What Can Patients Do In The Face Of Physician Conflict Of Interest?

I had the pleasure of meeting Dr James Rickert, an orthopedic surgeon and a patient, at the Road to Right Care conference put on by the Lown Institute in March. Dr Rickert works with the The Society for Patient Centered Orthopedic Surgery, advocating for health care reform and patient care that puts the patient in the centre.

One of the topics that he writes and speaks about frequently is conflict of interest in medicine and the financial incentiviazation of care which may be unnecessary or harmful to patients. 

To that end, his most recent contribution to the Health Affairs blog, What Can Patients Do In The Face Of Physician Conflict Of Interest?, describes some the major issues that emerge when caring becomes a business. There are also suggested Action Steps for patients to take when confronting these concerns.

Strong relationships between patients and providers are the heart of healthcare; we must work together to improve our culture and hold providers to a high ethical standard to stop the erosion of trust.

Source: http://healthaffairs.org/blog/2015/04/10/w...

Day 1 of Road to Right Care #Lown2015 Recap

What a great day!

Hundreds of mainly American (I am one of 4 Canadians here) doctors, patients, nurses, health administrators, and other health providers gathered today for the first of three days on the Road to Right Care Conference, put on by the Lown Institute.

Being in a room with so many like-minded individuals is invigorating but also offers hope that together, we can actually do something radical.

Main Themes:

  1. Patients and their families and advocates must be at the centre of this movement; young health care providers are the future of this and must be engaged early in their training
  2. Health care is not about consuming, being sick; most of what we do in medicine has no impact on health; health care should be about being well, and about people not diseases:
    “A good physician treats the disease, the great physician treats the patient who has the disease.”  - DR. WILLIAM OSLER

  3. Social determinants of health, especially poverty must be addressed for greatest impact:
     "I can cure homelessness. You just house them and it's cured. Completely curable problem." - DR. MITCHELL KATZ

  4. Our system must be radically transformed; we have many ideas but they boil down to the fact that HIGER QUALITY CARE leads to LOWER COST

  5. Barriers to improvement: financial conflicts of interest, profit-based systems, not listening to what patients really want (eg. independence)

  6. Things that will help us achieve RightCare: team work, communication, destroying the imbalance of power, narratives

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

My actions as a result of today:

What was missing?

  1. Emphasis on relationships between patient and caregiver. The ONLY big mention about meaningful relationships was by a Reverend B. Stanfield during his reflection at the end; the data tell us that strong relationship = better care, and less costly care
  2. Focus on patient safety. Americans talk A LOT about cost! Cost is important, but were this conference anywhere else in the world, the main focus would be on reducing harms done to patients by too much or too little medicine.
  3. Acknowledgement of this as a world-wide cultural issue. There was a lot of discussion about insurance companies, ways of paying physicians, etc. as if these financial structure problems all explain the issue; some people seemed to believe that changing the way doctors are paid – abandoning fee-for service payments – would fix everything. But, there is no system of remuneration that incentivizes good care. "Wrong care" is a problem around the world, even in socially progressive and fully public health systems. 
     

I can't wait to see what is in store for us tomorrow!

Update: POEMs help identify clinical practices for the Choosing Wisely Campaign

Update: Grad et al's paper is now published! View the full text: Patient-Oriented Evidence that Matters (POEMs) Suggest Potential Clinical Topics for the Choosing WiselyCampaign in JABFM.

[this blog post below was originally published Nov 24, 2014]


It can be challenging to cultivate topics for the Choosing Wisely Campaign; Montréal family physician and researcher Dr. Roland Grad (bio) and his group have found a unique way to harness an existing tool to do so easily.

Dr Grad presented a poster at the Family Medicine Forum (FMF) indicating one way forward could employ physician ratings of Patient-Oriented Evidence that Matters (POEMs).

POEMs are short summaries of relevant and valid information for clinicians. These are free for Canadian Medical Association (CMA) members (login to cma.ca, click on your name, and go to the Manage Newsletters section) and are basically quick reads with commentary on recent clinical trials, systematic reviews, etc. [Non-CMA members can go to Essential Evidence Plus]

Grad, Pluye, Shulha and Tang focused on one item on the validated questionnaire used by physicians to evaluate POEMs, which asked whether the POEM helped the practitioner in ‘avoiding an unnecessary diagnostic test or treatment’.

