Friday, April 18, 2014
The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles, from being concerned exclusively about individual patients to exerting influence on how health care dollars are spent.
"We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room," said Dr. Lowell E. Schnipper, the chairman of a task force on value in cancer care at the American Society of Clinical Oncology.
In practical terms, new guidelines being developed by the medical groups could result in doctors choosing one drug over another for cost reasons or even deciding that a particular treatment — at the end of life, for example — is too expensive. In the extreme, some critics have said that making treatment decisions based on cost is a form of rationing.
Thursday, April 10, 2014
As an I.C.U. doctor, I am trained to save lives. Yet the reality is that some of my patients are beyond saving. And while I can use the tricks of my trade to keep their bodies going, many will never return to a quality of life that they, or anyone else, would be willing to accept.
I was trained to use highly sophisticated tools to rescue those even beyond the brink of death. But I was never trained how to unhook these tools. I never learned how to help my patients die. I committed the protocols of lifesaving to memory and get recertified every two years to handle a Code Blue, which alerts us to the need for immediate resuscitation. Yet a Code Blue is rarely successful. Very few patients ever leave the hospital afterward. Those that do rarely wake up again.
It has become clear to me in my years on this job that we need a Code Death.
Until the early 20th century, death was as natural a part of life as birth. It was expected, accepted and filled with ritual. No surprises, no denial, no panic. When its time came, the steps unfolded in a familiar pattern, everyone playing his part. The patients were kept clean and as comfortable as possible until they drew their last breath.
But in this age of technological wizardry, doctors have been taught that they must do everything possible to stave off death. We refuse to wait passively for a last breath, and instead pump air into dying bodies in our own ritual of life-prolongation. Like a midwife slapping life into a newborn baby, doctors now try to punch death out of a dying patient. There is neither acknowledgement of nor preparation for this vital existential moment, which arrives, often unexpected, always unaccepted, in a flurry of panicked activity and distress.
We physicians need to relearn the ancient art of dying. When planned for, death can be a peaceful, even transcendent experience. Just as a midwife devises a birth plan with her patient, one that prepares for the best and accommodates the worst, so we doctors must learn at least something about midwifing death.
Wednesday, April 9, 2014
A Canadian study has found that almost one-third of patients never fill the prescriptions for the medicines they are told to take.
The analysis, published online in The Annals of Internal Medicine, was conducted in Quebec, where all residents are covered by health and drug insurance. There were 15,961 patients in the study.
Over all, 31.3 percent of prescriptions were never filled. But some types were filled more often than others. Prescriptions for headaches and migraines were filled more than half the time, but only 20 percent for bronchitis, and 25 percent for skin irritations. The more often a patient saw the doctor, the more likely the prescriptions would be filled, but medicines with high co-pays were less likely to be bought.
People under age 52 were much less likely to fill their prescriptions than older people, and men slightly less likely than women.
The lead author, Robyn Tamblyn, a professor of medicine at McGill University in Montreal, said the results sent several messages. First, the cost of drugs affects their use. Second, when patients are followed more closely by their doctors, they are more likely to take their medicine. And finally, she said, "chronic illness is the primary driver of ill health, and people who fill their prescriptions have a better rate of controlling their disease."
Tuesday, April 8, 2014
Saturday, April 5, 2014
It didn't come as a complete surprise when a Pennsylvania hospice told Phyllis Fine's family last year that she was no longer eligible to receive care.
Mrs. Fine, 84, enrolled in hospice in June 2012. After supposedly routine heart valve surgery, she suffered a major stroke, leaving her unable to walk, speak much or feed herself.
For months, hospice staffers cared for her in her nursing home. "They were awesome people," said her daughter, Audrey Marsh. "They bathed and changed her and kept her company. They fed her."
The hospice had admitted Mrs. Fine for 90 days, then another 90. After that, Medicare rules required re-certification every 60 days, meaning that a physician must attest she is likely to die within six months if her disease runs its normal course. In May, when Mrs. Fine was no longer losing weight or showing other signs of decline, the hospice apologetically said she no longer qualified.
Ms. Marsh understands the rationale: "She's not getting any better, but she's not wasting away."
Carol Willette, on the other hand, is seething. Her family had debated for months about calling hospice. Her mother Earlene Willette, 90, a nursing home resident in Mill Valley, Calif., had been ailing for several years — falling, battling infections, eventually losing mobility.
"Mom was trying to tell people she didn't want anyone prolonging her life," Carol said. "I was talking about hospice, but my siblings were in an uproar about it."
