Fungible

 

Health care is moving to assembly line medicine which means that physicians are completely interchangeable, or fungible, entities. This does not mean that people will get poor care, but it does mean that the role of the physician has changed from cultivating relationships to following algorithms. In the long run, those attracted to a medical career will be a different personality type than those in the past, as following algorithms is a different skill set than feeling the pleasure of healing relationships. I understand the value of fungibility, yet I am sad about this change.  Adapt or die, comes to mind, and so I will adapt.

 

 

 

 

Fungibility is the property of a good or a commodity whose individual units are capable of mutual substitution, such as crude oil, shares in a company, bonds, precious metals, or currencies.

It refers only to the equivalence of each unit of a commodity with other units of the same commodity. Fungibility does not describe or relate to any exchange of one commodity for some other, different commodity.

As an example: if Alice lends Bob a $10 bill, she does not care if she is repaid with the same $10 bill, two $5 bills, a $5 bill and five $1 bills or bunch of coins that total $10 as currency is fungible. However, if Bob borrows Alice’s car she will most likely be upset if Bob returns a different vehicle–even a vehicle that is the same make and model–as automobiles are not fungible with respect to ownership. However, gasoline is fungible and though Alice may have a preference for a particular brand and grade of gasoline, her primary concern may be that the level of fuel be the same (or more) as it was when she lent the vehicle to Bob.

 

http://en.wikipedia.org/wiki/Fungibility

 

 

Automated Medicine Versus Personalized Medicine…Narcissism Versus Self-Care

 

Financing health care fascinates me. So many folks who have private physicians resist changing to a health maintenance organization because they will lose the “personal touch”. I, who have advocated for the value of the physician/patient relationship, am always shocked by this choice. Sally, fifty-one, for example, spends $1500.00/month for her and her husband to maintain their physicians. This number represents their premiums, not their co-pays, or deductibles. The could spend half if they switched to an HMO, and finances are really tight for them. Plus, she and her husband are healthy, and rely on their physicians only for yearly check-ups. Still, the notion that they can call Dr. Lee, and Dr. Lee knows them, means so much to Sally, that she steadfastly refuses to change carriers. “What if the quality of health care was the same at an HMO, perhaps even better, would you still consider switching?” I ask, Sally, curious by what might be a sense of narcissistic pleasing, which comes with more personalized medicine, as is the difference between levels of service at three star versus five star hotels. “I don’t know. It just feels bad for me to switch, so I cannot think of it.” Sally says in a dismissive way, although I am also aware that her initial reaction to my comment is one of negativity, she often gives it deep thought. We, as a society, get used to a certain level of service, making it very difficult, even in the face of financial hardship, to go down to a system which meets the goal of good health care, without the special treatment of someone knowing your name and your family circumstances.  Personalized care is often mistaken for better care. Automated care might not appeal to one’s narcissism, but it might get the job done. The rules of business prevail. Making people feel good sells. Outcome measures, or hard data, does not sell as well. Concierge medicine works on this principle. Business minded folks understand the rules. The public, unless mindful, are vulnerable to financial hardship as a result. The Affordable Care Act will bring these notions into the foreground. The change in level of service will be interesting to observe. The doctor/patient relationship will still be there, but it will be expensive. Service costs money.

PMDD Walks Into DSM 5

 

