For the past 3 days I participated in a wonderful course – “Physiology on the Fly” – near Bar Harbor, Maine. The course continues for 3 more days.

This course is the “brainchild” of the chair of Medicine at Beth Israel/Deaconess – Mark Zeidel. He has a wonderful “old school” view of internal medicine. We who teach should use basic science, especially physiology, and we who care for patients should understand physiology.

So the course included discussions of the how physiology informs clinical medicine and laboratory exercise to reinforce the points. The 18 junior academic hospitalists had a growing enthusiasm for the topic while I participated as a speaker.

Apparently they chose me to be the keynote speaker because I use physiology in my clinical teaching regularly.

The most important observation that I have from this course is that it clearly put understanding as a first priority. We who teach must strive to understand and then communicate that understanding to our learners.

Will this old school approach catch fire? Can we energize clinician educators in an error of arcane documentation requirements, cumbersome electronic records and increasing focus on performance measurement?

In Maine I experienced the old spirit of internal medicine. Internal medicine for me represents the challenge of understanding, and then using that understanding to help our patients. Internal medicine is a wonderful calling and too many worry that excessive regulations are interfering with the profession. This course speaks loudly to the possibilities. Now we must fight the good fight and return internal medicine to its essence.

Diagnostic excellence requires time

I remember prior to starting medical school hearing the phrase – great diagnostician. During medical school I continued to have role models who championed the diagnostic process.

The IOM report focused on diagnostic errors, but we should also focus on the road to diagnostic excellence.

Many diagnoses are straightforward and simple but some require time and thinking.

Here are some more thoughts about how we get to diagnostic excellence and what interferes.

1. Many difficult diagnoses require time to think. Unfortunately, our payment system does not encourage spending more time on the diagnostic process.
2. The first clue to a diagnostic conundrum is the presence of a red flag or the absence of expected findings.
3. Diagnostic excellence requires deliberate practice. We must learn from every diagnostic conundrum – the ones we get correct and the ones we miss.
4. When we have to rush, we order tests rather than take a careful history – and the history provides major clues most of the time.
5. We receive no rewards for correct diagnoses yet the patient often suffers from incorrect diagnoses.

Some thoughts on diagnostic errors

The Institute of Medicine released a new report today – ‘Countless’ Patients Harmed By Wrong or Delayed Diagnoses

Over the next few days we will read many opinions on the problem. Readers know that I have a great interest in this problem. I have thought about it often, and talk about it frequently. Here are a few tweetable thoughts.

1. Allow patient admissions without a diagnosis. Insisting the emergency department label the patient w/ a diagnosis often leads to anchoring heuristic which can lead to errors.
2. Receiving physicians (either consultants or hospitalists or outpatient physicians) must be skeptical of any diagnosis.
3. If the patient’s course does not follow the textbook, you are likely reading the wrong page.
4. Teach learners to flirt with, even sleep with, but be certain before they marry a diagnosis (h/t Dr. Lourdes Corman).
5. When you feel confused, start again from the beginning, retake the history, redo the physical exam, and review the old records and the lab data.
6. Allow the responsible physician to delete incorrect diagnoses from the medical record.
7. Above all else, we must remain skeptical every day.

Table rounds prior to bedside rounds

For 30 years I have always conducted “table rounds” prior to seeing the patients. Many colleagues champion bedside rounds solely. While we each must find our most comfortable rounding style, I hope to convince other attendings of the value so that they might consider this style.

What are table rounds? We start rounds by quickly having students or residents give a brief report on each known patient. They need not provide every detail, but rather report on test results, consultant recommendations and any major clinical change. We look at pertinent images.

During this time we have several goals. First, the entire team gets an update on the patients. This allows the interns to know each other’s patients. Second, we can have a discussion of further testing plans, consultations, or discharge planning. We also can have discussions of test results, or revisit our diagnosis. Third, we can teach and make certain that everyone has an opportunity to participate and hear. Finally, we never embarrass a student or intern in the presence of the patient.

Next we present the new patients. Usually, this time allows for the most teaching. We discuss the approach to the differential diagnosis. We discuss treatment strategies. We point out information that we need at the bedside.

