American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, December 2, 2013

'To what end?'

To what end?

Those 3 words have become something of a mantra, a mission, a philosophy of care.
• To what end do I prescribe a medication?
• To what end do I make a diagnosis?
• To what end do I order tests?
• To what end am I documenting?
• To what end is there a patient record?
• To what end do I send a person to a specialist?
• To what end do patients need to come to see me in the office?
• To what end do my patients have me as a doctor?

This is tied closely to the thought process of a recent post in which I discussed the flawed idea of a problem-oriented health care system. When we treat a problem as the center of a person’s care, we look at one end in their care: fixing the problem (usually using a procedure).

You may rightly ask the question: “To what end are you writing this blog post?” Touché. To answer that smart-aleck question, let me go through several of the above bullet points for doctors who work for the usual employers: insurance companies and government bureaucracies, and those who work for my current employer: the patients.

1. To what end do I prescribe a medication?

This is actually what started me thinking on this line, as I found myself spending much more time talking people out of medications than I had ever done in my past life. The goal of medication in the old system is often muddled and confused:
• Q: Why give an antibiotic for an upper respiratory infection, or for “bronchitis” lasting less than a week?
• A: Because it takes too long to convince people they are not useful, and they have already waited for 2 hours to be seen and will be angry to leave the office without an antibiotic.

I find I am far more likely to hold off on medications now, as people know I won’t force them to come back in if they get worse. The cure for antibiotic overuse is “watchful waiting,” in which the body generally gets better without medication assistance. The problem with the old system is that pesky first word, “watchful,” which implies paying attention (aka communication).
• Q: Why use a cholesterol medication?
• A: To lower cholesterol. (Duh)

This, of course, is not the right answer for the sake of the patient. Cholesterol is a risk factor, not a disease, and there are plenty of circumstances where the risk heart disease or stroke is low enough that the risk of the medication becomes significant. I am now turning my patients’ attention away from cholesterol or other risk factors, and toward their risk. My goal is not to fix a little problem, but avoid a big one.

2. To what end do I make a diagnosis?

It’s a really complicated topic, actually, made much worse by the need for diagnosis (ICD code) to get paid in many/most cases.
• Q: Is obesity a disease?
• A: It is as long as the insurers pay for the diagnosis. They never have in the past, but recently have been doing so more and more.

I don’t actually care that much if it’s called a disease or not. To me, it’s something that increases the risk of certain things and reduces the quality of people’s lives. I don’t think it’s something that people should be ostracized for, but I also know that my weight struggles have been directly related to bad choices I make. The only reason to call something a disease is if doing so opens opportunities to reduce people’s risk or improve their quality of life.
• Q: What about symptoms like fatigue, irritability, or foggy-headedness?
• A: They go on the problem list as long as there’s an ICD code for it.

Symptoms are not diseases, nor are they risk factors. They are a report of the person’s experience in life. Symptoms are significant only in context of a person’s risk. If a person has chest pressure and shortness of breath, is that significant? The answer to that question is different for a 20-year-old female and a 56-year-old male diabetic smoker. In the former, even classic angina is not likely to be heart related, while in the latter even atypical pain is taken as possible equivalents to angina. Again, it all comes back to risk.

3. To what end to I order tests?

There is only one reason to order tests: to gather more information to make a decision. The end goal (as stated in #2) is not to make a diagnosis, but to decide what the path of action should be. I recently had a patient come to me (as is often the case) asking for me to order an MRI scan. In this case it was because of knee pain. When I suggested that perhaps a visit to orthopedics the patient resisted, feeling that I was somehow offering a lesser alternative. I countered with the following options:
1. We get the MRI and it is normal, in which case you still have pain in the knee that has not been addressed. I would probably refer them to surgery as I had suggested.
2. We get the MRI and it is abnormal. This would cause me to refer as well.
3. We don’t get an MRI and the orthopedic doctor decides to order one. This won’t cost you any more
4. We don’t get one and the orthopedic doctor decides to go straight to arthroscopy. This would save you hundreds, perhaps more.

For lab tests, it’s really important to understand the situation you are in, and there is no better statistical tool than the pretest probability (chance it is present) of the condition you are trying to diagnose or rule out. I usually think of pretest probability in three main categories:
• the problem is unlikely to be present,
• the problem is likely to be present, or
• I am not sure.

It helps me to ask two questions:
• Would I believe a positive or negative result?
• What would I do with a positive or negative result?

So if I swab someone’s throat for strep and they have a high pretest probability (red throat, fever of 102° F, no runny nose or cough, exposure to strep) a positive test would simply confirm what I know, while I’d wonder about the accuracy of a negative test. On the other hand, if the pretest probability was low (the person felt normal), I’d mistrust the positive result. It’s the exact same test, but the result is interpreted entirely on the pretest probability.

One more scenario in which a test is run is in the case of something that is low risk, but needs to be ruled out. This is generally done when the problem is too dangerous to miss (cancer in an adult, meningitis in an infant). It’s extremely important to have a very sensitive test in this case, that has a very low rate of false negatives.

4. To what end do people come in to see me as a doctor?

Back in the day when I was paid by insurance companies, the answer often was, unfortunately: “because it’s the only way I get paid.” There are many cases where the care could have been given over the phone, but that would shoot my business in the foot. Unfortunately, you can’t take care of people if you can’t pay your bills. Even though the business was not my primary goal in terms of priority, it was the highest priority in terms of order. I first had to have enough money to pay my staff, our office lease, my salary, and all the other expenses; then I am free to give care.

In my new world I am paid just the same if the office is empty (something that would have worried me in my previous life) than if it’s full. So why come in to be seen? There are really two reasons:
1. The patient wants to. Some people just would rather come in and talk to me. I am not sure if this is due to my sweet personality or some chemical imbalance on their part (just kidding, of course). That’s perfectly fine with me.
2. I can give better care by having them here. The physical exam is sometimes important. Sometimes I need to be able to look them in the eye when I talk to them.
5. To what end am I people’s doctor?

In my old practice the answer was often: to help them in case they are sick. The patient would probably say the same, with the addition of: so I can get medications and tests when I need them.

My new practice has two main goals:
1. To get my patients as old as possible.
2. To keep them as healthy and happy as possible while they do the old-growing.

The goal is no longer medical intervention, it is avoidance of care. The goal is not to treat problems, but to avoid them. The goal is not to order tests, but to not need them in the first place. The patient is my employer, and so my I do what keeps them happiest with my care.

And that’s a nice world to live in.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, 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.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, 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.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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