It took a diagnosis of amyotrophic lateral sclerosis, or ALS, to make everyone understand that Earlene Willette's condition was terminal and meant increasing disability. In mid-November, a local hospice enrolled her, and the usual team — aides, nurses, a social worker, a chaplain — began visiting. "They all said they were there for her and for us," Carol told me.
Less than a month later, the hospice discharged Mrs. Willette, saying she was not losing ground. "I told them how cruel it was to do this," Carol said.
Mrs. Willette can return to hospice care as her condition worsens (so can Mrs. Fine), but Carol worries that her mother will feel on probation, at risk of losing care she will come to depend on.
Hospices have always had the ability — and under Medicare rules, the obligation — to discharge some patients. The Medicare Payment Advisory Commission, relying on 2009 and 2010 data, has reported that 20 percent of hospice patients are discharged alive each year; the National Hospice and Palliative Care Organization says its surveys show that a third of discharges are initiated by patients themselves, and two-thirds by hospices.
But discharges are climbing. Gilchrist Hospice, the largest in Maryland, now discharges of about 20 percent of patients, and "we're on the low side," said its clinical director, Regina Bodnar. Indeed, a Washington Post investigation, analyzing a million records of California hospice patients, found that the proportion discharged alive rose 50 percent between 2002 and 2012.
What's happening here? Hospices have lamented for years thatdying patients wait too long to call, enrolling at the eleventh hour when they could have benefited months earlier. Now, we're hearing more about patients doing as hospice believers (including me) have urged, calling earlier in the course of a terminal disease — and then, in a substantial minority of cases, getting bounced.
Jon Keyserling, senior vice president for policy at the national hospice organization, points to several pressures.
First, the Centers for Medicare & Medicaid Services are peering over every hospice administrator's shoulder. "CMS, through its contractors, is looking much more carefully at longer-stay patients," Mr. Keyserling said. With hospices under increasing scrutiny, "they need to be even more careful about the patients they admit and the patients they keep."
The claims reviewers pay particular attention to whether a patient's disease is progressing. They want to see evidence: Does the patient need more oxygen? Have her medications changed? Is he falling?
In the past, "you never did weights on hospice patients," Ms. Bodnar said. Now, Gilchrist weighs patients; if it can't, it measures the circumferences of their arms. "We're looking for objective data" to justify recertifying patients, she said.
But hospice patients sometimes hit plateaus or temporarily improve; in fact, studies have shown that they live slightly longer than those with the same diseases but without the additional care. At that point, to comply with Medicare rules, "you have to seriously consider whether they're eligible to continue," Ms. Bodnar said. Patients can appeal discharges, but they don't usually win.
When auditors question hospice decisions, causing a flurry of expensive and time-consuming paperwork, they can hold up Medicare reimbursement for months or years — if the hospices are eventually found to be entitled to payment.
And if they're not? Medicare audits forced the 35-year-old nonprofit San Diego Hospice, California's largest, to close earlier this year; denied expected payments, the hospice owed millions of dollars and declared bankruptcy. "A sobering moment," said Ms. Bodnar.
At the same time, all hospices face shrinking budgets. The federal sequester reduced payments by 2 percent. With other cuts, some a vestige of the Bush administration and some mandated by the Affordable Care Act, Medicare reimbursements to hospices will be about 4 percent lower this year, Mr. Keyserling said.
One can sympathize with hospice organizations caught in this squeeze. Determining which patients will likely die within six months has always been difficult, especially with conditions like heart disease or dementia, whose trajectories can be unpredictable. To avoid being penalized if they guess wrong, hospices are taking no chances.
At least, that's true of hospices operating according to the regulations and honoring the movement's historic mission. The Post attributed much of the jump in discharges to the way for-profit hospices have come to dominate the field, enrolling ineligible seniors for long stays to bolster corporate bottom lines, then dumping them to evade Medicare sanctions. (The Times has also reported on growing hospice costs.) Whistleblowers and the Justice Department have sued several large national chains to stop these practices.
But I worry about families who have agonized about the decision and finally called for help, then feel betrayed when hospice withdraws, even though their relatives can regain hospice care when they decline further. They shouldn't get caught in this crossfire.
Was this really the intent of the 1983 hospice Medicare benefit – to have dying older people moved off and on the rolls, to have families receive crucial support and then lose it, depending on whether someone's weight has stabilized for a few weeks?