PMDD, premenstrual dysphoric disorder is currently a diagnosis in the appendix of DSM IV, meaning that if a physician believes the patient has PMDD, then he/she must write Depression NOS (not otherwise specified). At the same time, there are currently drugs approved for PMDD, despite the fact that it has not achieved diagnostic status. Well, come May, 2013, after Bill Clinton speaks to the American Psychiatric Association in San Francisco, California, the DSM 5 will be announced and the criteria for mental illnesses, in the United States, at least, but probably around the world, will change, including more folks, causing a large stir about the wider scope of psychiatric disease.  DSM IV came out in 1994, making almost ten years of a classification system, which for the most part, has not matched the explosion in psychopharmacology. DSM 5 has taken a long time, mostly, as I can tell, because the debates over the diagnostic system were tense. So, it is very likely that PMDD will hit the light of day and now women who suffer from terrible irritability before their periods will merit a psychiatric diagnosis. The good news is that there will be more acceptance of the biology of mood swings, and then hopefully more acceptance of psychopharmacological interventions. The bad news is that some women, through no fault of their own, will be labeled, potentially increasing their premiums for health insurance, life insurance and disability insurance. The triad of emotional lability, irritability and anger, during the luteal, or last phase of the menstrual cycle, in about 2-5% of menstruating women, had been validated in the research over the past 20 years. This additional research, the DSM 5 committee argued, gave good reason for PMDD to be “promoted” to  a diagnosis and out of the appendix. PMDD now joins the ranks of a full blown mood disorder; it is in parallel with bipolar disorder, which also has prominent mood lability and irritability, but PMDD symptoms cease on the first or second day of menses. Plus, PMDD comes with physical symptoms of bloating and breast tenderness, making it easily distinguishable from bipolar disorder. What about heritability? You ask, knowing that most psychiatric diagnoses run in families. The heritability of PMDD ranges from 30-80% which is indeed, a wide range, but enough to merit a full diagnosis. What about treatment? PMDD is ameliorated with an SSRI (Prozac and his cousins), quickly, unlike when an SSRI is used to treat Major Depression. Also, intermittent or continuous treatment are both helpful, suggesting that a constant blood level is not necessary, but rather more serotonin in the premenstrual or late luteal phase, seems to do the trick. So, the world will change in May, 2013, the psychiatric world, that is, and hence all of us who work, love and/or experience others who suffer with negativity, irritability, and quickly shifting moods. Now, women who cycle in and out of these mind states will be legitimized on the one hand, and maybe, but hopefully not, stigmatized, on the other.

The Embedded Psychiatrist

Oh, no. Psychiatry is heading towards another turn and once again, I am deeply concerned. As I understand the future of psychiatry, according to my highly respected colleagues, is that psychiatrists are now going to be ”embedded” in primary care offices where they may or may not see the patient, but they will consult on the diagnosis and psychopharmacological intervention for patients that are seen by nurse practitioners and primary care physicians. Now, understand, that I work in primary care, and I am a strong advocate that primary care physicians should have psychiatrists to consult with on their cases, but this does not mean that the psychiatrist should not have the ability and skill set associated with deep listening to patients and understanding the nuances of a good evaluation. My concern is that the psychiatrists of tomorrow will help primary care physicians prescribe psychotropics, without developing the tools of listening to patients and having continuity with patients. Psychiatrists will mostly be trained to consult, without having direct patient care responsibilities. Once again, this will change the field, both in terms of how it is practice, and in terms of who is attracted to this kind of work. In essence, the doctor/patient relationship, the most valued aspect of the treatment, will disappear from the field of psychiatry. I have previously posted about the development of a psychiatrist, strictly as a psychopharmacologist, has minimized the doctor/patient relationship, but this new development, where the psychiatrist is strictly a consultant, takes my issue into a deeper concern. I wonder if history taking and relationship building will be a lost art in medicine. I certainly hope not.

 

See also…http://shirahvollmermd.wordpress.com/2010/11/08/patient-centered-medical-home/

The Fatigue Question

“I am so tired,” Melanie, thirty-two, says at the beginning of each visit, twice a week, for the past year. “I think you should go to your primary care physician to check that out,” I say, repeatedly. “I don’t want to go to the doctor. He is going to tell me I am crazy.” Melanie says, inviting me to argue with her. “Well, what if you tell him that I thought you should go?” I respond. “Oh, I don’t want him to know I am seeing a psychiatrist. Then, he will really think I am crazy.” Melanie says, reminding me that I am part of her secret life. She does not wish to disclose our relationship to anyone. “Why do you think you are so tired?” I ask, probing to see whether she thinks her fatigue is secondary to her mental state. “I think I have a blood disorder of some kind, but I am too reluctant to check that out.” Melanie says, knowing that I will be frustrated by her comment. “If you do have a blood disorder then you could feel much better if it were treated,” I say, stating the obvious, but feeling like it needed to be said. “I know that,” she responds impatiently. “How can I help you?”  I ask, pointing out that she has put me in a bind. “I know you are not a primary care doctor, but I wish you could order the lab tests,” she says, almost begging me, but knowing that I won’t do that. “Well, even if I did order the tests, I would need a primary care doctor to review the results with me,” I say, again, stating the obvious. “I know. Forget I asked. I will just be tired all the time,” Melanie says, firming up her original position. “That’s a shame,” I say, pointing out that she is not taking care of herself. “I know,” Melanie responds with tears in her eyes. “I wish I knew how to take care of myself,” she says with deep feeling. “Well, maybe I can help you with that,” I say, reminding her that is one of the reasons she comes to see me. “You are just one of the few people I trust,” she says, reminding me that one of her reasons she is reluctant to pursue a work-up of her fatigues is a basic mistrust of most people. “So, maybe you can use your trust in me to mobilize you to see a primary care doctor, since I think it is important that you go,” I say, trying to use our relationship to mobilize her to constructive action. “Maybe,” Melanie responds, sounding a bit more open to the idea.

