Dear Santa

I realize that you’re very busy this time of year, and that getting my list to you at this late date is more than a little inconsiderate. I also recognize that as an adult, I’m not necessarily entitled to the same level of attention as my shorter, younger peers.

But I’m young at heart (sounds better than “immature”), and hell, there’s no harm in asking. Sure, maybe there’s roughly 0% chance that my daughter will wake up Christmas morning with wings, but did that stop her from asking you to turn her into a fairy for Christmas? No, it did not.

And with that, my list. I humbly request:

A new stethoscope. A nice one, please. I’m partial to teal, but any color will do.

A stack of post-its, with sticky stuff that actually sticks (no cheap pharmaceutical freebies, please) and which somehow resists “disappearing” at the hands of nameless, faceless desk thieves in the night.

A breast pump that somehow manages to extract more than my large hungry baby can handle before the patient in the exam room next door gets impatient and/or curious about the strange sound coming through the wall.

Scheduling staff that understand that those patients that seem the most hesitant to state the reason for their appointment are probably the ones who are most need of our long appointments, and are willing to schedule them accordingly.

An administration that realizes that there are ways to measure quality of care beyond how quickly a patient is moved from the waiting room to the exam room.

A new lab coat. Just cuz my old coat’s getting pretty dingy.

A bottomless supply of Plan B to hand out to anyone who wants it.

An EMR that magically connects to every other medical record in the city, seamlessly integrating patient care across facilities and providers. If my kid can ask to be turned into a fairy, I can ask for this.

A puppy.

(JK, Santa! I don’t have the time or money for a puppy. But the other stuff would be swell.) (Really, whatever you can do would be great. I’ll settle for a box of chocolates and one free lunch sometime in March. No pressure.)

Respectfully,

Down with templates

Problem with the computer

As noted previously, I love electronic health records. I love them despite their many (many) problems because I truly believe that most of these problems are fixable. In order to be fixed, however, one must clearly and persuasively identify what the problems are. So that the healing – er, fixing – can begin.

What follows is an example of one of my top issues with EHRs. This is the entire HPI for a note I recently stumbled upon, verbatim (minus any identifying info, obvs):

“sexual health history:
19 year old female presents with c/o Female reproductive OR GYN category  Engages in sexual intercourse with  Both, Last sexual encounter   about 1.5 mos ago, Number of different sexual encounters/partners in the past six months  1, Currently sexually active with  Not currently active, History of vaginal intercourse: If yes, are condoms used?  Always, History of STIs testing:  Yes, History of STIs:  No, Pregnancy prevention practices:  Yes male condoms.

Genitourinary female:
c/o menstrual cycle normal, LMP 1/9.  c/o frequent urination for few days daytime and night time, urgency.  c/o vaginal symptoms for few days itching, foul smelling discharge.  c/o burning w urination.
Denies : abdominal pain. fever. hematuria.
c/o R lwr back pain.

GYN:
Denies : abnormal vag bleeding. “

What are the chances that someone actually wrote this? Meaning, someone’s brain decided to assemble these words into these patterns, pretending to have produced coherent sentences? Roughly zero, right?

Thank you, templates. You are responsible for this complete abomination of medical documentation.

Seriously. “Presents with c/o Female reproductive OR GYN category”? “Currently sexually active with  Not currently active”?

WHAT DOES THAT EVEN MEAN? WHAT DOES ANY OF IT MEAN?

I mean, it sounds like she’s here with a few days of dysuria, urinary frequency, vaginal discharge and itching. I get that. But it takes far longer than it should for me to get there. And that sexual history is a mess. And – most importantly to me – THESE ARE NOT REAL SENTENCES. They shouldn’t pretend to be.

If you want to use templates for your review of systems, fine. If you want to use them for your physical exam, fine. If you want to use them to review patient education materials provided, fine. I won’t love any of it, but I’ll tolerate it.

But I just cannot get on board with using templates for the HPI. The History of the Present Illness is what the patient tells you about how they ended up sitting in front of you today. It’s a story, a narrative. To give that story justice, it should be documented accordingly. Huge swaths of meaningful information are completely lost when your patient’s narrative is reduced to a bunch of little buttons clicked clicked clicked – “present” “absent” “denies” “yes” “no”… NO. Hate doing it, hate reading it.

