A New Model for Primary Care

by Academy of Clinical Excellence on February 21, 2011

There is currently a shortage in the number of primary care physicians and many are speculating that the demand will continue to exceed the supply in the coming years.

New models for primary care delivery are being considered and tested.

The attached article on primary care was in the the New York Times and it describes One Medical Group, a model for primary care that hopes to set a nationwide example and create a particularly appealing experience for both physicians and patients. The group is now serving communities in both San Francisco and New York. One Medical Group’s founder is Dr. Tom X. Lee, the physician who also co-founded Epocrates.

One Medical Group is attempting to offer most of the services provided by concierge-type medical practices with only a minimal additional cost to patients, $150 to $200 / year. While it is unfortunate that any out-of-pocket costs to patients are required to make this model work, One Medical Group is expecting that many patients who are dissatisfied with access to their physician will switch to seek care at one of their growing number of sites.

Please see the article that was in The New York Times for additional details:

http://www.nytimes.com/2011/02/01/health/01medical.html?src=twrhp

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Grand Rounds Report: Miller-Coulson Academy

by Academy of Clinical Excellence on February 2, 2011


Earlier this month, I had the immense privilege of being the psychiatrist on a panel, along with fellow Miller-Coulson Academy members Roy Ziegelstein (Cardiology) and Steven Schwartz (Surgical ICU), at the recent Medical Grand Rounds.With the expert input of another member of the Academy, Raf Llinas (neurologist), the panel was able to demonstrate several components of effective clinical reasoning.

Disclosure:Scott Wright, Director of the Miller-Coulson Academy, had contacted us three discussants the night before to give us a clue.He said, “I will present a case of a middle age male who was recently admitted to our hospital.”

The format of the round the next day was as follows:Dr. Wright gradually revealed elements of the patient’s story, stopping periodically for commentary from the discussants as the clinical story unfolded.He started by saying that clinical problem-solving exercises are “somewhat artificial” and can be “nerve wracking,” but a “very nice learning opportunity.”He was right on all three counts.It was like a high-pressure game show, except in front of a brilliant audience and a Hopkins dean.

True to his word, Dr. Wright began by asking each of us how we approach a complex patient case.I replied that I listened with an ear to understand whether the patient’s problems are emerging from something they have (biological origin), do (behavioral origin), are (personality origin) or have encountered (psychological origin).Dr. Ziegelstein remarked he always wanted to hear the patient’s story and do an examination, rather than relying on anyone else’s history and exam.Dr. Schwartz said his patients usually are not able to tell their own story, so he tries to look at the big picture, and as a first step, makes sure that airway breathing and circulation are intact.

I’m not going to present the case and the discussion in detail here, but will summarize the experience and encourage you to attend one of these in the future to witness the excitement first-hand.It’s not only an intellectually engaging time, but also one which showcases how to use the wisdom of colleagues.We first heard the chief complaint (dizziness followed by a fall), which raised questions for Dr. Ziegelstein of cardiac problems and for Dr. Schwartz of head injury.Then came the personal history (a never-married, socially isolated middle-aged paint salesman who lives with his sister), which raised questions for me of psychiatric issues.As the case continued to unfold, we learned that the patient began having tonic clonic seizures.The patient said he drank 2-3 shots of vodka daily (which Dr. Ziegelsten advised might be an underestimate).He had abnormal vital signs (elevated blood pressure and pulse) and diagnostic tests (elevated white blood cell count, 1st degree A-V block with left atrial enlargement and right subinsular hematoma on head CT).Although panel members noted these abnormalities, we were not distracted by them and remained open to a range of etiologies for the patient’s presentation, including cardiac, traumatic, neurologic, and psychiatric.

