, lungs etc.
7. Radiation while destroying cancer cells also burns, scarsand damages healthy cells, tissues and organs.
8. Initial treatment with chemotherapy and radiation will often reduce tumor size. However prolonged use of chemotherapy and radiation do not result in more tumor destruction.
9. When the body has too much toxic burden from chemotherapy and radiation the immune system is either compromised or destroyed, hence the person can succumb to various kinds of infections and complications.
10. Chemotherapy and radiation can cause cancer cells to mutate and become resistant and difficult to destroy. Surgery can also cause cancer cells to spread to other sites.
11. An effective way to battle cancer is to starve the cancer cellsby not feeding it with the foods it needs to multiply..
*CANCER CELLS FEED ON:
a. Sugar is a cancer-feeder. By cutting off sugar it cuts off important food supply to the cancer cells. Sugar substitutes like NutraSweet, Equal, Spoonful, etc are made with Aspartame and it is harmful. A better natural substitute would be Manuka honey or molasses, but only in very small amounts.. Table salt has a chemical added to make it white in color. Better alternative is Bragg's aminos or sea salt.
b. Milk causes the body to produce mucus, especially in thegastro-intestinal tract. Cancer feeds on mucus. By cutting off milk and substituting with unsweetened soy milk cancer cells are being starved.
c. Cancer cells thrive in an acid environment. A meat-based diet is acidic and it is best to eat fish, and a little chicken rather than beef or pork. Meat also contains livestock antibiotics, growth hormones and parasites, which are all harmful, especially to people with cancer.
d. A diet made of 80% fresh vegetables and juice, whole grains, seeds, nuts and a little fruits help put the body into an alkaline environment. About 20% can be from cooked food including beans. Fresh vegetable juices provide live enzymesthat are easily absorbed and reach down to cellular levels within 15 minutes to nourish and enhance growth of healthy cells.. To obtain live enzymes for building healthy cells try and drink fresh vegetable juice (most vegetables including bean sprouts) and eat some raw vegetables 2 or 3 times a day. Enzymes are destroyed at temperatures of 104 degrees F (40 degrees C).
e. Avoid coffee, tea, and chocolate, which have highcaffeine. Green tea is a better alternative and has cancer fighting properties. Water-best to drink purified water, or filtered, to avoid known toxins and heavy metals in tap water. Distilled water is acidic, avoid it.
12. Meat protein is difficult to digest and requires a lot ofdigestive enzymes. Undigested meat remaining in the intestines becomes putrefied and leads to more toxic buildup.
13.. Cancer cell walls have a tough protein covering. By refraining from or eating less meat it frees more enzymesto attack the protein walls of cancer cells and allows the body's killer cells to destroy the cancer cells.
14. Some supplements build up the immune system (IP6, Flor-ssence, Essiac, anti-oxidants, vitamins, minerals, EFAs etc.) to enable the bodies own killer cells to destroy cancer cells... Other supplements like vitamin E are known to cause apoptosis, or programmed cell death, the body's normal method of disposing of damaged, unwanted, or unneeded cells.
15. Cancer is a disease of the mind, body, and spirit. A proactive and positive spirit will help the cancer warrior be a survivor. Anger, un-forgiveness and bitterness put the body into a stressful and acidic environment. Learn to have a loving andforgiving spirit. Learn to relax and enjoy life.
16. Cancer cells cannot thrive in an oxygenated environment. Exercising daily, and deep breathing help to get more oxygen down to the cellular level. Oxygen therapy is another means employed to destroy cancer cells.

1. No plastic containers in micro.
2. No water bottles infreezer.
3.. No plastic wrap in microwave.

Johns Hopkins has recently sent this out in its newsletters. This information is being circulated at Walter Reed Army Medical Center as well. Dioxin chemicals cause cancer, especially breast cancer. Dioxins are highly poisonous to the cells of our bodies. Don't freeze your plastic bottles with water in them as this releases dioxins from the plastic. Recently, Dr. Edward Fujimoto, Wellness Program Manager at Cast le Hospital, was on a TV program to explain this health hazard. He talked about dioxins and how bad they are for us. He said that we should not be heating our food in the microwave using plastic containers. This especially applies to foods that contain fat. He said that the combination of fat, high heat, and plastics releases dioxin into the food and ultimately into the cells of the body. Instead, he recommends using glass, such as Corning Ware, Pyrex or ceramic containers for heating food You get the same results, only without the dioxin. So such things as TV dinners, instant ramen and soups, etc., should be removed from the container and heated in something else. Paper isn't bad but you don't know what is in the paper. It's just safer to use tempered glass, Corning Ware, etc. He reminded us that a while ago some of the fast food restaurants moved away from the foam containers to paper. The dioxin problem is one of the reasons. Also, he pointed out that plastic wrap, such as Saran, is just as dangerous when placed over foods to be cooked in the microwave. As the food is nuked, the high heat causes poisonous toxins to actually melt out of the plastic wrap and drip into the food. Cover food with a paper towel instead.

This is an article that should be sent to anyone important in your life.

How to prevent a costly MRI.

Dear fellow group members.

Before ordering the damn MRI to "rule out osteomyelitis", please take apart the dressing and look at the effing wound first. Or read the wound care notes.

Sincerely,

CrankyKong,MD.

