ACP Internist Blog

Monday, May 20, 2019

The mystery of medical insurance coverage

“Does my insurance cover this?”

I cannot calculate how often a patient poses this inquiry to me assuming wrongly that I have expertise in the insurance and reimbursement aspects of medicine. If I, a gastroenterologist, do not even know how much a colonoscopy costs, it is unlikely that I can speak with authority to a patient's general insurance coverage issues.

Of course, patients assume that we physicians have an expansive expertise of the medical universe, both in the business and the practice of medicine. Often, friends and acquaintances will informally present a medical issue for my consideration that is wildly beyond my limited specialty knowledge, and yet they expect an informed opinion. ”Hey, aren't you a doctor?” Yes I am, but if you think a gastroenterologist, a Colonoscopy crusader, can advise you on your upcoming hip surgery, psoriasis treatment retinal detachment, or cardiac rehab, think again.

And, I likely know more about psoriasis treatment than I do about the enigma of insurance coverage. I have to check with our billing expert to understand my own medical coverage and I'm in the business. And, at the risk of appearing as a simpleton to my erudite readers, I cannot aver that I fully grasp the meaning of the E.O B. (Explanation of Benefits) forms that I receive for my own care that purport to explain exactly where my insurance company responsibilities end and mine begin.

Imagine for a moment that you are an actual physician as you counsel a patient who is sent to you for a screening colonoscopy. (To assist you in this role play, a screening colonoscopy means there are no symptoms or any other abnormalities that would justify the procedure. A screening study is done on patients who are entirely well as a preventive medicine exercise. In contrast, if a patient has a symptom, such as pain or bleeding, then the colonoscopy is considered diagnostic and not screening.) You advise your 50-year-old patient that his screening colonoscopy will be fully covered by insurance. The patient is happy. However, during the screening colonoscopy, a polyp is discovered and removed. Indeed, removing polyps is the mission of the procedure. However, polyp removal automatically changes the procedure from screening to diagnostic. And, guess what? Now, the procedure may not be free and the patient may be subject to copays or diving into his deductible. When the patient receives his E.O.B, and properly decodes it, he is no longer happy. Then, our office is likely to receive a phone call.

This is but one example of the Medical Insurance Industrial Complex. Even our most seasoned patients are no match against this machine. It's not a fair fight. They make the rules, change them at will and serve as the referees. And, if the insurance company ruling doesn't fall your way, relax, you can certainly appeal. This process is about as pleasurable as undergoing a rigid sigmoidoscopy. The appeals process is not for the faint of heart. You must have the patience of Job, the fortitude of a Navy SEAL, accept rejection gracefully, welcome irrationality, regard a dropped phone connection as an amusing event and have several consecutive hours available typically at times most inconvenient for you. On reflection, perhaps the sigmoidoscopy is the more pleasant option.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Dear doctor, here's why your patient didn't like you

The era of the empowered patient and patient-centered health care has been upon us for some time. Only a generation ago, there was a much more paternalistic approach to medicine. This has changed for the better across the western world.

As somebody who teaches and coaches physicians on how to improve their communication skills, I would say that the newer generation of doctors is much more receptive than many of their older counterparts, in learning new skills in this area (which is a pleasure for me to say, because they are ironically also the generation who has come through a system where they have to spend an unacceptable amount of their day attached to a screen). As with any service-oriented arena, how you communicate often trumps competency, in how people perceive you. I'm not saying this is right, just that it's the way things are. While being a doctor certainly isn't a popularity contest, being able to establish rapport and being a good communicator, is a core component of being effective at what we do.

If you've been around for any length of time, you've probably heard a patient or two say something along the lines of: “I didn't like that doctor”, based on only one interaction. Here are three reasons why that may have happened:

1. The doctor was visibly in a hurry
This is a big no-no. Every doctor is probably in a hurry, because that's the nature of healthcare. We work in a suboptimal system with multiple demands placed on us. But that's not the patient's fault. There are certain verbal and non-verbal cues that give this away like a red light (I wrote about some of these here). Part of being a professional, is having your “game face” on at all times. For physicians, that means not showing very obviously you are hurried, and carrying a calm demeanor.