They identified the top 20 POEMs in each of two years most commonly associated with helping avoid unnecessary tests or treatment. Interestingly, only 11 of the 40 POEMs had a corresponding item on the Choosing Wisely master list.

[short version: there's a huge collection of already identified practice-changing recommendations just ripe for the adding to a campaign like Choosing Wisely!]

Their process provides an easy way to gather possible topics for future Choosing Wisely lists and could aid in the expert panel approach.

The group's paper is now in the Journal of the American Board of Family Medicine.

Corruption: A devastating factor driving inappropriate health care in India

The Canberra Times highlights the challenges facing Indian citizens who seek medical attention in "Indian doctors shed light on massive medical procedure scandal."

Usually when I think about factors that drive inappropriate health care, I imagine it's a case of "good intentions and bad results." When doctors are trying their best for patients, sometime we go too far trying to fix a disease or result and lose sight of the person (the patient). Some negative pressures, like pharmaceutical marketing, fear of lawsuits, fear of being disliked, or a misunderstanding of the latest evidence can drive providers to do thinks that are not the "best care" though these choices may have seemed like good ideas at the time.

I never thought to put BAD INTENTIONS at the top of the list of things that drive health care providers to provide 'too much medicine' or to choose unwisely. It certainly happens (eg. Mount Sinai catheterization scandal, where people are told to lie in order to get in for unnecessary cardiac catetherizations paid by the public system), but – perhaps just by my wishful thinking – it's not as prevalent as bad acts driven by good intentions.

In India, maximizing profit appears to be the number one priority of some hospitals. Extra scans, surgeries, and avoidable deaths are all the result of doctors striving to meet "revenue targets" and taking bribes.

This is a devastating state of affairs.

One solution comes in the form of  Mission SLIM: the Society for Less Investigative Medicine. Hopefully they find success advocating against unnecessary tests and treatments, though they have their work cut out for them.

Source: http://www.canberratimes.com.au/world/indi...

Physicians are also squeamish about Advance Care Planning discussions!

The Vancouver Sun featured an article, "Refusal to face reality of death leads to increased use of aggressive, futile health-care efforts: Doctor calls on Canadians to 'normalize conversations' about end-of-life care"

It's great to see this kind of story popping up across the news. The more we talk about it, the less scary it is to discuss; the end result is that we'll provide less futile care and offer better palliation, sooner, meaning that patients can have the best possible quality of life until the end.

The title of the video basically says it all; cardiologist Dr Heather Ross talks about the challenges that physicians face when they need to talk with patients about end of life care. It's interesting that she should remark on her discomfort with these kinds of discussions, as that was not something that came up in the study that prompted this Sun feature. 

The study in JAMA Internal Medicine is Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians. You at al. surveyed 1256 Canadian health care providers to identify some of the major challenges with discussing end of life situations and they identified the following:

  • family members' or patients' difficulty accepting a poor prognosis

  • family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments

  • disagreement among family members about goals of care

  • patients' incapacity to make goals of care decisions

Clinicians did not view system factors as significant barriers to these discussions, which I find surprising since we usually talk about underfunding, overcrowding, paperwork, communication errors, and bureaucracy whenever we have a tough problem to solve.

Interestingly, health care providers did not feel that their own skills presented major barriers to having care planning discussions. Well! I find that hard to believe. Clinician factors probably contribute greatly and we seem to have a blind spot for our own weaknesses!  

Fortunately Dr You acknowledges this:

“Overall, the sense from the clinicians is that patients and families tend to get in the way” of making concrete decisions about a patient’s care plans, You said. “This is what they perceive,” You said. 
“But I think it reflects that if patients and families are having a difficult time, then one of the solutions clearly has to be that physicians need to be skilled communicators — they need to know how to navigate these sometimes emotional or difficult discussions and be sensitive,” he said

A clinician's personal discomfort, uncertainty about prognosis, fear of not being liked, and other individual factors are definitely contributors to the difficulty of talking about dying with patients. A lot of the things that make it hard for doctors and nurses to talk with patients about planning for death and dying also contribute to the more general problem of inappropriateness in health care. 