(after a horrible weekend spent batting cleanup)

A Patient View on Noncompliance

First, a question or two. Among increasing medical costs to patients, insurers, the government, taxpayers, and the insured, are extremely costly medications such as TNF inhibitors worth it at $15,000 a year? What about IVIG treatments for autoimmune dysfunction at $10,000 a treatment, where the treatment will reduce disability some but where the patient's life is not in danger? To me, such questions are not just individual applications but broader, ethical ones that extend to many other expensive healthcare decisions. When I asked how people a generation or two ago afforded their medical bills, one of my older friends pointed out that his family members and others did without--people simply managed most conditions without pharmaceutical or surgical involvement (and probably without a lot of complaining). But why stop drinking coffee or eating preservative-laden foods when you can take proton pump inhibitors? Is noncompliance in the case of chronic arthritis, autoimmune dysfunction, or GERD the failure to take a medicine or the failure to change one's diet or lifestyle?

These days, many patients--or should we call them consumers?--expect that doctors can cure any problem, failing to recognize that mitigation of symptoms is more likely than a cure, and that adverse effects of pharmaceuticals or surgeries may exceed the effects of the original problem. A woman with an early hysterectomy, for example, may expect to get osteoporosis at an earlier age and may greatly increase her risk for hip fracture. The expected one-year mortality from hip fractures is about 15-20%, 35% if the patient is older (link). Although a hysterectomy may be an obvious recommendation for moderate to severe uterine problems, perhaps sometimes thoughtful noncompliance is in order where discomfort and pain will continue. (I don't mean cancerous conditions or adventures in Xtreme bleeding.)

There can be other reasons for noncompliance. When patients sometimes fail to comply or follow up with other specialists as recommended, it's not to make their physicians pull out their remaining hair or to self-sabotage. (Here, I don't mean patients who are failing to take insulin or thyroid medication or who are abusing their bodies badly.) It is extremely difficult for patients to balance among multiple specialists. The medical system can be stressful, though necessary. When a patient can't remember a couple of specialists' names despite a decent memory, that patient may be a bit overwhelmed. In my case, today I had an appointment with my rheumatologist, and I have an appointment tomorrow with the dermatologist, an appointment Monday with the neurologist, and now I may have to see a hip specialist and the GI specialist too. I was spoiled by the luxury of having a few months without medical appointments. I have not yet scheduled with the PM&R doctor and wheelchair seating expert so I can get myself sitting up and out in the world more, only because I had been exhausted by appointments and am not thrilled about moving to different equipment. No, I don't want an MRI or a scope or cortisone injections that can weaken my hip, even though it could relieve pain. The in-network copays are killing our unemployment bank balance--an MRI copay would cost us several hundred dollars, a power wheelchair several thousand--and that's just the copay. Yes, my rheumatologist is doing his job, and a good one at that--his recommendations are sound (in my lay perspective--I've seen recommendations that aren't sound from a lay or scientific perspective). He thinks about costs and risks and the needs of his patients, and I will hold off on what we think I can (hip specialist and MRI, phone call to the GI specialist rather than appointment).

I've told my doctors that I have to work triage with myself, and they've laughed at my humor, but there's a truth to that. We have to prioritize, and sometimes that means postponing or temporary noncompliance in one area.

Are Hospitalists Necessary "To Follow" Post Op?

I suggested lightheartedly that hospitalists would be required to consult for pain management on surgical patients who's doctors have never learned to prescribe anything but Percocet and Vicoden, two drugs which may have seen their last days. The conversation got off track with this anonymous subspecialist comment, but I thought it raised some important issues to discuss.

Anonymous said...

I'm curious Happy.

Don't you make a living by seeing the "Specialist's" patients?

I don't mock the internists when they send me common things that they could treat....I figure they are happy to see my general medicine patients post op.

Am I wrong?

I responded with the following:

We are all specialists. Some are more subspecialized than others. So yes, I make my living almost entirely from the referrals of out patient family medicine and internal medicine specialists.

As far as being happy to see "general medicine" patients, I don't have any idea what that means. If there is an acute issue that needs to be addressed, elevated blood pressure, abnormal blood sugar, chest pain, fever I am more than happy the evaluate patients who need a physician specialist as my self to evaluate an acute issue. This is not general medicine. This is internal medicine.

If you are asking me if I am happy to see post op surgical patients to write discharge orders, address home meds and field nuisance pages, then you must be mistaking me for someone you should be hiring to do your work for you.

No specialist as myself needs to address stable medical issues. It's one reason why 99.999999999999999999% of the world's population does not have a live in physician outside the hospital. You do not need an internist "to follow for medical management", any more than I need an orthopaedic "to follow for orthopaedic management" on a patient admitted with pneumonia but has a history of a hip fracture

I am happy to consult on medical or surgical patients when I am being asked to evaluate an acute issue. I am not needed to see a patient "to follow". If that's what you need, you should hire your own PA or NP to assist your needs. The patient certainly doesn't need me in these situations.

Oh yeah, the comment about consulting a hospitalist to write for pain management was not meant to be taken seriously.

What do you think America? Not a day goes by where I am not called for "hospitalist to follow post op". Should I be happy to see stable general medical patients post op or medical patients admitted to medical subspecialist services with no acute internal medicine issues to address? I view these types of billable encounters as bordering on insurance fraud. I am being asked to create medical necessity when medical necessity doesn't exist. It is not difficult to generate a level two or level three follow up note (2 ROS, document the status of three chronic medical conditions, review pre op lab, personally review pre op EKG, review IV PCA plan, and discuss the care plan with the nurse). Viola, a level three follow up note that meets every criteria as required by the E/M Guidelines of 1995 or 1997.

Now was it medically necessary? You tell me. I am being asked to provide a service by the physicians asking for me "to follow". A service that should fall under the subspecialist's duties and responsibilities (if they don't want to do it, they should use the profit from their bundled payments to pay someone to do it (RN, PA or NP).