2. Brush things off
When patients come to a doctor with something on their mind, it's never trivial. For the doctor, who may want to focus on something else, there are subtle ways to redirect the conversation, but never in a way that appears to minimalize a concern or belittle a legitimate worry. Happens all too often I'm afraid.

3. Not caring
This is the absolute worst thing any doctor can ever come across as. Yet I hear patients complain all the time that their doctor came across like that (albeit a small minority of cases). No matter how long our days, hectic our to-do list, or difficult our patients— the onus is on the physician to display a caring and compassionate attitude. Certain techniques that help with this include active listening, eye contact and using open-ended questions.

Occasionally when I teach my courses, I get pushback from physicians along the familiar lines of: “Oh does this mean I just give my narcotic seeking patient what they want?!” or “We have such difficult and frustrating patients!” Another classic is: “Hospitals are not hotels!” Fair enough, but nobody is saying that hospitals should be like hotels. Those difficult interactions are also the minority of patients in most places. They should not be used as an excuse not to improve our communication skills, or to not have a level of self-awareness of one's own flaws. While no amount of teaching in the world can turn somebody who is a poor communicator, into an amazing one—each one of us can always go up a few rungs on the ladder, if we are motivated to do so.

Patients deserve the best performance from us during that brief allocated time slot we are given. Another statement I hear sometimes from doctors is: “Sorry, but I am not an actor”. Sorry, but you are already an actor! Every professional is. By using this word, we are not talking about being inauthentic or fake. On the contrary, anyone who is in a professional job or position of responsibility knows they have to put their “professional face” on—and deliver their best. Are you the same person you are at work as you are at home? Do you talk the same way to your patients as you do your family and friends? Do you take on a different persona when you don that white coat and step onto your stage? We know what the answer is. That's why we always want to master the art of appearing calm, listening to all concerns, and showing that we care—with every patient we see.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Friday, May 17, 2019

Eggs, oxygen, and the perennially breathless state of nutrition

Are eggs good or bad for us now? Yes.

A recent meta-analysis, widely covered by media ever hungry for just such dietary provocations, reported that the more eggs people ate over time, the more prone they were to heart disease. This, inevitably, has been juxtaposed with the advice in the 2015 Dietary Guidelines to abandon a specific focus on dietary cholesterol and unleashed the predictable round of breathless expostulations about the deplorable state of nutritional science and understanding.

Actually, the deficiency is sense, not science, and worse still, the perennial neglect of the former when interpreting the latter. Absent sense, science doesn't work, minimally, because it generates answers to all the wrong questions.

I'll get back to eggs, and cholesterol, and where sensible interpretation of all the relevant data takes us momentarily. For the moment though, let's just breathe together…

Breathe, as in … be centered, and calm, and in the moment, and all that meditative stuff. But also, breathe because otherwise you will die in a matter of minutes. You need oxygen, in every breath, to live. So, best to breathe.

But now, let's consider what we know about oxygen and the related research evidence.

We know, for example, that people living all their lives at high altitudes, in the Andes and Himalayas, adapt to that stress by having oversized chest cavities and lungs, and by having unusually high hematocrits (the concentration of red blood cells relative to total blood volume). These responses to high-altitude living help compensate for the low concentration of oxygen up there, but they are otherwise ominous in their implications for health. A high hematocrit raises the risk of potentially lethal blood clots; oversized lungs can impair the function of other organ systems in the general neighborhood, from heart to liver.

OK, then: too little oxygen is bad.

But, hold your horses if not your breath. Too much oxygen is bad, too, maybe even worse. First, we have evidence of a potentially lethal condition, ARDS, when people receive excess oxygen while on a ventilator. Oxygen is in fact so highly toxic, it effectively scorches the very organ that processes it. Permanent lung injury can result from exposure to high concentrations of oxygen in relatively short order, a matter of days, and sometimes, just hours.