"I get the need to right the ship and make sure only eligible patients receive benefits," Ms. Bodnar said. "My fear is that we're at risk of discharging patients who aren't dying fast enough."
On Saturday mornings, Cyndi Mariner puts on her Nikes, grabs a hat, and heads for Shoreline Park in Mountain View, Calif. Joining a handful of other people caring for elderly parents, she walks for an hour along San Francisco Bay. The walkers watch the kayaks and sailboats on the water, notice the hummingbirds buzzing across the trail. And they talk about things like how not to scream when your loved one with dementia has asked you the same question five times in a row.
The program that brings them together, called Meet and Move, began just a few weeks ago, but "I've already noticed a significant boost in my spirits," said Ms. Mariner, 55.
Four years ago, she moved in with her ailing mother, now 84 and in need of a great deal of help. "I was getting tired, mentally and physically," she said. Besides walking with other caregivers twice a week, Ms. Mariner religiously monitors the pedometer that the program provided; often she adds a 20-minute amble after work, or parks her car at the far end of the supermarket lot, aiming to record 10,000 steps a day. She has come to recognize, she said, that "I have to take better care of myself in order to take care of Mom."
Sometimes the best ideas are the simplest. El Camino Hospital in Mountain View and the Palo Alto Medical Foundation wanted to help family caregivers take a break, get some exercise and connect with others.
"By focusing on caregivers, we could improve the health and well-being of seniors and at the same time deal with the tremendous caregiver burden and burnout we see in our daily practices," said Dr. Sangeeta Kopardekar, chairwoman of geriatrics and palliative care at El Camino.
Traditional support groups serve that purpose, too, and have been shown to reduce caregiver stress and depression. But not everyone wants to sit in a circle of chairs and share. Some might find exercise, also a potent way to relieve stress and improve health, more palatable.
We are learning more about caregiver burden and its potentially pernicious effects. "Caregiver stress increases the likelihood of depression, other mental health symptoms and illness," said Steven Zarit, a Penn State geriatric psychologist who has led research on the topic for years. Predictable breaks from caregiving, he and his team have shown, are "very important emotionally, but also at a physiological level."
A study by Mr. Zarit and his colleagues, recently published in the American Journal of Geriatric Psychiatry, is among the first to demonstrate that a helpful intervention can affect not only caregivers' moods but their stress hormone levels.
The researchers asked 151 caregivers who lived with relatives who had received a diagnosis of dementia — one of the highest-stress situations — to collect their saliva five times a day for eight days. Later analysis showed that caregivers' levels of DHEA-S, a hormone that protects against the harmful effects of other stress hormones, were significantly higher on days after their relatives attended an adult day program.
In nightly phone interviews, the caregivers also scored higher on scales measuring positive mood on those days, reporting greater cheerfulness, calm and closeness to others.
Might other kinds of interventions — like regularly walking with other caregivers — have similar physiological effects? It's hard to say, and the Meet and Move program isn't designed to find out. But early participants — 32 have enrolled to date, most women, most caring for a spouse or parent — seem enthusiastic.
"Sometimes you just need to talk about it," said Margaret Hsieh, 72, who shares the care of a demanding 98-year-old mother. "It was a godsend to get to know other people in a similar situation. And it gets us out."
To help keep participants active and connected, Meet and Move provided water bottles and pedometers to those who signed up and asked them to log their physical activity and social interactions. A facilitator stays in touch by email, sometimes forwarding articles of interest. Every four weeks, those who send in their logs receive a $25 Visa or MasterCard gift card.
In parts of the country with less-enviable weather, of course, people starting such efforts would have to do some of their walking in malls, or other climate-controlled places with less sunshine and fewer hummingbirds.
I could also envision a more targeted reward for participating: an hour of home care. Meet and Move or similar programs could negotiate volume discounts with agencies, then provide caregivers with that rare thing, an hour off the clock.
Though Ms. Mariner, I should add, sounded quite pleased about her gift card. She works nearly full time, in addition to taking care of her mother, and she knew just how she planned to use it. "I'm going to get a massage," she said.
Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."
But closer examination revealed something curious: the patient reviews. "My husband went into surgery to have his appendix removed. … he died two days later," read one. Another: "Dr. Leggett and his staff strongly believe that the best physician-patient relationships are based on mutual respect and trust. That is, until we perform your surgery, after which we just dump you in the streets like a black baby in a dumpster."
One patient of Leggett's found this to be a curious way to attract business and asked about it during an appointment. "You've got a problem with your site," the man said. Leggett saw what was going on and quickly contacted authorities in Harris County, Texas.