Am I missing something? Does anyone have a defense of the template-based HPI?

Anyone?

Bueller?

But seriously, if you’re in love with HPI templates and consider them to be demonstrably superior to free-texting (a.k.a. WRITING) the HPI as a narrative, please, clue me in on how you’re making this work for you.

As long as your HPIs don’t look like this one. Because if you consider that mess to be superior to anything beyond tossing a bunch of Scrabble tiles in a pile and then randomly lining them up, then I’m not sure I can trust anything you have to say.

The care we want vs. the care we need

prescription

Alternative title #1: Why healthcare and retail are fundamentally different industries

Alternative title #2: The customer isn’t always right

Alternative title #3: PLEASE FOR THE LOVE OF GOD STOP DEMANDING ANTIBIOTICS YOU DON’T NEED

**********

When it comes to talking to patients about whether they need an antibiotic for their upper respiratory infection, I think I have a pretty decent spiel, wherein I spend boatloads of time talking about viral vs bacterial infections, and changes in clinical practice and evidence, and looming antibiotic resistance, and blah blah blah. Remember, last week, with that rockstar 6/6 AbxScore? I KNOW I can do this.

But as soon as I start talking, I can tell whether the patient is buying it. And yesterday, with my first URI of the day, she wasn’t buying it. Nope nope NOPE. Flat eyes, flat gaze. It looked like the effort required to avoid literally rolling her eyes at me may have been causing physical discomfort.

No big deal. I’ve been here before. And it’s okay, because I’ve been feeling like overall, this quest to reduce unnecessary antibiotic prescribing has been getting a little easier, slowly, over time, despite the occasional eye roll. Because WE’RE ALL IN THIS TOGETHER, RIGHT? And by WE, I mean all of us human beings, working together to maintain a world where antibiotics continue to functionally exist, one day at a time.

But also, and really, that WE is directed at every prescribing health care provider reading this blog right now. YES YOU.

Because sometimes I find myself reading articles like this one about the continued onward march of telemedicine, and wonder if maybe I’m on my own here.

With telemedicine, you simply log on from the comfort of your home, hand over your credit card number, and after a brief chat with a clinician, have a prescription sent conveniently to the pharmacy for you. No muss, no fuss, amirite?

Don’t worry. It’s not like they’re doing anything risky or irresponsible. “They can prescribe antibiotics and other common drugs for strep throat, headaches, bronchitis, and urinary tract infections, but not controlled-substances, such as addictive painkillers”, says Dr. Roy Schoenberg, CEO of some telemedicine company called American Well.

So, to clarify, this service exists pretty much ONLY to prescribe antibiotics, right? I mean, that’s essentially it, yes? What other drugs could they possibly be prescribing for sore throats and bronchitis, despite the fact that the vast majority of these antibiotic prescriptions are inappropriate?

I watched their YouTube video/ad and, surprise surprise, the example they used was of a sad, snotty guy with a red nose. After logging in from his iPad and describing what sounds like every viral upper respiratory infection ever, his kindly, white haired, white coated, and very male doctor delivers his diagnosis in a voice of supreme confidence: “Acute sinusitis.” And what does he get? A prescription that will “help with your mucus”. A prescription for YOU GUESSED IT an antibiotic.

And the guy is abso-fricken-lutely delighted. Of course he is! After all, that’s what he paid $49 for, right? He’s oh so sick, and far too busy and important to just deal with being sick like the rest of us mere mortals, so he wants to be able to lay out some cash in exchange for the pleasure of being told a) his congested misery is somehow more badass than everyone elses’ (because “acute sinusitis” sounds far more badass than “common cold”) and b) I’M GOING TO FIX IT. Here’s the fix-it pill, right here. Augmentin will solve all your problems. You’ll be back to the board room in no time! (Guy totally looks like he spends way too much time in board rooms.)

But wait. What about the evidence that shows that even patients who meet clinical criteria for acute bacterial sinusitis don’t get better any more quickly with antibiotics than without? What about that?