And, in some circumstances, an “excess” of oxygen will cause people in dire respiratory peril to stop breathing altogether. This one requires a bit more explanation.

Ordinarily, it is not oxygen levels that prompt us to breathe even while sleeping. Rather, it is levels of CO2 (carbon dioxide). The details here can get rather recondite rather fast, so let's keep in the shallows. C02 combines with water in the body in a way that releases acid (non-chemists, just trust me). The body regulates pH levels in the blood very strictly, because cells and enzymes can only function within a very narrow pH range (outside of that narrow range, we die, quickly). The result of all this is: the body strictly regulates CO2, rather than oxygen, and that dictates the compulsion to breathe, in most of us.

The exceptions are known as “CO2 retainers.” These are people generally with COPD (chronic obstructive pulmonary disease), typically as a consequence of long-term smoking. As the name implies, this disease is “obstructive,” and thus limits the ability to expel spent air from the body. That, in turn, results in abnormal retention of CO2, the principal component of spent air.

Over time, the body adapts to these higher levels of CO2, and even invokes other mechanisms involving the kidneys (don't ask; if you want the Full Monty, consider medical school) to keep pH as nearly normal as possible. But this comes at a cost: exposed constantly to abnormally high CO2, the body's native alarm that sounds “CO2 is high, breathe now!”, turns off. Perhaps the simplest way to think of this is that boy who cried wolf. With CO2 retention, that alarm never stops sounding, and the body learns to tune it out.

Under such circumstances, breathing of course goes on, but under new management. In this population, it IS oxygen that becomes the driver of breathing. As O2 levels fall, and the oxygen saturation of blood declines between breaths, this alternative stimulus goads breathing.

But here's the rub! This very population, people with COPD and CO2 retention, is very prone to bouts of respiratory distress that lands them in the hospital. When, for instance, someone in this condition gets bronchitis, the oxygen levels in their blood may fall to near a critical threshold (this threshold is a product of the oxyhemoglobin dissociation curve, and again, don't ask, just go to med school!). To keep them above that threshold, oxygen must be administered. But when enough oxygen is administered to rise above that dangerous tipping point, it can be enough to turn off the impulse to breathe entirely. Sometimes the window of therapeutic opportunity is agonizingly narrow.

So, too little oxygen, and someone in this state will asphyxiate, and maybe die. Too much oxygen, and they stop breathing, and maybe die.

So is oxygen essential or toxic, good or bad? Yes.

Is too much oxygen, or too little oxygen, lethal? Again, yes.

Were we to treat any other branch of science or medicine with the fatuous want of sense we apply to nutrition (and to be fair, sadly there are others we do, from evolution to vaccination, just to name two), we would be reaching the conclusion daily, in a flurry of fraught tweets and blogs, that we know nothing about anything. Based on the above, and utter confusion about oxygen, I can only infer we should declare the state of intensive care hopelessly mired in contradiction, and shut down every ICU in the country immediately. We are, after all, terribly confused about oxygen! Aren't we?

No, we are not. Not at all. We simply know that sometimes the truth has nuance. Sometimes the truth needs a little room to…breathe.

We know that all of the answers pertaining to oxygen are: it depends. The right amount of oxygen varies by circumstance. The right amount is vital. The wrong amount, which also varies by circumstance, is injurious.

Vexing though such nuance may be, defiant though it may be of our penchant for dualistic, Manichaeistic sound bites and simple-minded clickbait, it's the truth about oxygen. It's the truth about almost everything in science, and it's certainly the truth about food: actual understanding requires more than over-simplified, over-generalized summary judgment. It actually requires thinking, and interpretation, in context.

Sorry, but that's the truth our information-over-fed culture fails to chew, and refuses to swallow. And, yes, it's the truth about eggs.