‘Nonessential Medications:” Another Rant

Teaching Primary Care Residents, I learn so much. I also get frustrated, angry, and fantasize about going on the rooftops to let others know of my unhappiness. “Sometimes, when a patient comes in the hospital, and we are not sure what is going on, we stop the SSRIs and all the nonessential medications to see what is going on with the patient,” an excellent, smart, hard-working resident says to me. “Who says the SSRI is nonessential?” I ask, thinking that no one is checking in with the patient to see if he feels their SSRI is “nonessential”. “Well, you know, it is not life and death,” he says, understanding my discontent. “No, it is usually not life or death, but it is quality of life, and this can determine if the patient is motivated to help himself get better,” I say, knowing that the resident does not need an education about the importance of SSRIs, but that he is reflecting back to me the feelings of the team-the medicine team, composed of interns, residents and attendings. “I am sorry,” I say, “but I think that behavior suggests a dismissiveness to mental health. I think that the team is believing that SSRIs are relatively trivial medications and so they can be stopped, similar to vitamins.” He agrees, but looks at me with some sense of regret for bringing this to my attention because he can see my upset. I wonder how to push through this arrogance, sometimes seen in primary care, where they believe that physical health trumps mental health, every time, as if they are not closely linked. Medicine, as a field, has a lot of room for growth. Openness, as with all growth, has to be the first step. For now, I am stuck.

The OBGyn Finds High Cholesterol: Now What?

Continuing on our discussion about referrals, http://shirahvollmermd.wordpress.com/2010/07/07/the-referral/ and http://shirahvollmermd.wordpress.com/2012/02/27/why-dont-pediatricians-refer-to-child-psychiatrists/, Olivia, seventy-two, presents to me for issues of depression and anxiety. In the course of thorough history taking, we review her medical problems. She is remarkably healthy, absent major medical issues and she is trim and fit and active with a good energy level. We review her treating physicians. Dr. Lesley Lee, a prominent female OBGyn in the community has followed her for years for routine gynecological examinations. Twenty years ago, Dr. Lee noticed on the laboratory tests that her fasting cholesterol was high so Dr. Lee referred her to Dr. Jay, a prominent female cardiologist. “Why did Dr. Lee send you to a cardiologist?” I asked, shocked that Dr. Lee did not send Olivia to a primary care physician. “Well, I don’t know, that is just who she sent me to,” Olivia replies, indicating that she never considered this question before. “Do you have a primary care physician?” I ask, trying to mute my concern for this referral pattern. “No, I did not think I needed one,” Olivia replies, again, seemingly disturbed that I am intruding on her medical issues. Over time, we discuss the importance of primary care and over time, Olivia agrees to go to a primary care doctor that her friend raves about.

I am left to imagine why Dr. Lee sent Olivia to the cardiologist, Dr. Jay. Both physicians are female. Maybe they are friends. Maybe they go to female networking breakfasts. Beyond that, I cannot imagine why a healthy woman, with the only abnormality being an elevated cholesterol should not be referred to a primary care physician, so that diet, exercise, and maybe statins can be discussed in the treatment plan. Clearly a primary care physician can screen for heart disease, diabetes and other metabolic issues. The public health aspect of this referral also concerns me. Dr. Jay as a cardiologist needs to spend her precious time on those who need specialty care, not on those who can be handled by Internists of Family Medicine physicians. Are we, as physicians, not obligated to be concerned about how we use our resources in the best possible way, not just for the patient, but for the population as well? Sometimes, I feel so old-fashioned. Still, old ideas are not necessarily bad ones, as I have said many times.

