Monday, March 12, 2012

Advancing Care with the POLST Form

Coming soon, on April 16th, is National Health Care Decisions Day. Hoperfully this will be a reminder to medical care organizations to further reach out to their communities in order to provide education and access to advance care directives. The documents that attorneys provide and that are available on-line are the Living Will and Durable Power of Attorney for Health Care. These are also available from many state medical associations and other community service groups. A few communities such as La Crosse, Wisconsin have been very successful in promoting community wide use of advance directives.

There are now excellent resources for individuals, community groups, and states to further develop programs in advance care planning. A recent conference was held in San Diego, California. The remarkable efforts in California and the national progress pioneered in Oregon are now available. The "state of the art" in developing POLST (Physician Orders for Life Sustaining Treatment) programs can be found by visiting these two links.

The advancement in the development of POLST programs across the country is impressive. However, to enhance the effectiveness, more funding is needed for registries to be available 24/7 and more grants are needed for quality and outcome research. Progress has been made, but there's much more still to be done.

Friday, March 9, 2012

The Lake Woebegon Effect

There are two very interesting books out about how we, as doctors and patients, approach health care. One, How Doctor's Think gives us insight as to how doctors tend to approach the care of patients. The other, Your Medical Mind , also by Jerome Groopman with Pamela Hartzband, helps us as patients understand the complexities of medical decision making.

One perplexing dilemma I noted over the years in the ICU was the tendency of families to be unrealistically (from my perspective) optimistic about the survival chances of their loved ones. When I'd discuss a probability of a 5% chance of survival, or even less than 1%, in a direly ill patient on a ventilator with multiple organs failing, a family member might understand the poor chances, yet believe that they could beat the odds - much I suppose like the Las Vegas gambler except the stakes were so much higher in the ICU.

Educators are familiar with the Lake Woebegon Effect, in that when surveyed almost all feel that their students are above average. When it comes to health care in the ICU a recent study confirmed that families tend to have an optimistic bias. This, of course, seems natural when you think about it. Not wanting to lose a loved one, we martial all the resources to keep them alive - including an optimistic bias about the facts presented to us. To me this at least in part explains the very difficult process of shifting from full bore heroic ICU care toward palliative symptom control.

Part of it may be a doctor's reluctance to use such words as, "Your wife is dying and we are doing everything possible to make her comfortable, but I don't recommend attempts to attempt CPR or heart shocks which may cause pain and which would be ineffective."

The more we can understand the psychology of medical decision making, the better we will be at end of life care. It is the intersection of philosophy, religion, emotions - and life itself. The complexities of the interactions can be dramatic or mundane - but very human as doctors and patients try to work through the Lake Woebegon Effect.

Thursday, March 8, 2012

Excessive Use of "Health Care"

Ask almost any doctor or nurse, and they can tell stories about mess-ups in health care. Sometimes, it's under utilization, sometimes the wrong treatment or test is done, and sometimes it's inappropriate overuse of tests or treatments.

I was discussing this with an ophthalmologist recently. He had been working for a large medical group with a business office concerned about high overhead costs and the "inadequate" revenue from the expensive equipment. The 11 ophthalmologists were told directly by a VP administrator that they weren't billing enough and thus they weren't meeting their targeted revenues. They doctors countered that they were providing appropriate and high quality care for their patients. The administrator countered, "Listen, if you have a patient in the office and there's a billable procedure, DO IT"!

Six of the doctors rebelled and subsequently left this group, after making their position clear that they wanted to practice within both legal and ethical boundaries - and could no longer do so in the cost/procedure driven environment.

When I was scouting around for my first job in internal medicine, a group of doctors asked me if I was interested in becoming their "thyroid guy". They had just purchased a thyroid scanner and felt they had a golden opportunity to generate a high revenue stream from Medicare and insurance billing. They were also doing routine viral cultures on sore throats (not at all worthwhile) to generate revenue. I didn't say it directly to them, but why did they exploit the potential to overuse diagnostic procedures? Did they derail their idealism somewhere in training?

Amazingly there is very little documentation about unnecessary testing and treatment. Recently the Archives of Internal Medicine reported a study in which the authors researched the entirety of 21 years of medical literature evaluating 114,831 publications. They found only 172 articles with data on health care overuse—and most were devoted to either overusing antibiotics for upper respiratory infections, or three cardiovascular procedures.

It is estimated that 30% of health care costs are unnecessary, but how do we arrive at reliable information about overuse? Even more difficult, how do we change behaviors? All of us have ideas such as changing incentives, tort reform, more evidence based research, expert opinion guidelines, more primary care teams, etc. Unfortunately the current proposals for health care reform don't effectively attempt to deal with overuse of scarce and expensive resources. But the end of double digit health care cost escalation will come, like it or not. Let's hope the public discourse can be rational, not "don't let the government mess with my Medicare!"

It's quite likely that end-of-life care is unnecessarily costly, both in suffering and dollars. There is wide variation in hospice use and dying in the hospital from city to city. Such wide variation demonstrates how much improvement in care is possible.

PS: Having my own health coverage under Medicare now, I do appreciate this nationwide (gasp) socialized medicine. It is too costly at present, but if we can be successful in dealing with overuse, this will correct dramatically.

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