After table rounds (usually 45-60 minutes) we visit each patient. Sometimes we repeat the history; sometimes we demonstrate a physical exam finding; sometimes we just spend time making certain that the patient understands their diagnosis, treatment and further testing plans. We deliver good news and bad news. We discuss bedside manner at the nurse station after our encounters. When we obtain new information, we change our plan appropriately.

Many learners have told me that they find this style more educational and comfortable. I suspect that some will agree with this style, and some will disagree. What do you think?

Readmissions for pneumonia not related to performance metrics

CMS now penalizes hospitals for high readmission rates. They assumed that good care would prevent readmissions. This story, which gives a link to the original article, demonstrates that readmissions have no apparent relationships to “quality of care”.

Study: Quality of care may not determine pneumonia readmissions

The physicians that I talk with all have assumed that we would have great difficulty decreasing readmission rates. This study supports that view.

We have difficulty understanding the belief that we can have a major impact on readmission through better care quality. We did not see any evidence supporting that belief. If we live in an era where we should follow the best available evidence, then why do we have such payment measures.

Will this study change anything? I doubt it, because the rules are made outside an understanding of medical evidence. The physicians with whom I talk find this trend frustrating and difficult to understand. Just because you can measure something does not mean that the measures relate to the complex process that defines patient care.

Promising news from ABIM

ABIM 2020 Task Force recommendations, released today, provide reasons for optimism – Assessment 2020 Task Force Findings to Focus Discussion of Changes to ABIM Certification and MOC

Here is the short story:

Key recommendations from the report include:

Change the MOC exam.
The Task Force recommends replacing the 10-year MOC exam with more meaningful, less burdensome assessments.

Focus assessments on cognitive and technical skills.
Assessment of cognitive skills assures the public that physicians are staying current with the clinical knowledge relevant to patient care. Assessment of technical skills ensures that physicians can apply that knowledge to adequately perform the technical procedures appropriate to the discipline.

Recognize specialization.
The Task Force recommends exploring the need for certification in specialized areas, without the requirement to maintain underlying certificates, while being transparent about specialization to the public.

“The Assessment 2020 Task Force members provided useful insights and recommendations that will be instrumental as we reshape certification to meet physicians’ and society’s changing needs,” said Clarence H. Braddock III, MD, Chair of the ABIM Board of Directors. “We now need to hear constructive feedback from the internal medicine community on these recommendations, begin to determine their feasibility and develop implementation plans where needed.”

Recommendation #1 harkens the Anesthesiology Board change mentioned two days ago. Recommendation #2 recognizes that we can think rather than memorize, and that if we do procedures that we can do them efficiently and safely. Recommendation #3 should decrease the expense and hassle of subspecialists having to take multiple tests.

I hope these recommendations result in a new formative process for MOC. MOC should help us stay current. I am encouraged and look forward to further developments.

Proud to be a General Internist #ProudtobeGIM

SGIM (the Society for General Internal Medicine) launches today its #ProudtobeGIM campaign. As a full disclosure, I am a previous President of the Society. I am very biased towards SGIM and I am Proud to be a General Internist. Please consider the ProudtobeGIM website to learn more.

Here is my story. I finished medical school in 1975 and stayed at my home institution (Medical College of Virginia – part of Virginia Commonwealth University) for residency. During residency the idea of academic medicine intrigued me. In those days, academic GIM had not yet started at my institution. My advisors convinced me to do bench science. I chose a renal fellowship.

After 1 year I learned that I hated rats, and that I missed patients. I quit my renal fellowship and returned to MCV to join the nascent Division of GIM. During that year and my subsequent chief resident year, I had a wonderful epiphany. I love all of internal medicine and GIM would allow me to focus on the entire patient rather than one organ system.

In 1981 GIM included both outpatient and inpatient medicine. I had clinic patients and rounded a few months each year. I also began to do some research on sore throats.

Over the years I learned much from my patients and my learners. These days I no longer do outpatient medicine, because I prefer teaching inpatient medicine. However, my bedside skills clearly were honed during my 15 years of doing primary care internal medicine.