A turning point in the presentation came when Dr. Wright described the patient’s subsequent hospital course which was marked by a fluctuating altered mental status, agitation, and confusion. This is when I got really excited, as these signs, symptoms, and course are the hallmark of delirium: a psychiatric diagnosis.Now we just needed an etiology.Given the report of some alcohol use, the tonic clonic seizures, and the delirium, alcohol dependence and withdrawal seemed to be the most likely diagnoses for this patient.Dr. Wright, then, reported that the patient’s sister estimated his (the patient’s) alcohol use at upwards of 10 shots of vodka daily, these diagnoses became even more clear.With benzodiazepine treatment, the patient became less confused, stronger and could more safely ambulate over the last 5 days of his 10-day hospitalization and was transferred to sub-acute care for additional rehabilitation.

In addition to the Miller-Coulson Academy’s case presentation and discussion demonstrating how to approach a complex patient, how to use the wisdom of our colleagues, and how to avoid being distracted by abnormal test results, it underscored the basic logic of clinical reasoning.Clinicians are trained to recognize the clustering of symptoms, signs and course that define a clinical syndrome.Clinicians and biomedical investigators then proceed to identify the bodily pathology generating the clinical syndrome’s features, with the ultimate goal of finding the etiology (cause) of the pathology.Withdrawal from alcohol usually results in the hyper-alert, agitated, form of delirium, as seen in this patient. This form is more commonly known as delirium tremens (also known as DTs).

 

Margaret S. Chisolm, MD
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine


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DOCTOR’S DILEMMA

by Academy of Clinical Excellence on January 19, 2011

When caring for the patient collides with complying with the system.

He was hemiplegic with a tracheostomy needing a ventilator 12-16 hours a day. He was highly intelligent and a genius at fixing computer hardware and software problems - solving many problems for our staff, patients and visitors. He was also cantankerous and demanding, forcing us to agree to his schedule and needs. When we failed to do so, he would curse, throw things, and be verbally abusive to our nurses and staff. However, he finally settled down and we were able to adjust our routines to his preferences, which included not taking vital signs except when he permitted and allowing for an occasional “schnapps”. Under new rules from the State,he was transferred to a less acute skilled ventilator facility. Unable to adjust at the lower cost facilities, he died.

 

I am responsible for the care of patients, usually older and invariably frail, who have survived surgery and intensive care but remain ill and on life support (ventilators, dialysis, tube feedings and now left ventricular assistive devices LVADS). Some have end stage conditions requiring comfort and compassionate care at the end of life. Others can be liberated from artificial life support and return home. Yet there are some who, in limbo, require attentive care on ventilators for many years. They and their loved ones have elected to preserve life despite costs and adversity. The financial costs fall to insurance companies and when this support runs out, Medicare then Medicaid become the payers - which ultimately means the taxpayer.

The Department of Health and Mental Hygiene issued nursing home transmittal 202 April 11, 2006 which revised the criteria in the state of MD for chronic level of care that required patients not meeting the criteria should be transferred to lower cost centers, called ‘skilled ventilator facilities’. This sort of facility was where my patient was transferred. I resisted his transfer knowing how difficult it was for him to adjust but ultimately gave in. At our facility, he was engaged and content. One year after leaving our care - he died depressed and bitter. When I learned of his death and the misfortunes that fell upon him during his final year, I resolved to follow up personally all transfers similarly mandated by the State’s contractor under the new guidelines.

A total of 18 patients on my service have been declared “stable” ready for transfer to skilled ventilator facilities. Fifteen have died – often soon after their transfer. Currently,at the patients’ and their families’ urging, I have refused to move other patients declared “stable” and ready for skilled vent facilities. My decision was based on data - comparing survival of those declared “stable” and not transferred from our ventilator unit with those who were transferred. The resulting analysis shows a statistically significant increased mortality rate that is associated with the transfers. This follow up information suggested that the criteria and processes for deciding who to transfer was flawed.

Armed with this follow up data, I have not agreed to transfer patients against their will, or the wishes of their of loved ones.I have worked with legal aid of Maryland to defend my patients against these seemingly arbitrary criteria, and have since gone to the Administrative court, subpoenaed by my patients, to appeal the decisions for transfer. Only one patient won her case, but later lost in an appeal in the Circuit Court. In the course of this contest, the state has made some minor modifications in the paper guidelines which define “stability” but have not agreed to see the patients or their families. As might be predicted, these changes do not adequately address the problem.

