Choosing Wisely or Vicely

Bradley Flansbaum

Posted 4/29/12 on The Hospitalist Leader

The press gave the Choosing Wisely initiative, unveiled several weeks ago, a great deal of attention.  Briefly, the ABIM foundation collaborated with Consumer Reports to produce Top 5 lists from nine specialty societies to identify “five tests or procedures commonly used in their field, whose necessity should be questioned and discussed.”  It is a first step to engage patients and physicians in the shapeless “national conversation” on (sensibly) rationing  that everyone speaks of, but never hears.  I write about it now, not just because this process is inevitable—which it is, but because the Society of Hospital Medicine is amongst the next group of eight to offer up recommendations.

Voluntary guidelines generally do not command attention.  One envisions this list of 2500+ much the same way we view our bedroom walk in closets.  The filled shoeboxes of yesteryear are there, but we will not open or utilize their contents again.  Knowing they are near though allows us to sleep better, a token consolation, but alas, they are memories.

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This Is About Brussel Sprouts, Not Broccoli (And It’s Not What You Think)

Bradley Flansbaum

Posted 4/12/12 on The Hospitalist Leader

There is a lot of talk these days of personal responsibility.  Obesity, lifestyle choices and any untoward consequence of either are usually attributed to the individual, and the cost—both financial and in quality of life—are duly theirs.

As you will discover, this post will not deconstruct the literature base behind that sentiment.  It will however encompass some parts anecdote and intuition, as well as a few life lessons.  On the latter, if I convey by half a bit of my own takeaway, I will have achieved just rewards.

For framing, early in my training, I fervently believed that obesity, poor food selection, and lack of exercise were a choice:

–No gym membership?  Hit the pavement.

–Dearth of fresh vegetables?  Buy frozen.

–Have lower back pain?  Look in the mirror.

That was long ago.

It stemmed from inexperience, adverse sway in residency (still rife in programs today), and a shortage of familiarity with the forces behind one’s life options.  These outcome-shaping lifestyle choices are not availed to all.  And as a sobering gut check, just when I think I comprehend the determinants of health that allow individuals to pursue these alternatives, life imparts a new lesson.

In that vein, we all make the usual assumptions—suboptimal education, ethnicity, place of residence— are consequential and produce the disparities in society with which we are familiar.  However, these influencers, while real, are in the abstract and it is not until we challenge ourselves, do we see the sometime expansive distance between our patients and us.  What we discover on probing can be surprising.

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Health Care and the Supreme Court: Prepare Your News Dial

Bradley Flansbaum

Posted 3/25/12 on The Hospitalist Leader

To get a sense of why this case is different and will dominate the news cycle now until the decision in June, appreciate this fact: the time allotted for arguments—the period in which plaintiffs and defendants present their views to the justices—is six, instead of the usual one.  Moreover, the proceedings will transpire not just in one day, but three.  This is substantial.

There are several issues under debate, but the most significant, and the one you have likely heard about, is the individual mandate.  This is the requirement in the Affordable Care Act that all individuals without insurance must purchase it.  The alternative is paying a penalty (but not a tax)–and this is important.  Nevertheless I will revisit that below.  For most people, the mandate is not applicable, as folks with Medicare or Medicaid, or receiving insurance from their employer meet the necessary waiver requirements.

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So Rich

Bradley Flansbaum

Posted 3/13/12 on The Hospitalist Leader 

Here is a twist of irony.

Physicians, and rightfully so, are called hypocrites, when on one hand they decry the payment system for inadequate reimbursements (and threaten patient access), while on the other, abhor  solutions to remedy the same problem.  Adoption of midlevels (NP’s and PA’s), which obviously are less costly, but also crowd out physicians and encroach on sacred turf is a prime example:

Representatives of the American Medical Association and the American Academy of Family Physicians said they agree with the need to expand the primary care work force. But they questioned the institute’s recommendation to expand APNs’ practice scope.

“Increasing the responsibility of nonphysician health care professionals beyond their education and training is not the answer to this shortage,”

However, a twist. Today in Connecticut the governor’s office is proposing to replace nurses – which by law are the only professionals allowed to dispense prescription medication in the field, with less expensive  health aides. From a Connecticut’s home care trade association representative:

Wodatch says there are serious concerns on the minds of nurses and the agencies that hire them — from affordability to liability to figuring out which patients are best suited for the change.

She described the kind of patients who would benefit from still seeing a nurse every day: “One that has changes on a daily basis, one that may have outbursts, may have significant mood swings on any given day, not be safe with a home care aide who’s trained just in giving medications and not really recognizing symptoms, side effects, interventions that could be put in place to avoid further problems.

I just might frame this on my wall.

“Hospitalists Don’t Do It Like We Do. We’re Better.”

Bradley Flansbaum

Posted 2/13/12 on the Hospitalist Leader

How often do we hear declarative statements rooted in dogma, propagated over decades?  Countless times, physicians providing continuity care for chronically ill patients “assume” that by the very nature of that continuity, they outperform doctors not in that station, especially as it relates to intimate tasks.  “Hospitalists are ill equipped to obtain advanced directives; they don’t know the patient like I do,” or something to that effect.

That may be the case, but I suspect community docs are not completing the mission.  This is not a spiteful statement, but an observation rooted in experience and evidence.

The system is broke, and while I am sure community docs do know their patients thoroughly, that is not the focus of my post.  What is is that same intimacy and whether a physician penetrates it to achieve a consequential end—in this case a “break glass in case of emergency” portfolio.  That takes time and emotional energy, and both are in short supply.  As doctors, we are all men amongst equals in that domain.

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Observation Units. All Good. Right?