These days I obviously still do some writing, but consider myself primarily a clinician educator. I round over 100 days each year with students, interns and residents. I do morning report approximately twice each week.

GIM has provided me a wonderful career. My SGIM colleagues have inspired me and taught me how to find my passions within GIM. Many colleagues have helped develop the concept of clinician educator as a mainstay of GIM.

Yes I am proud to be a general internist. This campaign is wonderful. Please check it out.

Wisdom versus knowledge for practicing internists

I have given my Learning How to Think like a Clinician several times recently. Each time physicians in the audience seem to particularly like one line that I use – Wisdom trumps Knowledge.

In 2015, we all have rapid access to information. My team regularly uses smartphones, pads or computers to get precise information while on rounds. We cannot remember everything. More important than knowing is knowing what information we need.

In our 2014 Annals of Internal Medicine editorial we called for a formative rather than summative process. A formative process describes a process in which the learner gets frequent feedback and hopefully grows in knowledge and their thought processes.

The Anesthesiology Board has drastically changed their MOC process to fit this model – Anesthesiology Board Drops 10-Year-Exam for MOC.

The MOCA Minute that will replace the test next year epitomizes continuous, as opposed to sporadic, learning. ABA diplomats must answer 30 multiple choice questions every 3 months. Regardless of the response, the MOCA Minute software will display the correct answer, the rationale for it, and links to pertinent educational material. Physicians can tackle the questions one at a time whenever they want, and wherever they are, as the ABA will release a MOCA Minute app for mobile devices.

I hope that future ABIM adjustments will follow this concept. We should focus on improving physicians rather than merely testing them. A structured process that makes clear to physicians what new information they need to know could help us do our jobs better.

The Anesthesiology Board has taken a bold move. Will other boards follow?

I hope that we all understand the importance of focusing on understanding important new concepts rather than having knowledge on topics that we (here I refer to inpatient and outpatient internists) will not use. We should know when to bring in a subspecialist. We should know how to pick team members. We need not know the side effects of every new chemotherapy, immunotherapy or anti-viral, if we do not prescribe these agents. If a patient comes to our service with a concerning symptom, we need to know to ask the right question – could it be a medication side effect.

This is just one example of wisdom trumping knowledge. We need great knowledge, but that is not enough.

Are we to blame for the heroin epidemic?

During my training in the 70s, heroin use dominated our substance abuse horizon.  We saw many patients with IV drug related complications.  We saw heroin overdoses.

For the next 30+ years, we rarely heard about heroin.  Over the past 10 years we have seen increasing opiate abuse, but the opiates came from prescriptions.  Over the past 2 years, heroin has once again reared its ugly head.

This article blames physicians for opiate addiction – Doctors Play A Role In The Opioid Addiction Epidemic, Study Finds.

To begin to figure out how many, a team at the Mayo Clinic, led by pain specialist Dr. W. Michael Hooten, analyzed the medical records of 293 patients given a short-term prescription for opiates for the first time in 2009. These patients were being treated for acute pain — from traumas such as sprained ankles or major surgeries — so their doctors did not expect them to become long-term users of painkillers.

Yet just over 1 in 4 of these patients went on to use opioid painkillers for longer than 90 days, researchers found. A quarter of this subset engaged in so-called long-term use, defined as receiving at least 120 days’ worth of pills or more than 10 separate prescriptions.

In our defense, the pain lobby has put pressure on physicians to relieve pain. We are supposed to have patients grade their pain (1-10). Pain relief became a major focus for patient satisfaction and even quality.

Then legislatures figured out that many patients abused opiates. So they thought they could legislate opiate prescribing and ameliorate the problem. The opiate producers knew they had a captive audience, so their pills had significant costs.

So now we have expensive opiates and physicians encouraged to decrease prescribing. In comes the Mexican Cartel seeing a business opportunity. Heroin is relatively inexpensive to produce. It comes with a captive audience and many repeat sales. Bingo – we have a heroin epidemic. People can buy heroin more cheaply than prescription opiates (even if they could get them).

