Thursday, May 26, 2011

Keeping patients at home - Redesigning care delivery

The innovative telehealth programs described in this Globe and Mail article resonated with me this week as we continue to work on similar issues in our urology practice, namely, what is the best way and location to deliver patient care.

The article mentions programs in BC and Ontario where patients with heart disease monitor their own symptoms and vital signs, submit the data via phone or computer, and have regular follow-up by automated phone call.  Of course, all this is in addition to access to traditional, "live" care providers.  The classic model of care for these patients would be to travel to a large centre where specialist care congregates, and then have professionals do all the work.  The telehealth model delivers care in patients' homes, and engages them in their own healthcare.  It saves travel time, stress and expense.  While this delivery model wouldn't suit everyone, the patients interviewed for the article were very pleased with the programs.

In our urology practice, we're (once again) experiencing capacity challenges.  The combination of an impending retirement and several urologists working half-time (I'm a guilty party!), along with changes in OR time allocation, means our patients are waiting longer for consultation appointments.  As part of the Sask Surgical Initiative, our department has been given additional operating room time so we can complete surgeries for people who have been waiting a long time (many over 12 months).  However, as more of us are in the OR, it means that fewer are available to see new patients in the office. 

We're reviewing several aspects of our office care delivery to see how we can be more effective.  We've had success previously with trying to deliver care "closer to home".  We've had success previously with an alternate way of informing men about vasectomy reversal surgery.  We found that men referred to us regarding vasectomy reversal weren't actually asking for the surgery, but were using the office visit as a way to get information about the procedure, its success rate, costs and complications.  We developed an information package about the surgery, and when we received a referral, we send the man and his referring physician that package.  We invite the man to arrange an appointment with us if he has any further questions, or if he is convinced that he wants the surgery.  In the trial period, 2 out of 22 men arranged appointments.  The other 20 men were saved a trip to our office.

We want to identify other situations that can be managed in a similar way.  It may involve information sent to patients, or to family physicians to support them delivering care in their own practice.  This week, two of us reviewed several weeks of office visits to identify common reasons for urologic referral that we think could be managed by the primary care practitioner, for example, uncomplicated bladder infections, scrotal cysts, and enlarged prostates.  We've identified a few likely conditions and will develop information packages regarding investigation and management.  Importantly, we plan to discuss these packages with referring physicians to see what information is helpful for them, and to identify any other issues around the referral (e.g. patient "demands" specialist opinion, no local facilities for testing).

We hope to identify situations where the patient's needs can be met closer to home, by the provider with whom they already have a relationship.

Wednesday, May 18, 2011

Better care for patients with back and neck pain - an appropriateness success story. With a Saskatchewan flavour.

Here's a great story about the potential to improve care and reduce waste through system redesign.  And, it recognizes a Saskatchewan initiative as leading the way.

The traditional approach to wait times has been to throw resources at the problem.  If people are waiting too long for surgery, we open more ORs, train more nurses and recruit more surgeons.  There's a superficial appeal to this method: Let's do more of what we already know how to do.

The problem is that this solution deals with the supply of services but ignores the demand.  Specifically, it ignores whether or not the demand for a service is appropriate.  As reported in last week's Globe and Mail, a new way of thinking about treatment of back pain takes the bold step of addressing appropriateness of care.

The problem:

Patients with severe back and neck pain wait a long time to see spine surgeons
Many patients don't need to see the surgeon in the first place.  They need exercise, physiotherapy or back supports.
Millions of dollars are spent on unnecessary imaging (CT and MRI)

Quotes from Hamilton Hall, executive director of the Canadian Spine Society:

In an unscreened practice, where the surgeon sees 100 patients, no more than 10 would be surgical candidates.
As a screening tool for back pain, MRIs are worse than useless.