The 2015 Dietary Guidelines Advisory Committee, and the subsequent Dietary Guidelines, never said that eggs were entirely innocuous, and certainly never said they were “good” for us. They simply said, based on the weight of relevant evidence, that they were not a helpful focus for the current dietary guidelines. Guidelines are intended to help fix what's broken, and as of 2015, most Americans were consuming dietary cholesterol below the recommended threshold.

Short-term intervention studies of egg ingestion, including several from my own lab (industry funded, by the way, for those who want that disclosed immediately), have indeed suggested eggs to be relatively free of acute harms across a wide array of relevant measures. Large, observational studies over long periods of time have suggested much the same.

But, and here's the nuance, the right, large observational studies also help us understand why this might be both true, and false. Consider, for instance, the prevailing, and utterly misguided, pop-culture notion that saturated fat has been redeemed and is good for us now. Actually, the two meta-analyses underlying this contention simply showed that across fairly narrow and fairly high ranges of saturated fat intake, rates of heart disease were high and rather constant.

A 2015 study by researchers at the Harvard School of Public Health explained why. When saturated fat in the diet is replaced with added sugar and refined carbohydrate, which is how most Americans have replaced it over recent years, it's a lateral move. We have no evidence that saturated fat is good for us now; we just have evidence that there's more than one way to eat badly, and Americans are committed to exploring them all. (Tell them what they've won, Johnny!)

Everything causing confusion about eggs is readily interpretable when some related sense is applied. Eggs and dietary cholesterol are not a major public health concern at present simply because we've got bigger problems: sugar, ultra-processed foods, saturated fat, and sodium to name a few.

Eggs and dietary cholesterol were never declared “good” for us; the best arguments have only ever been lack of harm. But whether lack of harm is good, bad, or in-between is entirely, and obviously dependent on: instead of what? In the typical American diet, eggs for breakfast may be replacing toaster pastries, donuts, or multi-colored marshmallows masquerading as cereal. That might well be trading up, both directly, and because eggs are nutrient rich, and satiating, and might blunt appetite.

On the other hand, eggs in the place of, say, my own standard breakfast of steel cut oats, mixed berries, and walnuts, would certainly be trading down. These foods are decisively good for us, and “not harmful,” relative to “overtly good,” is, well, comparatively harmful.

That, in turn, explains the results of the new meta-analysis. People with the highest egg intake may have been directly harmed by that excess dietary cholesterol. They may have been harmed by some of the company eggs tend to keep, such as sausage and bacon (although the researchers attempted to adjust for this). And they may have been harmed indirectly because more eggs meant less whole grains, whole fruits, whole nuts.

The new study drops the sky on neither us, nor Henny Penny. It scrambles our understanding of neither nutrition in general, nor eggs specifically. Rather, it does what any one study always does: invites the application of sense to the task of interpretation in context, and posing the relevant questions. Eggs, instead of what? What, instead of eggs? Eggs in the company of what other foods? How did diet patterns, diet quality, and lifestyle practices vary with egg intake? Absent this routine application of sense to science, we will be forever stuck in dietary Groundhog Day, using each news cycle to repudiate the epiphanies of the prior.

Folks, here's the harsh, stark, like-it-or-lump-it reality check: no volume of data will save the witless from themselves. Science will only ever work reliably in the hands of those who interpret it with a bit of basic (but seemingly quite uncommon) sense.

Is oxygen good or bad for us? Yes.

Are eggs good or bad for us? Yes.

Nutritional nincompoopery of the sort that dominates our culture? Bad, every time.