Does consulting me make it medically necessary? Well, Medicare and their carriers seem to think so. No claim is ever rejected. So what am I to do? Do I say no to the physician's request? Or do I do it and submit a claim. Thus is the life of fee for service. Should I be grateful for this easy money while the Medicare National Bank goes bankrupt? I find great personal internal conflict from this type of practice that never ends. I believe I have no role in these patient's care plan. I believe medical necessity is generated by physician request where none should exist.

This is a huge area of co-management controversy in hospitalist medicine. What exactly is the role of hospitalists in patients with stable internal medicine conditions, if any?

Like I said above, patients with stable medical issues do not require a daily internists for evaluation and management any more than they require an orthopaedist to follow my pneumonia and afib patients who have a history of a hip fracture.

When's the last time...?

Dr. Cranky just manually disimpacted an 85 year old who hadn't gone in 2 weeks. Now if that don't get me the Physician of the Quarter award...

Guns, Not Hydrocodone

Extending the "guns, not butter" government policies of the last decade to a new policy, "guns, not hydrocodone," an advisory panel for the FDA has voted to take physical medicine specialist Dr. Bernie Smith up on his acerbic statement to 64-year-old chronic pain patient Ellie Whitt, "There's not a lot we can do other than take you out back and shoot you."

"I was just joking!" protested Dr. Smith in a phone interview Tuesday afternoon.

Undeterred, the FDA panelists, many of whom have investments in the rheumatoid arthritis drug Enbrel, maintain that acetaminophen use can kill, but guns will be quicker for those who can't use TNF inhibitors. "Our new slogan is 'Guns, Not Hydrocodone,' because if you think about it, guns don't kill people, hydrocodone kills people," said one panelist, who preferred not to be named.

"We also can't make any profit off generics that cost $1.00 a day," said another panelist, Robert Blanco. "Enbrel, though, that's $15,000 a year per patient." Blanco has already contracted with an architect to build a multi-million dollar vacation home in Cape Cod. "I expect to make a killing. No pun intended," he says.

"God, why didn't I go into pain management," Dr. Smith was heard to mumble to himself. Doctors expect a run on pain clinics soon and a shortage of pain management physicians to write prescriptions for stronger drugs.

"Now I can get that drug that starts with a D. What's the name? Dilaudid? It really works and is completely safe," said metastatic cancer patient Michelle Munroe.

But the public has no need to fear that zombified and addicted patients will be driving in a neighborhood near them anytime soon. While pain patients might expect that they can switch to safer and less addictive drugs such as oxycodone, the FDA has decided to continue its moratorium on oxycodone production.

"On January 1, patients can go to a local pharmacy and duke it out over who's going to get the 100 tablets allotted to each pharmacy for the year," said an FDA spokesperson, Max Joseph. "Those unable to duke it out will be handed guns and a single bullet to use in the privacy of their own home. If they can't pull the trigger, we'll be glad to assist. Recent changes to assisted suicide laws in many states have given us easier and less expensive solutions to deal with disabled patients who can't take drugs we own stock in."

When asked whether most prescription medicines don't cause some risk to the liver, a risk that can be mitigated through monitoring, Joseph said that the FDA will soon focus on the real problem, the classes of the most dangerous medicines: generics. They will especially target those medications that cost under $5 a day.

"Nitrofurantoin, for example, has been known to cause sudden allergic reactions, liver damage, changes in EKG, psychosis, and deadly fungal pneumonia," said Joseph. "It's an older drug that just can't compete with the newest generation of floroquinolones, which just don't carry these risks. In fact, we're going to mandate that all patients receive Levaquin instead. You can never be too careful. I take it all the time."

The FDA, however, does warn against a projected crime rise as drug abusers and desperate pain patients hoard pain medicines, and then, thirsty as rats on arsenic, leave their domiciles seeking these dangerous drugs.

Members of the FDA panel have declined voluntary participation in a clinical trial in which patients are given spine surgery or hip replacement and then denied PCA pumps or narcotics. However, after her incidental surgery for wisdom tooth removal Wednesday morning, panelist Maureen Fish was heard to say, "Wait! I've changed my mind. I have a high pain tolerance and had babies naturally but this is just unendurable."

"Wimp! Who would take hydrocodone for that? A Tylenol will do," Michelle Munroe commented, holding a protest sign outside FDA headquarters while doubled over in her wheelchair.

Parody only, except the ban will be real if the FDA follows the vote of the committee: http://www.nytimes.com/2009/07/01/health/01fda.html?_r=1.

My favorite patient...

Mr. H, 101 years old...chief complaint: "I passed out while I was working out. Happened twice last week." I LOVE this guy...

Clinician versus Utility

I've become somewhat disgusted with a new "vision" for hospitalists at our institution, and I wanted to get some feedback.

Just prior to the Society of Hospitalist Medicine meeting in Chicago, I read a post from another hospitalist blogger lamenting the push to degrade hospitalist medicine from a specialized clinical field of internal medicine into a "jack-of-all-trades" utility that provides a "convenience factor" for proceduralists. He called for strong leadership from SHM to voice disapproval of this dangerous trend. I didn't hear anything as definitive as I would have liked.

It seems that some hospital administrators have the misguided goal of having hospitalists admit 100% of the patients in order to allow all of the specialists (read: obscenely well-compensated proceduralists) to perform as "technicians".

At first, I thought the push to get a very small hospitalist program to start doing pre-operative medical evaluations was noble... until I realized we were only doing them for highly-lucrative elective procedures for surgeons already making 7 figures.