 

Our facility is losing financial support for those patients who have refused to be transferred and suffers substantial financial hardship with the threat of not being able to continue to support ventilator patients should losses escalate. The administration, though under great pressure fiscally, has supported my decision not to comply with transferring out patients termed “stable” by the State’s contractor when they and their families have refused to be moved. However, the pressures on our “not for profit” facility continue to escalate.

In long term care, staff (including physicians, nurses, and others) come to know patients and their families’ very well - with a sense of caring and protection that often goes well beyond what can be established in acute care settings. To practice best care, one must know what happens to our patients in the current health care system when they are transferred through the many series of “silos” which they must pass. Decisions for transfer not based on follow up data may result in injuries, rehospitalization, or death. Truly caring for ones patients’ demands knowing what happens to them; sometimes this requires collecting the critical data that others will not. This is what has become necessary if we are truly committed to clinical excellence in our system in which subcontractors and insurance operatives who have never seen the patient are making the decisions.

William B. Greenough III, M.D.
Professor of Medicine
Division of Geriatric Medicine
Johns Hopkins Bayview Medical Center

 

 
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Doctors Who Put The Patient First

by Academy of Clinical Excellence on January 5, 2011

My colleague, Dr. Colleen Christmas, sent me this letter that she sent to another physician. She wanted to share what happened and her gratitude to the doctors who had made it possible. Too often these stories go untold, enjoy:

 

Dear Dr. Kang,

I am a geriatrician here at Hopkins for the past 14 years, and never have I been more proud of the collaborative and innovative spirit here as I was yesterday, thanks to Drs. Hinds and Wang.

I care for a patient who is bed-bound with a very painful squamous cell carcinoma (SCC) on his ear. We tried using narcotics to keep him comfortable but he had a lot of toxicity with that, so I tried getting him in to see a dermatologist in hopes he could have some palliative treatment. Unfortunately, in trying to get him in for a derm appointment his daughter dropped him trying to get him out of bed and he broke his fibula. This resulted in an overnight stay in the hospital and a quick biopsy of the lesion demonstrating the SCC pathology. The derm team then advised he would need to come in for a plastic surgery appointment despite my insistence that it was too dangerous to try to take him out of the home again and we were really looking for palliation. Thank heavens I was then introduced to Ginette Hinds who was willing to think way outside of the box with me. She and Tim Wang made a house-call with me last night and resected the lesion at the bedside, which he tolerated very well, and the family (and I) was incredibly grateful.

Once, about a decade ago, I cajoled an orthopedics resident to come make a home visit with me, but I am quite certain what happened last night has never happened here before, and probably nowhere else either.

Tim and Ginette, I will be waiting to return the favor somehow.

Happy holidays,

 

Colleen Christmas, MD

Program Director, Johns Hopkins Bayview Medical Center

Division of Geriatric Medicine

Division of General Internal Medicine

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Grand Rounds Report: Clinical Pathologic Conference

by Academy of Clinical Excellence on December 22, 2010

Of all the formats of Grand Rounds, Clinical Pathologic Conferences (CPCs) are my favorite as they move through a nice progression of a resident presentation of clinical data, followed by a discussion led by a scholarly physician, and finally ending with a pathologist who provides the punch line (that is hopefully the answer provided by the scholarly physician).This past week’s Grand Rounds followed this pattern, but provided more clinical acumen than usual.

There was a unique aspect from the start, as the widow of the unfortunate deceased patient was in the audience.She was introduced at the start and spoke most eloquently at the end.The case was that of a 52 year old man who presented with a few day history of a seemingly innocuous upper respiratory infection that progressed to more significant right ear and neck pain.Once admitted to the hospital, neck swelling became quite prominent and imaging showed a massively enlarged thyroid.Despite broad spectrum antibiotics, the patient developed sepsis and died.