So I’m sitting here, watching this video, getting all bothered about some well funded group of smoothies selling the illusion of quality care, and I decide I want to find out whether telemedicine visits produce more antibiotic prescriptions per visit than in-person visits. And it turns out that, surprise surprise, they do! Because OF COURSE they do. The implied transaction being offered is cash for antibiotic, not cash for cracking The Mystery of the Stuffy Nose. Mr. Board Room didn’t cough up his $49 to get advice about how to use a Neti pot.

But let’s be real. Over 90% of in-person visits for “sinusitis” end in an antibiotic prescription too.

And this is why this post isn’t really about telemedicine. It’s about how it can be really hard, and frustrating, and sometimes lonely, figuring out how to provide the type of care that people want – treating our patients like consumers, as we’re being increasingly encouraged to do – when that care comes in direct conflict with what the enormous and growing evidence base of medical knowledge indicates they need.

Because I think most health care providers are more customer-service-oriented than we let on. We WANT to heal and help and please people! That’s why we’re doing this in the first place! So I really and truly get why so many of us fall prey to the feel-good trap of overdiagnosis/overtreatment, particularly when our patients make it clear that’s what they want, and, of course, when they get better (which, remember, they will, whether or not they take antibiotics).

I don’t LIKE the feeling of entering an exam room ready to engage in rhetorical battle, when the chief complaint is “sinus infection x 2 days; wants antibiotics”, any more than anyone else does. It feels yucky.

But I also don’t like feeling as though I’m being less than honest with my patients. I’m uncomfortable with the idea of putting on my best “authoritative confidence” voice to deliver a plan, and a prescription, that I know isn’t supported by the evidence.

So I guess for now, I’ll keep doing what I’m doing, particularly since I know that usually, most of the time, the patient gets that I’m on their side and we all leave the visit feeling warm and fuzzy.

However, if it turns out that there’s actually some world of knowledge I’m not privy to – maybe it involves a private club with a secret handshake (and fabulous cocktails, and three piece suits, and wait how did I end up inside a Mad Men episode?) where everyone laughs about how antibiotic overuse isn’t actually such a big deal after all and we should all keep prescribing to everyone who walks through the door so our patients continue to think we’re THE BEST EVER –

Can you please let me know?

#AbxScore Week 2

This was a less than successful week when it comes to rocking the AbxScore. Quick rundown of my progress this week (and to refamiliarize yourself with how scoring works, visit my initial and more optimistic post here):

Day 1: 1/2

Day 2: 0/1

Day 3: 1/1

Day 4: 1/2

First off, you can see right away that for whatever reason, I haven’t been seeing so many of the garden variety upper respiratory infections this week. Plenty of other fun stuff, don’t you worry, but the URIs were few and far between.

Which was just fine by me, because the ones I did see had me feeling like I was banging my head against a wall. Total AbxScore of 3/6, or 50%. Sad face.

Longer post to follow, wherein I go on far too long about responsible prescribing and ethical practice and telemedicine and some other stuff. Because I can, because it’s my blog. Lucky you!

 

No, Gardasil didn’t make your period go away

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A new patient came to see me this week, concerned about the fact that her period was a little over a month late.

After ruling out the obvious (no babies), we ran some labs. A few days later, she returns to review her test results (yay normal!) and she presents me with this, the real reason she’s worried: she had her first dose of the HPV vaccine two months ago. And she’s been hearing some stuff about Big Bad Things happening to young people everywhere because of it. In fact, she’d read something somewhere about a girl who went into MENOPAUSE after she received it. Could Gardasil be the reason her period is overdue? Will she ever have a period again???

Let’s see. In the past two months she’s also moved to a new country, started a graduate program, been ROBBED (ugh – thanks for nothing, Big City), and engaged in several other unspecified interpersonal conflicts. In other words, she’s been going through a rough stretch. I’m thinking that maybe, just maybe, there might be a few other things going on in her life right now that could be affecting the regularity of her menstrual cycle besides the HPV vaccine.