"It was a case of online impersonation, which is illegal in Texas," says Lt. Gary Spurger, of Harris County's High Tech Crimes Unit. "It looked almost identical to his real site, but it was not complimentary of the doctor. At all."
Lt. Spurger traced the source IP, which led to the home of web designer Vector Thorn. Thorn, who had legally changed his name to sound like something out of a James Bond movie for reasons unknown, had obtained the URL within a week of having a procedure performed by Leggett in September 2012. He didn't populate the site with fake reviews until June 2013.
Thorn was charged with a third-degree felony and released on bond. When asked by Spurger why he waited almost a year to do something, Thorn had no good answer. But Spurger knew the motive: "He wanted more narcotics."
There is certainly nothing new or novel about people being mean to one another on the internet. But health care occupies a unique space amid critiques of restaurant appetizers and roofers: Because the Health Insurance Portability and Accountability Act (HIPAA) of 1996 prevents doctors from discussing patients, disgruntled and anonymous individuals can pick fights over their quality of medical care with little chance of being successfully hit back, leaving physicians almost powerless to defend themselves. In some instances, aggravated patients use that advantage to mount calculated attacks with the intention of inflicting irreparable damage to careers and reputations. In the life-and-death world of health care, a disgruntled few could impact the medical decisions of thousands already struggling to make sense of new marketplace mandates and regulations.
"I would say the internet has not yet matured to the point where there's a way of easily understanding the difference between an allegation that has some merit and an allegation that's simply someone venting who has an axe to grind," says Gary Nissenbaum, an attorney specializing in commercial litigation. "It's very hard to tell the two apart."
Thursday, April 3, 2014
Tuesday, April 1, 2014
Removing pressure from medical school while teaching students skills to manage stress and bounce back from adversity improves their mental health and boosts their academic achievement, Saint Louis University research finds.
Stuart Slavin, M.D., M.Ed., associate dean for curriculum at SLU School of Medicine, is the lead author of the paper, which is published the April edition of Academic Medicine. The problem of depression among medical school students is significant, Slavin said, affecting between 20 and 30 percent of medical students in the U.S., and potentially compromising their mental health for years to come.
The study looks at the well-being of first and second year students before and after changes to Saint Louis University's medical school curriculum that are designed to prevent depression, stress and anxiety. It compared the performance of five classes of 175 to 178 students – two before the changes and three after – measured at medical school orientation, the end of year one and the end of year two.
"We've seen dramatic improvement in the mental health of our students. Depression rates in first year medical students went from 27 percent to 11 percent and anxiety dropped from 55 percent to 31 percent. At the same time, our Step 1 board scores went up, meaning student performance improved," Slavin said. "Our students know more, and will be in a better situation, emotionally, to care for our patients."
The first of many licensing exams, the Step 1 boards are given to medical school students at the end of their second year to assess whether students can apply basic science concepts to medical questions. Scores help determine admission to residency programs.
For about 60 years, administrators have recognized the number of students who feel depressed or anxious increases during their time in medical school, Slavin said.
"For many years, nobody did anything about it," he said. "Then, the first approach to addressing the problem was to get students better access to psychiatric and mental health services. That was followed by schools adding activities that encourage wellness and teamwork, such as Olympics-style athletic competitions and optional wellness seminars. While those things are great, they're not enough."
SLU administrators decided to take stress reduction beyond offering resources and wellness activities. They started by asking student why they felt anxious and depressed.
"We decided to design and implement curricular changes that would directly address these stressors and would produce a less toxic educational environment," Slavin said.
Without sacrificing critical educational components, SLU changed its curriculum to remove unnecessary stressors, a dramatic paradigm shift from seeing stress as an inevitable part of the path to becoming a doctor, and added a required class that teaches strategies to de-stress, Slavin said.
"The approach is preventive and the model is very simple. We tried to reduce or eliminate unnecessary stressors in the learning environment itself. At the same time, we helped students develop skills in resilience and mindfulness to better manage stress and find some measure of well-being."
The curriculum was changed so students receive pass or fail grades for their pre-clinical courses in the first two years of medical school, which is a practice adopted at about 40 other medical schools, rather than letter grades or honors/ near honors grading systems. They spend fewer hours in the classroom, giving them more free time, choice and control over their schedules to explore expanded electives and engage in newly established learning communities. In addition, SLU modified the content of some classes and the order they were taught.