But that wasn't enough. Now the proceduralist/technicians want to maximize the number of procedures (which are supposed to include a global 90-day period of post-op care) without having to deal with all that pesky time-consuming post-op management. Hospitals that make money off the backs of these guys salivate at the notion of boosting their procedure output. What's the new en vogue way to achieve this? By turning over all of that post-op care to the hospitalist. We are being shamelessly used to construct the assembly line that plucks the money off the Medicare (and occasionally privately-insured) tree.

Now, at our institution, it's a total crapshoot whether or not the hip fractures wind up on medicine with an ortho consult, or ortho with a medicine consult. In either case, our surgeons do typically leave daily notes on their patients (but I use the word "note" quite loosely). I have rarely seen a shred of "management" being provided ("plan: per hospitalist"). But one doesn't have to look far to see where this is going -- the hospitalists are being used as bargaining chips to pacify the proceduralist/technicians... especially those that can uproot and take trauma-center status with them.

And so the slow march to shove inappropriate patients down the hospitalists' throat ensues. Epidural abscesses are admitted to medicine because an infection is a medical problem. Prisoners with jaw fractures are admitted to medicine because they're on psych drugs. Otherwise healthy 30-somethings with appendicitis are admitted to medicine because... well... does it really matter?

Make no mistake, I plan to exit stage left the moment it's in the cards, but is this a pervasive problem in the field of hospitalist medicine? Am I going to have to ask every potential future hospital to what degree they try to manipulate the Medicare National Bank at the expense of the hospitalists? Do you know how much money is wasted for me to do an H&P at 3am on a patient that I will literally be making absolutely no medical decisions for? With all the other bullshit hoops we have to jump through to get paid for our work, why is this not Medicare fraud?

For the moment, our proceduralist/technicians are having a field day with the administrative support for dumping on the hospitalists. I, for one, am ready to cease using the prefix "Doctor" for someone who wants to be treated like a glorified mechanic (even though I've long thought of interventional cardiologists as slightly-better-educated plumbers). You want to be a technician? Then maybe it's about time you were paid like one.

And the Shell Game Goes On

So I had this semi-voluntary meeting to attend this week. Some physician-based consulting firm (god I need one of these jobs) hired by the hospital to do battle with the minions that CMS has hired to try to recoup "overpayments" to physicians. The fact that we're even suggesting that Medicare is paying doctors too much is, in my mind, hilarious. Nonetheless, I had to listen to this crap.

Years ago, doctors were under instructions to make "everything" an inpatient admission. Under no circumstances were we supposed to admit someone to observation.

Now, the buttclowns at CMS are in a frenzy trying to ask for money back for admissions that should have only been observation.

As I sat and listened to this physician (mostly only able to think about the fact that the practice of medicine was so painful for this individual that he chose to get his MBA and escape the clinical circus), I wondered if those elected officials in the ivory tower really understand what's going on.

Healthcare will be reformed in some way. And it will almost certainly affect the bottom line of the hospital in ways that mean less vacations to Europe for our administration. Do they not understand that the shellgame is underway? That any effort they make to limit payment to hospitals will result in an entirely new industry devoted to trying to game the new system?

I'm so frustrated with American healthcare that I'm seriously wondering how long I can tolerate this B.S. I just want to take care of sick people. I bring enough value to the table as a hospitalist as-is. I'm going to get very sick and tired of being recruited as a utility in efforts to preserve a hospital's unsustainable profit margin in an era of regulation designed to erode it.

Suburban Mom Bias

I haven't posted for a while but something has been bugging me. 

Few weeks ago, we admitted a 38 year old with pneumonia. Fever, chills, white count, the works. Ground glass infiltrates,hypoxia, wheezing. She smoked about a pack a day so she got the COPD treatment. She didn't get better. I HRCT'd her. Took another history. She had a parrot that died suspiciously so hmmm--psittacosis? (chasing Zebras by this time). She got better, then got worse.   Went back, took another history, quizzed her and her (lovely) family. She was a housewife, took care of her disabled child, lived in the outer burbs,  etc. etc. I work part time so my partner took over. He persuaded CTS to do a VATS biopsy. (for some reason the pulm consultant didn't want to do anything,thought it was DIP,and threw more steroids at her.

   It was PCP. 

   The whole point of this post being that if I had not sat face to face with this stay at home mom with her Norman Rockwell-esque family in the affluent outer New York suburbs, I would probably have dragged her off to the bronchoscopy suite myself, drowned her in Bactrim and sent her whole family off for HIV testing.  I had seen more than enough cases during my training (in Harlem)

    It stinks coming face to face with your own prejudice. 

Meeting of the Minds

I presume a fair number of y'all are at this lil shin-dig in Chicago. I hope to see feedback here regarding your experiences.

I've been to a fair number of medical meetings. I was hopeful that this crowd would be palpably different than previous meetings (this is my first hospitalist party). I was expecting a brighter-eyed, happier, more energetic and (let me just say it) younger group than the average conference attracts. Granted, I'm basing most of that on my experience at the pre-course session yesterday. So maybe I'll meet more like-minded peeps today. Although I must admit, I'm torn about the special interest forums later today -- I apparantly belong to 3 special-interest groups.

It makes me wonder what the breakdown is when it comes to the underlying reason so many have become hospitalists. There are a lot of people who see hospitalist medicine as a means to an end (fellowship, a more comfortable retirement), but for me, I see hospitalist medicine as probably my last shot at finding a satisfying medical career (short of massive and well-executed healthcare reform -- an event I'm not holding my breath for).

I *really* hope this meeting just doesn't come down to bitching about what we hate about our jobs. I hope to hear some real voices of leadership with ideas and solutions for protecting an emerging profession that can potentially be one of the powerhouses in American healthcare.