The solution:

Establish a multidisciplinary screening/triage program to evaluate patients
Refer to appropriate treatment without unnecessary waiting for MRIs and surgical consultations

The benefits

Quicker access to appropriate treatment
Shorter wait times to see surgeons for patients who will benefit from surgery
Fewer unnecessary MRIs
Shorter wait times for MRIs for patients who will benefit from this testing

As the Globe and Mail story points out, Saskatchewan is leading the way by training family doctors to assess which patients need referral to a back surgeon, and providing the trained physicians special access to the multidisciplinary clinic, appropriate imaging and surgical referrals.

The Globe and Mail followed up with this editorial earlier this week.

Monday, May 9, 2011

Tales from the Representative Assembly II - Appropriateness of testing

A story in today's Star-Phoenix about possible overuse of CT scans in kids reminded me of some more discussion from the weekend's RA.

One doc spoke about his frustration in not being allowed to order certain tests for his patients, specifically CT scans.  In some health regions, only "specialists" can order CTs and MRIs.  Rationale: reduce overuse/misuse.  Side effect: delayed diagnosis for patients.  He felt that he had been practicing for long enough that his clinical judgement should be trusted.

The next doc to speak told the RA that it was nearly impossible for him not to order certain tests or treatments because patients demanded them.  He gave the example of PSA for prostate cancer screening in men aged 80 and over, multiple repeats of cholesterol testing, and antibiotics for viral infections - all of questionable value.  If he didn't order the test, then they would be angry at him, and just see another doctor to get them done.  

The juxtaposition of these views was puzzling.  On one hand, docs are feeling powerless to refuse requests from patients, even though their clinical judgement tells them the testing is not helpful.  On the other hand, docs are making a case for broader privileges to order more expensive, possibly risky tests.

I think these are different sides of the same clinical problem:  appropriateness.  Tests and interventions may be underused (insufficient use of a test that has been proven to be beneficial, like cervical cancer screening), but most inappropriate use falls into the category of overuse (like the CT scans in the SP article).  The restrictions to ordering CT scans that the first doc complained about are in place to reduce inappropriate testing.  Even with long years of experience behind him, I doubt that even the most clever doc would consider himself up-to-date on the indications for CT scanning in all subspecialties.  And, given the second docs comments about the pressure felt to acquiesce to patient requests for testing, we can expect that opening the CT floodgates would, in fact, bring a flood. 

So, how can we assure appropriate testing, based on best practice, yet allow timely access for patients?  

We can't all be experts, but we can have access to expert opinions.  But, rather than having family docs call up specialists to get "clearance" to order certain tests, there are clinical decision tools.  The Ottawa Ankle Rules are an example of validated guidelines that reduce unnecessary testing without negatively affecting outcomes.  Similar guidelines could be developed for situations that commonly lead the primary care physician to consider whether a CT scan is indicated.  If the guidelines/clinical decision tools were agreed upon by GPs, relevant specialists and radiologists, then patients could get the appropriate study done promptly without the wait and expense of seeing a specialist first.

Would docs feel it was an insult to their clinical acumen if they had to use a clinical decision tool?  No, they would understand the importance of appropriate decision-making for the benefit of their patient, and would not let misguided professional pride get in the way.  A well-crafted set of guidelines could also be a valuable educational tool for the second doc who was frustrated with patient "demands" for testing.  While he may feel he doesn't have enough time to give a thorough explanation of why he recommends against certain testing, he could send the patient home with the guidelines and ask them to reconsider after studying the expert opinions.

Sunday, May 8, 2011

Tales from the Representative Assembly

I haven't regularly attended the SMA's biannual Representative Assembly (RA).  But, after attending yesterday's session, I'm going to make an effort to attend in the future.  What a fantastic and frank exchange of ideas!

Canadian Medical Association Past President, Anne Doig, asked the physicians present to think about whether the healthcare system was giving good value for money, and what responsibility physicians and patients had toward the system.  Several of my colleagues told about abuse of emergency services with patients arriving at 2 am with trivial problems that could have waited until the morning.  The phrase that characterized these patients was "demanding".