PS, My take on eggs: Whatever harm they might do is generally obscured by the bleak character of the typical American diet. To isolate and observe effects on, say, blood cholesterol, we must test them in the context of very high-quality, plant-predominant or exclusive baseline diets. I think they are better for us than much of what passes for food in America these days, but not nearly as good for us as whole grains, whole fruits, nuts and seeds, beans and lentils, or vegetables. And, yes, we should consider the treatment of hens, often subject to rather horrible abuse on large “factory” farms. If you do eat eggs, try to source them locally, from a farm you can visit, and where, maybe they even name the chickens. Failing that, at least confirm that no hens were confined, and clipped, and abused in service to your breakfast.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his Linked In page.

Doctoring the CIA

One of the biggest attractions at medical meetings is the exhibition space, where publishers and companies peddle their wares and outfits looking to hire doctors sing what they hope will be a siren's song.

The Exhibitors' Hall at the annual American College of Physicians meeting is certainly among the most grandiose medical marketplace, if not the world's largest. When I approach the hall, I'm always reminded of Louis Winthorp's description of the NY Commodities Exchange to Billy Ray Valentine in the 1983 film Trading Places:

“This is it. The last bastion of pure capitalism left on earth.”

At ACP 2019 there were dozens and dozens of exhibitors, ranging from tech startups to health insurance providers. Digital stethoscopes? Check. Work for the newest telemedicine outfit? You bet. There were also journal and textbook publishers and purveyors of online medical information..

But by number, no category is larger than the recruiters—health enterprises all looking for medical personnel. Passersby definitely are made to feel needed in such a milieu.

Recruiting at ACP 2019 were hospitals, ambulatory groups, and academic practices all looking for help. There were also state, county and correctional facilities on the market for docs.

But I was surprised to see a recruiting booth from the CIA, America's Central Intelligence Agency. It was one of the smaller booths, with but a flag, some brochures, and a lone recruiter, who by Agency policy couldn't officially speak to me or be quoted.

So who is the Agency looking for? Primary care doctors and psychiatrists.

What does the job entail? Working abroad in embassies caring for CIA staff and their families.

Why, I wondered, if the job involves serving at U.S. embassies abroad, does the State Department not handle the recruiting?

Turns out that CIA doctors must be eligible for and able to obtain security clearances. In order to be considered, you must be physically and mentally fit, and able to pass both a background check and a polygraph test. You need to be a U.S. citizen, too.

The best of the brochures on the table dispelled 12 of the most common myths about working for the CIA: essentially, it ain't what you see in the movies. Forget about car chases or secret gadgets.

Other brochures led with catchy slogans like, “Everything you do here matters,” or “Utilize your medical skills on the world stage.”

The CIA is not just interested in doctors. Like the real world around us, the CIA is looking for nurses (particularly with experience in occupational health), physician assistants, nurse practitioners, and clinical and research psychologists.

I asked the recruiter what a primary care doctor like me would do in the CIA. I'd once read about the CIA hiring doctors as medical analysts to render opinions on the health of world leaders. The recruiter told me that she was not charged with finding medical analysts at the ACP or her other recruiting stops–only doctors to work as medical professionals. Though with adequate experience and interest, changing roles while in the Agency is considered.

Through the conversation I learned that the CIA operates in five “directorates:”
1. Analysis (think information gathering and synthesis);
2. Digital Innovation (think cybersecurity and warfare);
3. Operations (think spies, these are the folks in the famous clandestine service who handle missions and collect human intelligence);
4. Science and Technology (think ‘tradecraft’) and lastly;
5. the humble Directorate of Support (“delivers everything the CIA needs to accomplish its critical mission of defending our nation.”)

Would-be CIA physicians apply for jobs in the Directorate of Support.

How much does a CIA doc earn? According to their website, the salary range is $157,000 to $164,000 per year, with ‘a progressive physician comparability allowance up to $30K per year.’

This might be the kicker, though. How young does one have to be to join up?

It might surprise you like it did me, but the recruiter said the Agency considers hiring doctors up to 60 years old!

So should you tire of domestic life and the day-to-day of clinical care here in the U.S., the CIA is an unusual way you can serve your country.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience. He also hosts StudioTulsa: Medical Monday for Public Radio Tulsa.