So what can we do? Start here: It's Time to Talk: Advance Care Planning in BC. 

I'm proud to be a part of the Doctors of BC Council for Health Economics and Policy (CHEP), which is where Dr. David Attwell  spearheaded the creation of this policy paper.

Take a look. It's never too late to start talking about it!

On “Why your doctor always keeps you waiting” & Wellness vs Work [Cross Post from @DrOttematic]

THIS IS A CROSSPOST (from DrOttematic)


A friend shared this article, “Why your doctor always keeps you waiting”. Take a look.

It perfectly sums up the struggle of a day in clinic for a primary care physician (family doctor). I can identify strongly with the author, Dr Sanaz Majd. She’s thorough, she’s dedicated, she cares about her patients, she doesn’t mind that much missing a lunch, and she cannot live with doing anything less than her best.

Trouble is, this kind of care is not sustainable. It is a recipe for burnout.

Is the answer to see fewer patients? Yes, that might help but then many Canadians would be without a doctor, we would not earn the money required to pay overhead, malpractice insurance, to attend conferences, or to live well. We have worked hard and a lot of us (those who aren’t yet burnt out) take a lot of our work (figuratively and literally) home with us.

Are we greedy? Maybe. But if someone got into medicine to make money, they are in the wrong field! Most clinicians are book-smart enough to succeed at business or investing or something else that is less personally demanding, but we enjoy medicine because it is a challenge not just intellectually, but emotionally. It is an opportunity to do something to help others while at the same time feeling stimulated and productive.

I get paid well, and I appreciate that is recognition for the intensity and length of my education, for the responsibility I assume, and for the fact that is is not “just a job” but a life and I cannot turn off ‘being a physician,’ ever.

In addition to lots of journal article reading to keep up to date, I also spend about 20 hrs a week working (without pay) on my project, Less is More in Medicine. This involves reading related articles, spreading the word on twitter, attending conferences, preparing lectures, networking, teleconferences, etc. all on my own time. I do it because I am passionate about it and feel I have a duty to make the health care system better. If I could get paid for it, that would be great! In fact, that’s a dream.

If I was paid to do the advocacy work that I feel is so important, then I could have more time to practice the “wellness” that I preach to patients. Constantly I am bombarded with messages from friends and family to “slow down.” My very patient partner has advised me that I need to view this advocacy work as ‘work,’ and take time for myself, but I haven’t done very well at listening. He suggests I take one week off each month, which technically I do (I keep it free from clinical work) but (he’d tell you) I fill it with meetings and writing and preparing for conferences. Plus I work some of the nights and weekends during the rest of the month, so I wind up doing as much clinical work as anyone else, and I enjoy this also. Whether paid or not, I will continue my advocacy work, because I cannot let go.

There are a lot of mixed messages. On the one hand, I hear I should make sure I am well: As a physician I advise exercise, healthy eating, meditation/self-reflection, and community involvement. I have seen burn-out and suicide and hospitalization of my colleagues thanks to the pressures of this profession. Numerous groups, like The Physician Health Program of BC have talks and booths at conferences, reminding us to take care of ourselves before we take care of others. Parents and partners worry.

Some comic relief in a day of stupid paperwork: Medical Reconciliation forms must be filled out when patients are admitted in order to make none of their usual medications are missed. This is important.
The pharmacist was upset that I left this page, a prescription for a generic erectile dysfunction drug (like Viagra), blank.
"Just doing my job," I know, I know. But what a system we would have if people kept only "just doing my job."

On the other hand, I should work harder and do more with less: patients are upset they can’t find a GP taking patients, they complain about waiting in the office or in the ER, colleagues ask for their shifts to be covered, emails come in constantly seeking locums, while in the middle of telling someone their loved one is dying a nurse calls and ask “when are you going to come and see this patient?!”, hospitals grow more crowded and we are seeing people in hallways, the public tells doctors we are paid to much and work too little and I’m to blame for everything that is wrong with their health, despite electronic records the pile of paperwork only seems to grow, the government of Quebec tries to pass legislation to (#PL20) forcing doctors to work more hours and take on more patients.