Even though I think "demanding patients" is an unfortunate choice of words, I was glad to see that this was a forum where doctors felt able to express strong feelings about how the healthcare system is not working.  It's tempting to tut-tut these docs and conclude that "they just don't get it".  That would be a mistake.

My colleagues are expressing their frustration with the poor functioning of the healthcare system.  However, rather than seeing it as a system problem, they've framed it as a behaviour problem with patients.  There may be many reasons why someone turns up in the ER with a seemingly trivial medical problem in the middle of the night.  Perhaps they tried to see the doctor during working hours, but appointment wait times are 2 weeks.  They may have phoned the ER for advice on how to manage their earache and been told that the nurse couldn't give out advice over the phone.  Whatever the reason may be, I think it's safe to conclude that no one wants to be in the ER at 2 am, so their presence could indicate an unmet need.

I sympathize with my family practice colleagues, however.  I have the luxury of having my 2 am ER calls come from the ER doc, who has already assessed and treated the patient, and now is calling for specialist consultation.  The rural family docs, in particular, face regular sleep disruptions which must be maddening.

In private discussion, several docs assured me that in fact there do exist truly demanding patients who aren't satisfied by the best efforts to provide timely and appropriate care.  I don't doubt it.  But, I think that, however we define inappropriately demanding patients, they make up a very small part of the larger group of people who are being tarred with the same brush.  It seems to me to be too easy to label someone as being inappropriately demanding rather than exploring what their needs truly are, and how we have failed to meet them.

I can't be angry at either the patient who "demands" care at 2 am, or the physician who considers this behaviour inappropriate.  Rather, I'm upset at the system that pits physician and patient against each other.  It's a dysfunctional system that:

- doesn't offer timely clinic appointments to deal with minor problems at convenient hours
- doesn't allow non-physician care-givers to work at top of licence, and provide advice and care independently
- doesn't reward or encourage efforts to educate patients on self-management of common conditions

What can we do?  Philosophically, we can try to convince docs that the problem is with the system, and not with patient behaviour.  We could explain that the healthcare system's purpose is to provide appropriate care, where and when the patient needs it.

We could try that, but I think it would be cold comfort for the doc who's wakened from a sound sleep.  Instead, measure the problem and, in doing so, identify the barriers that the system has thrown in our path.  Rural ERs could survey patients arriving after midnight to find out their perceived problem, its duration and whether they had tried to access any other sources of care.  Ask these questions with genuine interest in improving care delivery.  Don't judge or disapprove.  Aggregate data from several (all!) rural hospitals so as to get the big picture more quickly.  Once the barriers to timely, appropriate care start to reveal themselves, so will potential solutions.

I welcome comments from my GP colleagues who struggle with this issue every night they are on call.

Thursday, May 5, 2011

"Medical Justice" makes no sense on so many levels

Hi, I'm Dr. Visvanathan.  Please come into my office.  Before I provide you with high-quality, compassionate care, I'd like you to sign this agreement that you won't bad-mouth me publicly.

According to the American company, Medical Justice, this is how all my patient visits should start.

This story is a jaw-dropper.   Medical Justice markets itself as protector of physicians' reputations.  The problem, they say, is that anyone can anonymously blacken a physician's reputation via the internet, particularly on doctor rating sites (such as RateMDs).  The physician has limited recourse.  Medical Justice's solution is to have all a physician's patients sign an agreement that allows the physician to remove from the internet any unwanted comments the patient may post.

Doctor rating sites - and their use and misuse - aren't a new story.  Back when (now defunct) Plain Brown Wrapper was the international sensation everyone was talking about, I posted about an experiment I tried using RateMD, one of the doctor rating services.  Rather than try to shut down patient comments, I left a message on my rating page inviting comments, but challenging people to leave constructively critical comments.

My post on the site said: "Hi, it's Kishore Visvanathan here.  Thanks for leaving a comment on RateMD.  I'd like to use your comments as a way to improve the service I give.  If you have any concerns about the care I provided to you, please make a constructive comment about how I can improve."