The discussant was Dr. D. William Schlott, Philip A. Tumulty Associate Professor of Medicine.His discussion was led off by his reminiscing about how it had been 50 years since he first had been at Johns Hopkins Bayview Medical Center (then Baltimore City Hospital) as a medical student.He discussed how from early in his career, he was always encouraged to go see patients (even if he was not caring for them) who had an unusual physical finding or an unusual illness.He related that he had never seen a patient presenting like the current case, with massive thyroid enlargement and a picture of sepsis.

When charged with figuring out the case, he first turned to the internet, to peruse the literature.He was fairly certain the diagnosis was suppurative thyroiditis, but to make sure, he took a crucial second step, “turning to a partner in medicine.”He sought out who he believed was the best clinical radiologist and had him look at the patient’s neck CT with him.The radiologist agreed with the diagnosis and was able to point out findings specific to the diagnosis.However, at the same time, Dr. Schlott did caution that too often physicians rely on imaging, rather than clinical sense.

This was one of those Medical Grand Rounds that made me reflect on the beauty of medicine.Even after 50 years of practicing medicine, a master clinician had just discussed and made a diagnosis of something he had never before seen.

Please share comments.

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How Do You Put “Relationship” on a “Sign-Out”?

by Academy of Clinical Excellence on December 8, 2010

Dr. Charles Rammelkamp, my mentor at Cleveland Metropolitan General Hospital, taught my class of residents the importance of the continuity of relationships in the care of patients.Our firm cared for patients both in and out of the hospital.If “your patient” wasn’t followed by you personally, he or she was followed by a member of your team, essentially a small group practice.

Rammel, as we called him, taught us that relationship is the most powerful tool in our black bag.The institution of resident duty hour rules along with the imminent tightening of these rules, the increasingly shortened patient lengths of stay in hospital, and the burgeoning documentation and regulatory requirements have seemingly changed the delivery of care in academic settings and have eroded the time available to spend at the bedside and in the clinic-- time that is all important for building a therapeutic relationship. “Continuity” has been replaced by “episodes of care” linked, but quite tenuously, by discharge summaries and“sign-out” lists. The Joint Commission’s National Patient Safety Goals Standard on hand-off communications notwithstanding, I haven’t figured out a way to put “relationship” on my sign-out without either burdening my colleagues or sewing discontent with the patient and their family.

I lost a patient recently.He was particularly special to me.Our relationship had transcended cultural and religious differences.We had shared celebrations and then several weeks ago his family and I had to endure his sudden death at the end of a complicated hospitalization that spanned multiple hospital services and teams.He and his family sought my counsel at every juncture even when I was “off-service”.I would not have done anything differently therapeutically from what my colleagues did during his hospitalization but the “hand-offs” and my input did not and could not include the relationship that had been forged over time, through adversity and celebration.In the end only I could guard him, not leaving him alone. It was left to me to tell his family of their loss and to try to console them.For me, it was an inconsolable surreal scene.The “covering” team could not manage that transition of care.

Please share your thoughts.

Edward Kraus, MD
Division of Nephrology
Johns Hopkins University School of Medicine

 

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Grand Rounds Report: A Great Two Strike Hitter

by Academy of Clinical Excellence on December 3, 2010

Roy C. Ziegelstein, MD, along with Reda E. Girgis, MB, BCh and Kathleen T. Grieve, RN, BSN, MHA, CC presented at Grand Rounds this week “A Great Two Strike Hitter”.Mrs. MB, an 83 year old patient who was kind enough to share her experiences in person, and the presenters discussed Mrs. B’s experience living a long and productive life despite complications of rheumatic heart disease requiring surgery twice for mechanical mitral valves in adulthood (strike 1) and GI bleeding in the setting of life-long anticoagulation for that mechanical valve (strike 2).

Mrs. B related how she was “extremely sick” when she was 6 years old.The doctor heard a heart murmur and told the mother that he did not expect Mrs. B to reach her 18th birthday.Mrs. B did, obviously, make it to her 18th birthday, and lead a successful and productive adult life.She had a daughter, and did well until she reached her forties, when atrial fibrillation developed.She was found to have severe mitral valve disease and severe pulmonary hypertension in 1977, and underwent surgery for her first mechanical mitral valve.