What common symptom is associated with death within the next five minutes?

I thought about this last night as I sat down to dinner with my family. Then came the page from the hospital many miles away that an adult patient admitted with one problem now has a new one:

Chest Pain

Headaches from intracranial hemorrhage can kill you, but are not common. Abdominal catasrophies such as a duodenal ulcer eating into the aorta can kill you quick, but are not common, and most patients would have weeks of ulcer symptoms. Ruptured aneurysms aren't common. Sepsis doesn't kill quickly. Except for intracranial bleeding and ruptured anuerysms, few people die from non-traumatic bleeding withing five minutes.

Neurologic symptoms can portend life-threatening disease, but usually not within five minutes, and are not nearly as common as chest pain. Don't drag your feet when the patient says, "This is the worst headache of my life!"

I have a fax machine at home, but we've all seen heart attacks with normal EKGs. So that's no reason to relax.

It's melodramatic to say that chest pain is the bane of hospitalism.

But ignore it at your, and your patients', peril.

Am I missing anything? What other common non-traumatic symptom is associated with death in the next five minutes?

The Nite Bot

The founder calls it The Night Hospitalist Co, LLC.

I think he should change it to The Nite Bot. I swear the thing looks like Wall-E

The only problem I see is how is it going to date and sign its orders?

The "conscience rule" - Should we have the right to refuse to give care?

I'm sure there are plenty of things that you see everyday as a hospitalist that you don't agree with. Perhaps some even morally. Maybe even ethically? But I suppose it never crossed my mind that I did not have to talk with a patient/family about things I objected to. Maybe that's just me.

I would imagine one of the most common things we see, as hospitalists, are the COPD'er, who continues to smoke, returning to the emergency room with shortness of breath. We treat with bronchodilators, maybe throw in a touch of antibiotics, start a steroid taper. But if I'm morally against cigarettes, I can refuse to treat? What if I'm morally against stupid behavior, can I refuse to see the patient?

I know, I know. I'm exaggerating. For the most part, it seems as though there are doctors who would refuse to talk about abortion and/or contraceptive issues with their patients. If you're a cardiologist, it seems as though it would be out of your scope of practice anyway. But an OB/Gyn, a family medicine doc... it would seem to be something in the scope of practice.
I can understand not wanting to perform an abortion, but to refuse to talk about it? Refuse to give the patient the option and have the patient see someone else willing to do it?

How far does this rule go?

I'll need to look into this issue more, but I can imagine it would be a slippery slope to allow a "conscience rule" to go forward.

Any thoughts?

Respiratory's Guide to Respiratory Testing for Primary Care

It's sad that I can't follow doctor's orders much of the time when it comes to doing pulmonary function testing. It's actually a misnomer to say that I "can't" when in reality it's that I won't since I know the results that I'll get from the test requested aren't the results the physician wants. I then end up doing a bit of sleuthing to determine the reason for the original referral, and end up adding components to the test, which makes the test longer, which means I often end up going over my allotted appointment time and getting behind with every other PFT in line after them. In talking to the physicians ordering the test, I'm getting the impression that quite often the boxes are checked without the physician in question being fully aware of what studies are done.

I've joked about writing a memo called "Respiratory's Guide to Ordering PFTs, You Fools" at work to combat this problem, but in thinking and background writing I've found myself yearning for something larger. This post will attempt to describe the different veins of respiratory testing, their indications and limitations, and alternatives.

The most obvious is a pulmonary function test. What is a pulmonary function test? Ask three people and you'll get three answers. Every pulmonary function test should include baseline simple spirometry which will give you a flow-volume loop to interpret, as well as the most core of values: FVC, FEV1, FEV1/FVC ratio, PEFR, and FEF=25-75%.

What do these values tell you? Very little. Simple spirometry can, generally speaking, tell you if the lungs are normal or not, but not much else. For this reason, their use should be limited to the screening of individuals for normal lung function, such as, say, for respirator testing or pre-operative for anaesthesia's knowledge of the patient's baseline lung function. It is of little value when attempting to diagnose lung pathology.

This is not to say that the simple spirometry is valueless. It's the base from where all other values come. A good quality, reproducible flow-volume loop is the template on which all other pulmonary function tests are based. I can't do diffusion studies or lung volume studies without knowing the patient's estimated vital capacity (VC), so measuring it at the beginning in the form of a forced vital capacity (FVC) is the most reliable meter to use.

When evaluating respiratory pathology, it isn't enough to simply know that the patient has flow obstruction or restriction on their flow volume loop. While the loop will give us enough information to know if it's a fixed (inspiratory and expiratory) obstruction, or an inspiratory-only or expiratory-only flow obstruction, it will not tell us where the obstruction is coming from and whether or not it is reversible. While the loop will tell us that the patient is unable to exhale to predicted vital capacity, the loop will not ultimately tell us where the rest of that gas went. While the loop will show us a patient's diminished lung capacity, other testing must be done in order to determine the impact of this diminished capacity on a patient's gas exchange.

It's mostly for the reason of reversibility that I recommend that in cases where the physician is thinking simple spirometry is all that's needed that you don't just check the box labelled "simple spirometry" and leave it at that. That box doesn't authorize me to give a dose of bronchodilator and measure bronchodilator response. If for any reason you'd be suspecting that the patient has expiratory flow obstruction, please find the box labelled "Pre & Post Bronchodilator" and check that one instead.