These messages are hard to reconcile, which is why we need to challenge the status quo. (I learned this formally, once). We need to change the way health care is delivered. We need a revolution in primary care, and we can only do this by using our time outside of clinical hours.

We must be brave and tackle conflict and embrace controversy. This makes life more difficult, but how can we – the thorough, the dedicated, the caring, the hungry, the unwilling to give less than 100 % – live any other way?

How to Get Kids to Eat Their Vegetables

Sometimes simple intervention can create massive improvements in health.

This article in Modern Farmer shows how a small change to routine can get kids to eat healthier foods by challenging the traditional learn-lunch-recess-learn model of midday scheduling in elementary school.

If we let go of the traditions that have us (arbitrarily) doing something a certain way, it opens up a lot of possibilities. Is this a perfect solution for childhood obesity and unhealthy diets? Maybe not, but it sure makes me consider if there are other parts of a child's (or adult's) routine that are worth re-inventing. 

Creative thinking is an essential part of "Less is More in Medicine" thinking. Some lament finite resources, but such situations force us to use careful thought and to challenge assumptions rather than throwing more money and resources at a problem.

"Necessity is the mother of all invention" so maybe accepting and realizing the crisis (eg. 31% of Canadian kids between 5 - 17 years old are overweight or obese), we'll get a little more clever about tackling it!

Source: http://modernfarmer.com/2015/01/science-co...

‘Choosing Wisely’: a growing international campaign

As you may know, the Choosing Wisely campaign, originally started by the American Board of Internal Medicine (ABIM) Foundation in the United States, was launched in Canada in 2014. It has now spread to over 12 countries and many others are working on recommendations in line with the work.

Dr Wendy Levinson (Chair), Dr. Sam Shortt (Vice Chair) and Dr. Sacha Bhatia (Evaluation Lead) of the Choosing Wisely Canada campaign join colleagues Dr. Daniel Wolfson (Executive Vice President and Chief Operating Officer ABIM), Dr. Eve Kerr (Director, VA Center for Clinical Management Research), and Marjon Kallewaard (Director of Quality, Dutch Association of Medical Specialists) in authoring a paper summarizing the international efforts of Choosing Wisely.

The article in BMJ Quality and Safety describes the growth of a campaign from its American-launched roots as an effort "to encourage physicians and patients to talk about medical tests and procedures that may be unnecessary, and in some instances, can cause harm."

Several charts in the article compare the stages, stakeholders, and special issues in each of 12 countries as well as outlining the common principles of the campaign.

Portion of the table comparing 12 countries and their variations on the Choosing Wisely Campaign, the involved parties, and the unique challenges faced.

The most interesting section for me is "Challenges." Here, Levinson et al. describe some of the major barriers to developing and implementing the recommendations, as well the need to discover if the campaign has been effective.

Read the article at BMJ Quality and Safety.

Source: http://qualitysafety.bmj.com/content/early...

Atul Gawande: why the health care system should stop trying to help everyone live longer

Quality matters. It's not just quantity that counts towards the end of our lives, and in fact, most people would choose "good time" over "any time." Physicians know this but for many reasons we can't always help patients have the best life possible before death.

Dr. Atul Gawande recently did an interview with the Washington Post on the subject, and it felt authentic. While admire his work, I do not consider myself an unconditional devotee. However, this article is truly amazing.

It is a call to action. He graciously and decisively invalidates all the excuses that physicians create to not tackle end-of-life discussions with patients, confessing some of the challenges along the way.

Read more in The Washington Post.

Some of my favourite excerpts are here:

HP: One tough question. I watched your lecture today with some primary care physicians. Their reaction was to say, “Of course all this information about the need for conversation in end-of-life care was revelatory to you, Dr. Gawande. You’re a surgeon.” In your telling of the story, how much did the culture of specialty care fail to prepare you adequately for the challenges recounted in your book?