Students also take a short, focused course that helps them develop lifelong strategies to cope with stress.
The class teaches students to better manage energy by taking breaks, sleeping, eating properly and exercising; being mindful or paying close attention to what's happening in the present moment; reframing their perspective to be more realistic; recognizing negativity; controlling their reactions to situations; and cultivating a positive and optimistic outlook that ultimately leads to more happiness and personal satisfaction.
In addition to exhibiting lower rates of depression symptoms and less anxiety and stress, students who followed the new curriculum felt more connected to each other than the pre-change group.
It's important to our health care system to address depression and stress among medical school students, Slavin said.
"Physician depression and burnout are significant problems in the United States and may rightly be viewed as a substantial public health problem, particularly given the evidence of the negative impact that mental health can have on clinical care by reducing physician empathy and increasing rates of medical error," he said.
"Unfortunately strong evidence supports that the seeds of these mental health problems are planted in medical school."
The lessons learned from the curriculum changes can be applied in any high pressure environment – from high schools to the most competitive law firm, Slavin believes.
"Everybody is feeling so much stress these days. We need to try to find ways to prevent it when possible and better deal with stress when we can't."
Saturday, March 29, 2014
Jenny is not long out of her teens; the previous week, she had collapsed – from a haemorrhage, the result of an abnormality in the veins and arteries of her brain. She had been close to death: late at night, Henry had operated to remove a blood clot and save her life. But a later scan showed that the abnormality remained. If the problem was not corrected, she could suffer another bleed at any time. So this will be the second time he has been inside her skull.
While Jenny is prepared, Henry paces the hospital's long corridors. There is time for us to sit and have a sandwich. He is restless: he wants to get on. He didn't get this right the first time. He needs to get it right now.
I first encountered Henry Marsh late one night on my sofa. I was too tired to go to bed, and so kept the television on as one programme ended and another started. This was The English Surgeon, a 2007 documentary by Geoffrey Smith about the work that Henry has been doing for over 20 years now at the Lipska Street Hospital in Kyiv, Ukraine. Following a meeting with Igor Kurilets, a Ukrainian neurosurgeon struggling against the post-Soviet culture of poor resources and entrenched, old-fashioned thinking about medical care, Henry began volunteering his time in Kyiv. He brought not only his skills but equipment that had been discarded – generally for no good reason – by the NHS, packed up in wooden crates he made himself.
It is a remarkable, moving film and I was struck by the humane, caustic eloquence of its subject, which seemed unusual for a man in his profession. At the time I was running the books pages of the Times; I thought that he would make a fine reviewer. I emailed him, care of the hospital, not really expecting an answer, but he replied by return. Sure enough, he proved an excellent addition to my stable – and this month he's published a fascinating memoir, Do No Harm: Stories of Life, Death and Brain Surgery, which is why I'm here with him now, waiting to stand beside him as he operates on Jenny.
Henry is 64: he will retire next year. He is tall and white-haired; outside the operating theatre he is given to wearing battered leather boots and a long duster coat. You read in books of people with "surgeon's hands", long, tapered and delicate. Henry's hands are not like that, but rather like the hands of a skilled woodworker, a keen gardener and an energetic beekeeper, all of which he is. He wears round, owlish spectacles that give him the air of the don he might have been; his first degree, from Oxford, was in philosophy, politics and economics. Medicine came later – he didn't become a junior doctor until the relatively late age of 29, after spells as a teacher in West Africa and a hospital porter in Ashington, Northumberland.
When he finally went to medical school, at the Royal Free Hospital in London, he wasn't sure about his choice. "I thought medicine was very boring," he says bluntly. Henry is not a man to refrain from speaking his mind. "I didn't like doctors. I didn't like surgeons. It all seemed a bit dumb to me." In Do No Harm he writes of his revulsion at what much surgery generally entails: "long bloody incisions and the handling of large and slippery body parts". But while working as a senior house officer, he observed a neurosurgeon use an operating microscope to clip off an aneurysm – a small, balloon-like blowout on the cerebral arteries that can cause catastrophic haemorrhages. It is intensely delicate work, using microscopic instruments to manipulate blood vessels just a few millimetres in diameter. It is also, as Henry says, like bomb disposal work, in that it can go very badly wrong – with the crucial difference that it is only the patient's life at risk, not the surgeon's. If this or any other kind of serious neurosurgery goes right, however, the doctor is a hero. "Neurosurgery," he smiles, "appealed to my sense of glory and self-importance."