 

The next 20 years were “good ones” for Mrs. B, but by 2003 her she was experiencing shortness of breath with minimal exertion, and episodes of syncope.Her first mechanical mitral valve showed severe stenosis by catheter, and her pulmonary artery pressures were 100 mmHg.Despite the high risk, she underwent a re-do of her mechanical mitral valve, with the hope that her high PA pressures would resolve, at least in part with improvement in her mitral valve function.She did well surgically.Unfortunately, her episodes of syncope continued, as did her very high PA pressures.This leads us to the first clinical pearl: left heart disease accounts for 80% of pulmonary hypertension.Left atrial pressures drive pulmonary hypertension.Fortunately, experimental treatment with an edothelin receptor antagonist (bosentan), improves her symptoms.

 

Six months later however, she developed GI bleeding.Mrs. B required multiple, multiple transfusions, but EGD and colonoscopy could not find the source.Enteroscopy to the jejunum and capsule endoscopy are negative.She was initially assumed (and later confirmed by enteroscopy) to have bleeding AVMs.This leads us to the second clinical pearl: 5% of patients with GI bleeding have no source identified, and this is called GI bleeding of obscure origin.Most of these patients are bleeding from the small bowel, and commonly from AVMs.Mrs. B also had moderate to severe aortic stenosis, leading to the third clinical pearl: Heyde’s syndrome, or AVM bleeding associated with aortic stenosis.Heyde’s syndrome is thought to represent an increased tendency to bleed, rather than an increase in AVMs.

 

The fourth clinical pearl is AVM growth may be related to increases of vascular endothelial growth factor, or VEGF and Thalidomide and its analogue lenalidomide (Revlimid) may be an effective treatment.Mrs. B did well for two years on Thalidomide treatment, but eventually it had to be withdrawn due to peripheral neuropathy.

Lastly, the presenters showcased how patient centered care (in this case using the Guided Care model), with tight coordination of outpatient resources, including physicians, nurses and even infusion centers can avoid hospitalizations and improve patient outcomes. Mrs. B was able to avoid hospitalizations, by getting close oversight and even blood transfusions as an outpatient. This leads us to the fifth and final clinical pearl: Patient-centered, coordinated care may have significant benefits to patients with chronic illness.


Please share your comments.

Eric E. Howell, M.D.
Division Director, Collaborative Inpatient Medicine Service
Division of Hospital Medicine
Johns Hopkins Bayview Medical Center

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Counseling and Consultation Time

by Academy of Clinical Excellence on November 17, 2010

 Is there anything that we give our patient that is more valuable than our time? We are encouraged to see patients for shorter and shorter periods of time, but time is the one thing that our patients really appreciate. I see a lot of patients referred by other physicians who've seen outside neurologists.I've yet to see a patient who didn't receive: a reasonable work up, a reasonable differential and nice concise note.But most patients say the same thing, "he didn't spend time with me”, “he didn't explain what was going on”, "he didn't tell me why this is happening to me”.

At the request of one of my favorite internal medicine faculty I called a patient I've never seen before in Arkansas who had just been given the diagnosis of ALS. I saw the records, the thought processes, and evaluation, were all correct. Every ‘I’ dotted every ‘T’ was crossed correctly.That's what he has, ALS.I called him while I was driving into work one morning during some particularly bad traffic. He and I spoke for about 45 minutes. He told me all about himself. How worried he was that his illness would decimate what he's able to leave his wife and family financially and about how we plan to work until the very end. He also told me a story about something he said to his neurologist. He told his neurologist that since he had such a rare and unusual type of ALS that maybe the neurologist should be paying him. I burst out laughing. The man told me that his neurologist didn’t even crack a smile.

It is said that William Osler, MD could spend five minutes with a patient and make them feel like he had spent an hour. Perhaps this was the surest sign of his genius and his most important contribution to the patients who taught him everything he knew.