When to order full pulmonary function testing as opposed to spirometry is a bit of a greyer area. For starters there's the question of access; it's entirely possible for a doctor's office to keep a bedside spirometer on hand for quick testing. A full pulmonary function test will typically include spirometry as well as lung volume studies, which requires high pressure gas systems and analyzers requiring a high degree of maintenance. This type of testing is usually only done in a dedicated pulmonary function laboratory, which in many locations is maintained exclusively by respiratory therapists.

When are lung volume studies useful? It is useful to have lung volume studies done on any patient's first pulmonary function test, and in some patients it may be useful to repeat this with future pulmonary function testing. The usefulness of the test depends on the method of testing done.

There are three ways to do lung-volume studies, which measure functional residual capacity (FRC) including air that cannot be exhaled (also known as the RV or Reserve Volume.) Ordinary spirometry cannot measure RV as spirometry can only measure air that is exhaled. With lung volume studies, either the nitrogen-washout method or the helium-dilution method can be employed to determine FRC using inspired gases. Additionally, body plethysmography is another way to measure all air in the thorax. These tests have limitations to their usefulness, however, and are most beneficial when they can be compared to one another (inspiratory gas tests vs. body plethysmography.)

Nitrogen washout and helium dilution are both heavily dependent on patient cooperation. If any air is exhaled into or inhaled from the atmosphere and the test becomes invalid. It's also highly dependent on all the air in the patient's chest being able to communicate with the atmosphere. Patients with bullous emphysema most especially will take a long, long time to reach equilibrium with test gases, and in most cases, will not reach equilibrium within a reasonable amount of time (5-10 minutes.) In order to re-test, equilibrium must happen with the environment which usually requires twice as long as the duration of the test. If I spend five minutes trying to determine FRC in someone using nitrogen washout, and I fail to gain an acceptable value, I then have to wait ten minutes before even attempting a second try. Most of the time, if the maneuver fails in the first go, the measurement is not repeated. In these patients, body plethysmography becomes the most useful way to measure trapped gas.

Body plethysmography has its own disadvantages. To begin with, it measures all trapped gas in the patient's thorax -- including air bubbles in the abdomen if there's lots of abdominal movement, any small pneumothoraces, and bullae that don't communicate with the atmosphere. The measurement may also vary from maneuver to maneuver dependent on technique and patient effort.

Total lung capacity obtained through either of these methods should be considered an educated guess: it's more important to observe the VC to FRC ratio than to have hard-and-fast calculations about the volume of the patient's lung.

The DLCO test is another test that's sometimes added to a "full" pulmonary function workup, depending on your facility. This is the diffusion of lung carbon-monoxide test, a test which acts as an index of the patient's lung's ability to pick up oxygen quickly. The DLCO value varies directly with the patient's lung volume and may vary depending on the technique used (steady-state or single breath, with the latter being the most popular.) DLCO can be decreased in almost every respiratory pathology, and because it's directly related to alveolar volume, it's often referred to by its cause: a low DLCO caused by a direct loss of lung volume (restrictive) or an uneven V/Q match (obstructive). A low DLCO is not specific for oxygen desaturation at rest or on exertion; home oxygen assessments must be done on these individuals, consisting of resting oximetry at the very least, and ideally an arterial blood gas.

For any questions about pulmonary function testing, feel free to ask me or to look it up in the Manual of Pulmonary Function Testing by Gregg Ruppel, which is a book I still refer to. Join me next post for a discussion of sleep testing!

How to be an Effective Hospitalist

I do most of of my work in the hospital, and have tried to find ways to be more effective and efficient. Premium is the time I spend with patients, so I try to be efficient with the paper work and phone calls to allow me to spend more time with patients. Here I my top tips for making it through the day:

1. Bundle your work. When I go on to each floor, I get the charts I need, and prefill out the vital signs, labs, x-rays and assessments. I check the MARS daily and note "medications reviewed." I also read other physicians notes so I fully apprised of other physicians' plans. I can always add to my assessment/problem list. This allows me to go in to the patient's room fully versed and ready for questions. When I use an EMR, I prepopulate all my notes, and order medications and studies first thing to get them done faster.
2. Tell patients when you will call their families. Sometimes it's more efficient to call families daily, as you end up spending less time in the end. I make all phone calls in the afternoon when I am finished rounding.
3. Never schedule family meetings in the morning, if possible. I schedule them for the afternoon, again, hopefully when I am done rounding. I believe that I owe it to my other patients to have seen all of them before I spend time in an extended family meeting. I know this is not always possible, but I try to mindful that I have at least 15 other patients that need care as well.
4. Write legibly. Avoid pages by ward secretaries asking if you wanted lantus or lanoxin.
5. Consider giving your pager number to families. This can avoid endless telephone tag, and I have NEVER had a family abuse this.
6. Learn every EMR short cut you can. I use EPIC and Meditech, and am still learning all the bells and whistles.
7. Call specialists early in the day. One of the benefits of pre populating notes is that you can see problems early, and call specialists in sooner vs. later, resulting in better patient care.
8. Make sure you have answered and addressed ALL your patients' and families' concerns before leaving the room. Before exiting, ask if anyone has any other concerns or questions that need to be addressed. Avoid complicated explanations. Yes, you will still get pages from nurses asking you to come explain (again!) to the family why Grandpa needs antibiotics for his pneumonia but you will cut down on these calls.
9. Use a check list. When I am rounding, I have a paper list of my patients. I have several columns that I check off as I see each patients. These columns are headed as follows: meds (I check this off when I have reviewed their medications), labs (checked when labs are ordered for next day), x rays (checked off if I have ordered studies), and note (when note is completed.) I also put here anything I want to follow up on.
10. Communicate with nurses effectively. When they call you, make sure you know what they want, and insist on read backs on all verbal orders. If you are changing the treatment plan,tell the nurse! They are your front line on getting things done, and can make the wheels turn.