But heroin packages do not come with a potency description. Addicts do not know how much they are injecting.

So we have a marked increase in heroin overdose deaths.

And since they are injecting, we have a significant increase in infections (especially endocarditis) related to less than perfect hygiene.

We started this cycle, under pressure from the pain control lobby, but biology (some people really enjoy opiates) and addiction have made this a major problem. Once again few politicians understand the problem and their solutions tend towards draconian strategies.

We will once again be fighting this problem for many years (just like the 70s and 80s). And, oh by the way, we will have more hepatitis C and hepatitis B and HIV infections.

A philosophical query concerning performance measurement

Insurers increasingly use performance measurement (often mislabeled quality measurement) to impact physician pay.  The idea behind performance measurement follows from the belief that we can measure quality and therefore pay physicians for delivering quality.  On the surface, many experts believe that without external motivation physicians will not put enough effort into improving their performance.

On further consideration, we must reframe performance measurement.   Performance measure schemes represent a new type of  paternalism.  Performance measurement lays out exactly how we should provide care (at least for the few diseases and measures that are specified).  Performance measurement advocates often exclude patient factors.  A few anecdotes highlight this philosophical problem.

At dinner the other night an internist told a story of a new diabetic patient.  The patient had a HgbA1c greater than 10.  The patient insisted that he would never take insulin.  This internist had cared for several such patients.  What should he do?  His performance measurement will suffer from this patient.  What should he do?

Over my career, a major philosophical change has occurred.  As a student we were implicitly taught paternalism.  More recently we have moved toward a patient centered philosophy.  Our job, as this philosophical viewpoint stresses, transcends our beliefs about treatment, but rather switches the control to the patient.  We all experience this conundrum.  Patients do not always agree with guidelines and measures.  Should we deny care to patients who deny the guidelines?

A pediatrician friend cares for several anti-vaxxers.  He strongly disagrees with them philosophical and scientifically.  Yet his practice, unlike most other practices in our city, does provide care to these patients.  He explains that they need health care and he cannot with good conscience refuse care to these children.  Yet, if he gets graded on his patients’ vaccination rate, his measure will suffer.

The performance measure paradigm implicitly imposes a paternalistic approach to disease management.  That conceptualization does not comport with patient-centered care.  We try to work with patients and allow them to make many health care decisions.  But if our pay and even our public reputation (read about Physician Compare) suffer because of our patients, we face a horrible conundrum.

Another physician at that dinner, a noted health care researcher, told an important story.  He had worked in 3 different practices over the past 20 years.  The first practice included mostly middle class patients.  He told us that he had brilliant diabetes measures.  He knew that he was a superb physicians.  The second practice included an underserved population.  His diabetes measures dropped dramatically.  He left that practice and went to another middle class practice.  As if by magic his measures recovered to their initial brilliance.  His experience raises a very important question about the patients.

What have the measurement advocates really done?  We have no great examples of measurement improving care.  We do have examples of the unintended consequences of measurement.  Why do we insist that performance measurement will improve care?

Do patients want performance measures to rate physicians?  Do they ever ask how well physicians meet measures?  These questions, while obviously written for emphasis, raise a most important question.  What do patients want?

Talk with patients and ask them.  They want a physician who spends time with them.  They want a physician who looks at them and listens to them.  Many want a physician who will carefully explain their disease(s) and the options for diagnosis and treatment.  They rarely worry about the HgbA1c.  They worry about taking a statin to prevent acute coronary syndromes, even when the statin is clearly “indicated”, because they worry about possible side effects.  They want a say in their care, even if their choices are not the “prescribed” choices.

The philosophical underpinning of performance measurement requires further evaluation.  Everyone must understand that performance measurement implies a paternalistic approach that does not match patient desires.

We are moving further down a slippery slope without adequate evidence.  CMS, directed by the Affordable Care Act, continues to develop the Physician Compare.  Physicians face a major challenge.  We must stress these problems and hopefully eventually change the prevailing winds.  The idea has major philosophical problems.  The idea started as a wonderful approach to improving management.  But implementation of the idea places physicians and patients into very uncomfortable decisions.