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Rafael H. Llinás, MD
Associate Professor of Neurology
Johns Hopkins University School of Medicine

 

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A Smile

by Academy of Clinical Excellence on November 11, 2010

I had known him for a few months, when, for the first time, J greeted me with a smile. The persistent sad veil over his eyes had lifted. This simple facial expression changed my whole day.

J is from Central America and was hospitalized with what turned out to be disseminated tuberculosis affecting his lungs, liver, lymph system and gastrointestinal tract. At the same time, he was discovered to have advanced HIV and with a very low CD4 count and a viral load off the top of the scale. At discharge, it was arranged for him to have follow-up at the Baltimore City Health Department for his tuberculosis treatment which would entail directly observed therapy. The Health Department had contacted me to provide ongoing health care, especially related to his HIV diagnosis.

When I met J, he had finished about four weeks of tuberculosis treatment. He spoke no English and my medical school Spanish knowledge has definitely diminished over the years. We used a phone interpreter to help. I often felt a bit perplexed using the interpreter as J’s three minute responses sometimes became one sentence in English from the interpreter. J and I built rapport, but with the language barrier, it was not quite the same.
J had a family in Central America and was here working. He could not apply for medical assistance as he had no “papers”. We could provide him health care using our Ryan White Grant. Even with the grant, we needed to establish his residence in Baltimore City. On his second visit, he brought in a paper certifying that he “lives in Baltimore City with 3 amigos”. It was good enough for me.

Being treated for disseminated tuberculosis, J never felt well. It took several weeks, but slowly his fatigue and night sweats went away. He still weighed less than one hundred pounds. Four weeks into tuberculosis treatment, I initiated anti-retroviral treatment for his HIV. He developed immune reconstitution syndrome and felt terrible all over again. With a lot of encouragement and some prednisone, he finally was feeling better.
J had gained eight pounds since I last saw him and this was easy to see. I did not need an interpreter when he said happily, “Me siento muy bien.” We talked more and before leaving to have his blood drawn, he thanked me repeatedly and gave me a hug.

When I think about this patient now, I can still feel that hug and it reminds me that continued effort and encouragement can make all the difference for a patient and can help them to smile again.
Please share your thoughts/comments.
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David Blumenthal, MD, MPP, who serves as the National Coordinator for Health Information Technology, under President Barack Obama, spoke at Medical Grand Rounds this week.

Dr. Blumenthal’s objective in his role within the U.S. Department of Health and Human Services is to “build an interoperable, private and secure nationwide health information system and support the widespread, meaningful use of health IT”.
In the talk, he shared information about his background as a primary care physician and how this has influenced his view of information technology within healthcare; Healthcare I.T. makes one a better physician.
He shared two examples from his days as a primary care physician to illustrate this:
In caring for a patient diagnosed with a urinary tract infection, he input the medication that he had prescribed into the system Sulfamethoxazole/Trimethoprim and received a notice that the patient was allergic to sulfa. As a result of access to this information in real time, he was able to quickly change the prescription, averting a potential serious allergic reaction, before the patient left the office .
For another patient, he was ordering a test and the system alerted him to the fact that a similar test had been done for this patient within the last three months. This notification made him rethink the indication for the test and he ultimately elected not to order it. The resultant monetary savings for the system, and avoidance of additional patient exposure to radiation was beneficial to all parties.
The talk also included published studies proving that healthcare I.T. provides the opportunity to upgrade our health care delivery system: Quality goes up and costs go down with limited compromise of clinical autonomy.
Another interesting assertion was the notion that using electronic medical records routinely may become a marker for professionalism in medicine. Dr. Blumenthal explained that physicians who choose to practice without a tool that can enhance quality and safety, the electronic health record, may be breaching their commitment to our professional standards.

For more information on EHR’s:
http://patients.about.com/od/electronicpatientrecords/Electronic_Patient_Health_and_Medical_Record_Keeping.htm

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