Good luck out there! One of my friends (an ID doc) asked if being a hospitalist was like being an intern. Some days it feels like that, but other days it's like butter!
What tips do you have?

Are You Hiring Nurse Practitioners?

A reader asks the question:

I've heard of hospitalist groups hiring NPs. Is this common? In what capacity do they work with the hospitalists?

Thanks.

Happy's Hospitalist group doesn't employ nurse practitioners. So I can't answer that question. Perhaps others can.

A Happy Hospitalist: It Shouldn't Have To Be That Way

A Happy Hospitalist: It Shouldn't Have To Be That Way

How many times has this happened to you?

80 ish patient falls at home, sustains some minor injuries. Maybe some rhabdo, a little dehydrated from lying on the floor overnight, "makes troponins", so gets renal failure from the ACE, a septic workup because they've become hypotensive from the beta blocker, then deconditioned from the 7 to 14 day hospital stay. Of course PT/OT recommends Subacute rehab or long term care. 

Patient refuses, saying they want to die in their own home. So you sic the psych people on them to declare them incompetent, ship them off to the nearest facility, where they begin the ER/ICU/floors/SAR circuit, and they never get their wish.

Because God forbid, if your 87 year old patient dies peacefully in their own bed, the lawyers will get you...

Cranky thinks about her W2's.

  It is a sad, sad state of affairs when one makes more as a part time hospitalist than one ever did as a full time physician in a private pulmonary/IM group...Well, sad for medicine, happy for me...I'm just glad I still have this job.

Get Ready for a Pay Cut

Every year Medicare threatens to reduce the physician fee schedule by 5-10%. And every year the Congress comes through in the Spring with a reprieve from the pay cut.

Until this next cycle.

I predict Obama, Reid, and Pelosi are serious about sticking it to the doctors this time. And it will take years, if ever, to catch up.

I forecast a 15% fee reduction, for starters. What do you think?

I've been JCAHO'D!

Today I received an email warning me that JCAHO was expected to visit one of the hospitals where I work. The headline on the email was "JCAHO Site Visit Imminent." Shivers immediately ran down my spine. I hate the fact that hospitals turn themselves inside and out for JCAHO, and that hospital administration basically has a JCAHO cam to keep track of where JCAHO may appear next. God forbid that there could be a violation and the hospital get dinged.

I think we should all be mindful of patient safety, "effective communication between caregivers", safe use of medications, and clean hands. (The email states it pertly: "gel in, gel out, every patient, every time.") If we as care givers aren't cleaning our hands we DESERVE to be sanctioned! Since when do we only care about clean hands, patient safety, signed orders and effective communication ONLY when JCAHO is about to come? The email even reminds us that there is a special hand book we can carry around with us in case the JCAHO examiners pin us to the wall and interrogate us.

So why do I care? Because I care about patients. There needs to be SYSTEMS in place to insure patient safety and excellent care. Sending an email is not a system, it's a quick fix with out substance. I am cynical because such emails pay lip service to these important standards, and do nothing to create long term change. It is the Hawthorne effect: change will occur briefly, but then revert to the norm once the attention is removed. So Mr. Hospital Administrator, here are five steps you need to take LONGTERM:

1. Insure there are FILLED hand gel dispensers EVERYWHERE. How many times have I tried to use an empty gel can? It needs to be part of house keeping's job to check these dispensers two times per day!
2. How many times have I asked for a sitter for a patient to avoid falls, poseys and over medication, only to be told it costs too much? If you are serious about reducing these never ever events, provide the resources, not just an email reminding me to keep patients safe.
3. Have pharmacists review every medical reconciliation. One of the hospitals I work at has no system what so ever to fill the medical reconciliation out. The physicians usually end up doing it, close to discharge sometimes! Identify WHO is to fill out this valuable paperwork, and put in a system to make sure it is completed AT admission or the next day.
4. Hold surgeons to the same standards as the rest of us. Yes, the surgeons bring in the money, but how many times is there a pre-op h and p on the chart? One hospital I work at has a hospitalist assigned to each elective joint surgery. The hospitalists make sure there is an h and p, and follow the patient through out. The idea is that the hospitalist will make sure there are less medication errors, and prevent problems before they occur. I think it is a great system, and hopefully my perception is reality.
5. Institute check lists on patient handoff at every level. Yes, radical that I am, I think physicians should have to follow a standard hand off system too.

Well, I'm sure that hospital administrators every where are racing to implement systems just as I described. (What are you smoking?!) In the mean time, I suppose I should tuck a copy of the "Survey Readiness Guide" into my white grey coat with the dirty sleeves.

Once Upon A Time

Dr. Scalpel comes up with a doozy that I have thought about for a long time but never put down on paper.  The Self Censoring Of The Medical Record.

There was a time, once upon a time, long before my years, where the medical record was a book of facts.  Facts about the patient.  The status of their condition.  The treatments.  The recommendations.  There was a time, once upon a time, where physicians could all gather in front of a medical chart, read it, and understand exactly what the clinical scenario was.  A time where they could immediately begin discussing the facts of the case, based entirely on the written prose of the chart.

As I practice hospitalist medicine today, I come across several distinguished physicians who still write their hospital notes in prose.  Several paragraphs of point by point thought process that explains the rationale of their medical decision making.  These docs are ones who have been around for years.

You'll find them dead before you find them writing a S.O.A.P. note.  