What can I do? I ask myself. I can try to persuade Olivia to develop a relationship with a primary care doctor. Yep, I did that. Should I call Dr. Lee and discuss my issue with her? I don’t think so. I don’t have a relationship with Dr. Lee and I am not sure I know how to make that call without making her defensive. Should I call Dr. Jay and discuss my issue with her? Again, without a personal relationship, I only stand to make her angry and upset. So, this post serves as my outlet for my discontent. Thanks readers for allowing me to vent.

Electronic Medical Records: Do You Want Fries With That?

  The Affordable Care Act, the digitization of our world, and the changing delivery of health care all comes together to roll out electronic medical records, now active at Kaiser, and soon to be active in almost every primary care setting, certainly by 2014. To be clear, I think that this will be a net positive for patient care. Medical information will be helpful to emergency room visits, doing health maintenance, and tracking prescriptions. I am optimistic about the benefits for the vast majority of patients who now have fragmented care, or no care at all. My concern is how will electronic medical records change the joy in the practice of medicine. Will taking care of patients retain the fun, if a menu comes down for every patient, reminding the provider to remind the patient to wear his seatbelt when he drives in his car? Again, I think it is a good idea, and it will help, for the computer to prompt the physician to remember preventive medicine questions, as preventing accidents, for example, is a very important part of health care. Now, though, that conversation, stems from a general concern for the patient, usually discussed, at a visit where critical medical issues have already been addressed. Yes, of course, the computer eliminates the human error, inherent in trying to remember too many things, especially when the provider has too many patients. At the same time, the fun in patient care, at least for me (and I am not a primary care doctor, I understand that) is the spontaneity of conversation, which is based on a deep training of important questions which are well-timed to the moment of most open communication. For example, there is a big difference if you tell a patient to stop smoking in a rote fashion, as opposed to telling them to stop smoking after they just told you that their uncle died from lung cancer. I fear that this art of persuasion will be lost with the advent of electronic medical records. In so doing, I fear the fun of patient care will diminish considerably. Sure, there is an upside. Efficiency is going to make the doctors feel better, as inefficiency, in the current system is degrading and demoralizing to physicians. Balancing it out though, I still fear that this roll out will be a net gain for patients and a net loss for providers. As with so many of my grim predictions, I really hope I am wrong.

Medical Aggravation

  Lew, thirty-three, has a rare genetic disease requiring pre-authorization for a very expensive medication which he takes by mouth once a month. He switched insurance companies because his wife lost her job, and so now that she has a new job, Lew has new insurance. Consequently, Lew had to find a new primary care physician. This physician has to connect with Lew’s insurance company to state the reason Lew needs this medication, even though Lew has been taking this medication his entire life. Doctor Lippe, a male, newly trained primary care physician, is quite personable and seemingly sensitive to Lew’s needs. Yet, the authorization does not go through and Lew begins to experience vague, non-specific complaints of fatigue, joint pain and headaches. Lew believes his insurance company is to blame, but upon further research, he discovers that his physician never filled out the needed paper work. “You need to get another primary care physician,” I tell Lew, with uncharacteristic directness. “You need a physician who will be your advocate and follow-up with the details of medical work.” I say, sharing Lew’s frustration and aggravation about this critical, although not life-threatening, delay in care. Lew has a hard time understanding my point of view. “He is so nice,” he repeats. “It is hard for you to see that Dr. Lippe might be nice in his office, but the lack of follow-through could be a bad sign for more urgent matters down the road. ” I say, forcefully and unequivocably. “Yes, it is hard for me to see that a physician might be lazy, or not motivated to help his patients, or inattentive to details,” Lew says with uncharacteristic naiveté. “Well, they can be,” I say, with such  obvious frustration about Lew’s poor medical care. “I have to think about this,” Lew says, with agony, partly because he is without his medication, and partly because of our intense discussion. “One issue is that because you did not get your medication, you are in a compromised position to advocate for yourself.” I say, understanding and articulating that medically vulnerable people are doubly hurt because first, their bodies betray them, and second, they are less able to defend themselves against incompetency and unnecessary delays. “Yes, it is hard for me to think straight right now,” Lew says, understanding his vulnerability. “I am so sorry about that,” I say, again feeling the frustration of the health care system.