Bradley Flansbaum

Posted 2/06/12 on the Hospitalist Leader

Would you like to read about some good policy, but bad execution?  Browse on.

On the physician side of the ledger, we trust that observation units, i.e., geographic weigh stations to determine fitness of admission or discharge, are a good thing.  Earlier discharge, focused resource use, possibly less exposure to hospital badness—all winning strategies to improve efficiency.  What is the problem then?  From todays WSJ:

The issue arises when a Medicare beneficiary who comes to a hospital is placed in a status called “observation care.” This is supposed to mean that patient is being watched while doctors decide if she can be discharged, or if she is ill enough to be admitted as a true inpatient. Observation is typically supposed to last 48 hours or less.

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A Pain I Did Not Know

Bradley Flansbaum

Posted 1/22/12 on The Hospitalist Leader

It was apparent for many at the vanguard of hospital medicine 10-15 years ago, that certain provinces of practice—end of life and palliative care, nosocomial infections and prevention, delirium, bioethics, perioperative medicine—were understudied and overlooked.  Our niche and ascent on the wards were particularly rapid, in part due to the application of these domains to most hospitalized individuals.  They are essential components on our admission checklist.

Personally, I was interested in mastering these competencies as it placed me at a strategic advantage relative to my peers.  Even today, they are the cornerstones of my practice identity.  Moreover, I find them fascinating and they keep me engaged in hospital medicine.

Another forte on that list is pain management.  If we are similar (I hope), our focus on acute pain control is an outgrowth of the previous era’s neglect and need.  We still manage pain poorly, but through reading the literature and in conversations with colleagues, I am noticing a change, mostly positive.

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Bundle in the Jungle

Bradley Flansbaum

Posted 12/09/11 on The Hospitalist Leader

First, before I discuss bundling as a method of payment for healthcare services, I wish to declare my neutrality on the subject.  The merits are appreciable if providers approach the implementation properly, and conversely, the detriments are equally clear if they (we) bungle it.  Enactment and downstream effects are so murky however, that prognostications are premature.

Second, bundling may not be the preferred payment method for all procedures or diagnoses.  Beyond CMS demonstrations and a scant sampling of commercial side ventures—all procedural—little to no chronic care evidence exists (COPD, CHF, sepsis).

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GME for Me, GME for Thee, But Watch That Cutter Behind the Tree

Bradley Flansbaum

Posted 10/9/11 on The Hospitalist Leader

As many of you are aware, the exodus from primary care, long and painful, persists despite attempts from professional societies and government to attract new graduates.  The reasons are well known, and solutions, however well intentioned, are cash poor and lack the reorganizational mass to develop a meritable system that balances all medical specialties.

Many institutions rely on trainees to support clinical services, but more importantly, the dollars that complement their presence are a key revenue stream for facilities.

Now that discussions are proceeding in our nation’s capital to reduce the debt, dollars to subsidize training programs are in play, and cuts to federal graduate medical education (GME) dollars are likely.

This is a good opportunity to review what GME is, and how it affects hospitals.

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Doctor Nurse or Doctor Doctor

Bradley Flansbaum

First posted 4/2/11 on The Hospitalist Leader

In New York State, the issue of scope of practice is at the fore.  Mainly, what activities can non-physicians (NP’s) engage in, with or without physician supervision?  It is a heated subject here where I reside, but not the one I will address below.

Today’s New York Times discusses a similar matter, although altogether more controversial.  Many of you are aware nurses are obtaining doctorate degrees and advancing their training.  The divisive issue is how those with newly minted degrees should present themselves to the community, and secondarily, their pay, delay of entry into the workforce and its effect on patient access, and the necessity of this added qualification.

“Hi. I’m Dr. Patti McCarver, and I’m your nurse,” she said. And with that, Dr. McCarver stuck a scope in Ms. Cassidy’s ear, noticed a buildup of fluid and prescribed an allergy medicine.

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Readmission Drivers, Not Stabilizers

Bradley Flansbaum

First posted 9/25/11 on The Hospitalist Leader

I am always leery of briefs from think tanks and trade associations.  They are not ideal sources for balanced takes on important issues.  I am especially wary when the same bodies espouse viewpoints that might be similar to mine.  No individual is above self-reinforcement, and basking with like-minded souls in serene waters blinds us to the sirens call.  The call in this case, and the thrust of this post, is the accountability connection as it relates to hospitals and patient readmissions.

As hospital penalties for unnecessary readmits draw near, the attention to attribution, mainly, root causes for revisits, are accelerating debate and obliging those of us on the front lines to unmask pitfalls in conventional (CMS) thinking.

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Twenty-Four Seven

Bradley Flansbaum

First posted 8/07/11 on The Hospitalist Leader

Two recent articles, one from The New York Times, the other from The Hospitalist,initiated some 24/7 staffing issue rumination on my behalf.  It stems originally from a recent op-ed by Lucian Leape:

“Given the accrediting council’s reluctance to act, the federal government needs to get tougher. If we are serious about curbing the tide of injuries stemming from medical errors, Medicare should make its funding of graduate medical education contingent on hospitals’ limiting work hours. We can’t afford to wait another 40 years.”

How do the aforementioned pieces resonate with the above quote?

The NYT article, well written, examines pediatric training, errors that stem from doctor “fatigue,” and the root causes behind these errors—presumably due to burdensome hours and the legacy of educational norms of decades past.  The author, chief of pediatric cardiology at UMass Medical School, cites the evidence before and after implementation of trainee work hour restrictions in 2003 (not overwhelmingly positive incidentally), and concludes that it may not be the stretch worked—although this is a factor, but how information is communicated doc to doc, and shift to shift.  This is not news to hospitalists.

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