I'm not even sure when the first SOAP notes were created.  Who created them, or why.  I do know they are a colossal waste of time.  For those of you that don't read medical records, no physician making medical decisions ever reads anything but the and plan (and sometimes the assessment)  Nobody cares  about the Subjective and Objective that another physician documents in their S.O.A.P. note.  

99.9999% of the time, it is irrelevant to the care.  All doctors care about is what is the problem and what are you going to do about it.  

In other words, the medical record is filled with pages upon pages of useless medical information that means nothing to anyone.  So why do we write S.O.A.P notes?  Why do we waste hours upon hours writing information that is irrelevant to the care of patients?

Because S.O.A.P. notes are written for insurance companies and the Medicare National Bank.  In the classic wisdom of the almighty federal bureaucrats, they created rules and regulations, called the Evaluation and Management Guidelines. The first version , went live in 1995.  Because E&M 1995  weren't good enough the first time, a second version was created, E&M 1997.  And now we have two sets of rules to pick and choose as we see fit.

What does this have to do with anything?  Well, it turns out that in order for Happy and all other physicians to get paid AND not to be accused of fraud, the E&M guidelines just happen to be organized around the SOAP note format.    You can see my discussion of billing and coding for hospital follow up visits CPT codes at 99231, 99232, and 99233. This is what medical care has become.

So, what does this have to do with anything?  Well, it means that the medical chart, and all electronic medical records being developed today are nothing more than giant invoices used to generate a bill.  Not to document important information about patient encounters, but rather to generate invoices for insurance companies.

The docs who still write their notes in prose,  I love their notes the best.  They state exactly what I need to know for my patients.  But, I gotta say, I have absolutely no idea how any of them get paid beyond a low level 99231 follow up visit, in spite of the management of highly complicated conditions.  

I say this because should those notes ever get audited, I know they would all fail anything higher than the lowest level coding.  And the difference between a low level 99231 and a high level 99233 is  thousands of dollars a week. 

So what does this have to do with Dr Scalpels cocaine patient?  It has everything to do with it.  You see, when insurance is paying the bills, insurance makes the rules.  And insurance determines your rates.  And insurance controls your medical destiny.  

Under the current insurance market in the US, if you have Medicare, you get everything paid for.  No preexisting conditions.  If you have "Chest Pain"listed as your primary diagnosis, it means nothing to you in terms of your insurability or your payment rates.

If you have private insurance (or no insurance but looking to get some in the future), putting a diagnosis of "Chest Pain" is a red flag symptoms that will cause the patient great stress for the rest of their insurance lives.   Insurance companies are strange like that. If you are going to cost them money, they will charge you more.  Or they may say you are not insurable.  And in the future, if government insurance takes root, you will find yourself at the mercy of what ever system takes hold.  That might mean that the new Medicare may decide "Chest Pain"  patients are treated differently.

On a daily basis, I find myself being very careful about describing "red flag"symptoms.  Is it "Chest Pain"?  Or is it "Muscoloskeletal Strain"?.  Years ago, my father went to the doc with a complaint.  I don't even remember what it was.  The doctor wrote in his medical record "possible MS".  Now, I can tell you my father categorically does not have MS, but it took a bunch of hoops to go through to get that entry discredited many years later.

I find myself self censuring the medical record all the time by picking my words carefully.  Being as general and generic as possible as to not cause undue pain and suffering down the road for patients caught in the insurance catch 22.  

If the medical record is going to be treated as a giant invoice, than that's what they shall get.  

I didn't see a single thing in Obamacare talk about abandoning E&M guidelines.   Guidelines that ARE the source of systemic inefficiencies in the care of patients.  I could double or triple the number of patients I see if my medical documentation was not forced to be a giant invoice. 

Once upon a time... 

Health Facts from Charity Navigator

Some interesting facts from Charity Navigator:

-Tobacco companies spend $28 on marketing for every $1 state governments spend on prevention.
-Since 2001, the Joint United Nations Program on HIV/AIDS has estimated that roughly five million people were newly infected each year, even though billions of dollars have been spent in the last four years on prevention and treatment.
-In 2003, 2.3 million 12- to 17-year-olds -- almost one in 10
-- abused at least one controlled prescription drug.
-Over the last 30 years the rate of childhood obesity has tripled among youngsters aged 6 to 11 and has doubled for those aged 2 to 5 and 12 to 19.
-Since 1982, the standard size of a hamburger has increased 112 percent. Bagels are 95 percent bigger than they were two decades ago and servings of pasta have gone up 480 percent.
-MS is the most common neurological disease affecting young to middle-aged adults and is typically diagnosed between the ages of 20 and 50.
-Every 49 minutes, an American is spinal cord injured.
-An estimated 556,500 Americans will die of cancer this year, the nation's second-leading killer after heart disease. Some
1.3 million will be diagnosed with cancer.

I'm particularly interested in the food issues. Jumbo serving sizes are the enemy--in our house half a bagel is enough and we split restaurant orders and enjoy leftovers; this also makes eating out on occasion more affordable. In some coffee shops we've seen that one muffin or cookie in the display is large enough to serve a whole family. Teaching people to measure portions and count calories seems to be important--and this goes for hospital meals too, where I've also seen surprisingly large portion sizes for people who don't need to gain weight.

Athete's foot update

I figured it would be much simpler to do what at most was 10 to 15 minutes of admission hooha than to fight with everyone (the ER, the podiatrist,the hospital).  In the end I admitted him as a cellulitis, (it really looked that bad).  The dermatologist thinks it's something more insidious. The ID doc threatened to shoot me if I called her for a consult.

Oh, and Dr. T, I feel your pain.  My group admits 11 to 14 patients a night. And we are in a dinky 150 bed community hospital.