Actually, I'm paraphrasing, because when I visited the site for the first time in a long time (prompted by writing this post), I found that my invitation for constructive criticism had been removed.  Interesting...  I wonder if they are concerned that doctors might subvert the original purpose of RateMDs, and actually turn it into a way that doctors and patients could have a dialogue about improving quality?

Other doctors have different approaches to RateMDs.  As do some medical students.

I digress.

If Medical Justice wants docs to worry about anonymous comment posting, how will "asking" patients to sign their agreement help.  Anonymous posting is... difficult to track.  I presume they're willing to make the effort to force website managers to cough up the names of the offending posters.

Most importantly, if a doctor is so worried about his/her reputation, why not earn that reputation through consistent efforts to improve service?  Sure, there will always be people who have an unhappy experience and want to gripe publicly about it.  I doubt that they would be thwarted by the Medical Justice gag agreement.

Medical Justice's legal circling-the-wagons drives a wedge between physician and patient.  We should invite feedback from our patients.  Some comments may be personal and painful to hear.  Those are the ones to pay close attention to.

Focusing on patient needs in the OR

I had a great conversation with a group of OR nurses last week.  We were talking about "multitasking" in the OR, and how we wanted to make sure our attention was on our patient during critical times.  It's not always as simple as just saying "Let's pay attention".  There are a lot of subtle factors at play.

Some interesting suggestions and comments came out of the discussion:

Agree on a “safe” word/phrase that anyone could use to remind everyone in the room to focus on the task at hand.  One suggestion was “focus”.  The word  would have to be non-judgmental and non-threatening.

Perhaps part of the surgical checklist could be stating a commitment/reminder that everyone in the room would be attentive to the patient’s needs.
Concern that some people may take such reminders personally and be upset with the other person.  This subtly intimidates people into keeping their concerns to themselves.
There is a mix of people in the room including nurses, surgeons, anaesthetists, residents, students and there are often lots of conversations going on.  Who can judge which conversations are important for patient care and which ones could wait until later?
Maybe we should set aside “critical times” like takeoff and landing a plane where conversations are only about the task at hand, ie safe patient care
Staff noted that patients may overhear “inappropriate” conversations while they are awake and it may be upsetting to them.  Even though their surgical outcome may be good, they may be left with an overall bad impression of their care.

We didn't solve anything that morning, but I was encouraged to hear the level of interest in pursing this opportunity to improve patient care.  Next step: gather suggestions from the entire OR staff.  Maybe an invitation to discuss this at a weekly inservice meeting?  Hint, hint.

Monday, May 2, 2011

Don't ask people if they're satisfied with the status quo until you've shown them what's possible

As I walked by my son's room, I heard a familiar song playing on his radio.

"Hey", I said, "That's a classic!. Alone, by Heart, right?"

"Who's Heart," he asked. "Anyway, this isn't them."

As I listened to the song, I realized it was a remake of the Heart tune. A passable remake, workmanlike, but missing the beautiful original arrangement and powerful vocals. I told him so.

"Well, I think this is a good version," he replied.

I whipped out my iPod and cued up the original version.

"Oh, yeah," he said, seeing the light (circa 1987). "That is better!"

So, how do you know how good something can be if you've never experienced it?

Provincial patient surveys show a high rate of satisfaction with healthcare.  A survey late last year, showed that half of Saskatchewan residents surveyed rated their healthcare as good - the highest rating in the country.

But, "good" compared to what?  How many people surveyed know what's actually possible?

What would the results be if we showed people how their care could be delivered, such as using the US Veterans' Administration comprehensive electronic medical record?  Or Jonkoping's streamlining of patient flow through consideration of the needs of their prototype patient, Esther?  Or Alberta's systems innovations in providing joint replacement surgery?

Here's an interesting experiment: Educate one group of people about healthcare's best practices around the world.  Leave another group uninformed. Then give them the healthcare satisfaction survey.