AG: Look I’m a surgeon--highly procedural, geared towards always being able to offer something more. It’s no surprise that this field did have prepared us formally for these kinds of conversations. Furthermore, I’m in an academic medical center, high-end Mecca. Many people come there because they want that experimental therapy, the last ditch maneuver against all odds.

. . . If these [end of life] conversations are so important--and people across other fields seem to know it--we’re still not having them. It’s not happening for two-thirds of people with advanced cancers for example. We have evidence that these conversations are even less likely to happen for other common things people die of: congestive heart failure, for example.

Maybe that’s because families and patients tend to move on to a specialist rather than the primary care doctor for these conversations, but I often find primary care doctors aren’t having them, either.
HP: Even if they had the skill to have the conversation, that’s not really who the patients are looking to for these conversations.

AG: If you look at the studies, they find that having a palliative care doctor or geriatrician more closely involved in care can lead people to forego aggressive therapy sooner and have better outcomes--not only less suffering but even improved survival. But we don’t have enough of these doctors to go around. Furthermore, there’s something wrong with the idea that you outsource this kind of decision-making and discussion.
HP: One of your book’s saddest quotes comes from a hospice patient, who says: “The oncologist and the heart doctor told me that there’s nothing more they can do for me.” It’s as if palliative care and hospice are the consolation prizes we give you when we really can’t do anything more.

AG: . . .
Even when we are needing to handoff, I’m involving someone who is going to have palliative care or hospice or primary care team. I’m not involving them because there’s nothing more I can do. I’m involving them because we require other people’s expertise to help us achieve what we’re trying to do.
Source: http://www.washingtonpost.com/blogs/wonkbl...

Must Watch VIDEO: (TEDMED) Are zombie doctors taking over America?

I don't know how I hadn't already seen this. It is perfect.

I've been feeling lately that it is impossible in this system to deliver good quality care and to be 'happy and well and fulfilled' myself, I can related to almost everything Dr Zubin Damania (aka ZDoggMD) says in his TedMed talk.

For years I've enjoyed ZDoggs hilarious videos but for some reason I did not see his TED talk until today.

Physician Zubin Damania, Director of Healthcare Development for Downtown Project Las Vegas, has a plan to fight back against a system that can dehumanize doctors and patients alike.

So much of what he says about his journey into medicine resonates with me, but this one section captures it all perfectly:

"A typical day in my life went something like this:

It begins with a mad scramble from room to room seeing complicated, sick and scared patients and their families, followed by three hours of paperwork using an electronic medical record that's two keystrokes away from becoming sentient and destroying humanity, all the while answering phone-calls from insurance companies, colleagues, and administrators each asking that I do more and more with less and less while improving quality and patient satisfaction. And speaking of which, that patient for whom I refused Vicadin because I was convinced it was destroying his life just ripped me a new one on Yelp! And I get through my 31st voice mail and I'm trying to delete it and it won't delete and I'm thinking I have to call I.T. now and I realized the reason it won't delete is that it's a live person I'm talking to. And it's my wife. And she's asking me to come home.

When I finally do get home, I can't be present with my two little girls because all I can think about is 'could I have missed something in this insane shuffle that could hurt or kill somebody?' Later, rinse, repeat for an entire career."


"Enough was enough. I realized I had a choice to make. I could either submit to this insane system and retire and then do my thing, but have my soul crushed and join the ranks of the swelling physician-zombie apocalypse. Or, I could surrender.

Just give up the external validation, drop the mask, and really surrender to who I actually was and have some hope of reconnecting to my purpose."


I need to do that. Dr Damania and Iora Health understand the fundamentals of providing the right kind of care. If we weren't wasting so much time and energy on all kinds of things that don't really matter, we could start to care for people again.

How can we do it?

- remember "medicine is about human relationships"
- "fix the reimbursement system . . make it an affordable, flat fee that incentivizes everyone to keep everybody well."
- "revolutionize the care model and the culture of the team; health coaches, nurse practitioners, doctors, and patients working together collaboratively non-hierarchically to change the health of the whole community"
- "glue it together with technology that helps rather than obstructs
- "do things FOR people instead of TO people"

I want to be a part of a clinic like that!

Source: http://www.tedmed.com/talks/show?id=34752