But here’s the thing. Even though I’m absolutely confident in saying that it’s highly (HIGHLY) unlikely that the vaccine had anything to do with her menstrual issue, can I say that there’s 0% chance? That it’s completely, unequivocally impossible? Well, no. But only because I’m almost never willing to commit to 0% or 100% certainty on anything. (See how even there, I said almost?) Because SCIENCE DOESN’T WORK THAT WAY.

This can prove to be a problem. Because it means that when you’re talking to someone who’s unfamiliar with how the research process DOES work, saying things like “it’s highly unlikely that” or “there’s no evidence to suggest that” or “no more frequently than placebo” may be accurate, but they can also sound suspiciously like “I’m not sure. Maybe?”

And if you’re, say, a cynical manipulative media type desperate to remind people that you have a daytime talk show no one seems to know exists (*cough* katie couric *cough*) then all you have to do is book a few sad stories for an episode that exploits this disconnect between perception and reality – because apparently a couple of anecdotes without any confirmed link to the vaccine in question are equivalent in relevance to an enormous and growing scientific evidence base – and before you know it, hey, people are talking about you again! Win!

Back to my patient. What I said was this: there is zero evidence or theoretical support, at this time, for a link existing between the HPV vaccine and anything scary whatsoever, including a late period. And, what we DO know is that the vaccine is highly effective at preventing HPV. Which is associated with the development of the vast majority of cervical (and vaginal, and vulvar, and anal, and oropharyngeal, and penile) cancer. And which you’re practically guaranteed to be exposed to if you plan on being sexually active with another human being at any time in your life, ever.

So, yes. You should most definitely plan on coming back for dose #2.

It’s not that I don’t want you to have a Pap…

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Hello, 18-year-old patient,

It is so fabulous that you’re as motivated about your health as you are, scheduling a Pap as soon as you arrived at college! You. Are. Awesome. And I can’t wait to talk about all the ways you can continue to be empowered about your gynecologic and sexual health. Before we get started, though, I have good news (I hope you’ll agree!). You don’t need a Pap test today! In fact, you don’t need a Pap at all until age 21!

See, the thing is, the guidelines changed awhile back, and it’s now no longer recommended for women to have Pap tests at all before the age of 21. I’m not really sure why your provider at home has been asking you to come in for Pap tests every year since you were 16. Weird. Maybe you can ask them?

The thing is, your immune system is in such tip-top shape at your age, and (sorry to say) HPV is so very, very (VERY) prevalent, that even if you have been exposed to HPV, and you develop a few abnormal cervical cells because of it, it’s all but guaranteed that your body will take care of the problem completely without us needing to do anything at all. Yay immunity! And if we did a Pap anyhow, and found a few of these funky-looking cells, and then did a whole bunch of procedures on your cervix you didn’t need…believe me, this guideline change is a good thing.

Plus, you’ve had the HPV vaccine, right? That’s loads of protection against the highest-risk strains of HPV right there. You’re already doing everything you need to do right now to defend yourself against cervical cancer.

Keep in mind that when we talk about the Pap test, we’re talking about one very specific thing – a screening test for cervical cancer – and there’s tons of other stuff for us to cover today.

Now, let’s talk about contraception. And chlamydia screening. And smoking. And sleep. And…

*****

Hi there, 22-year-old patient,

It’s great to see you again! It seems like just yesterday you were here for your first Pap last year. Did you change majors again? How was your semester abroad in Barcelona? Have I mentioned how fun it is to live vicariously through your adventures?

I’m delighted that you’re so on top of things, coming back for your Pap test exactly one year after the last one. But I have good news (I hope you’ll agree!). You don’t need a Pap today! In fact, you don’t need another Pap for two more years!

See, the thing is, the guidelines changed awhile back to recommend that Pap tests be performed every 3 years for young women. I know, it’s hard to wrap your head around a change like this when you’ve been hearing about getting your “yearly Pap” since you were a little girl tagging along with your mom to her doctors’ appointments. But I’m not really sure why your provider at home still wants you to have a Pap every year. Weird. Maybe you can ask them?

The thing about HPV-associated cervical abnormalities is that they usually move really. slowly. Seriously slowly. And, most of them resolve on their own, without us doing a thing about them. So when we used to perform Pap tests every year, often we’d find abnormalities that your immune system would have cleared up completely if they’d had a little more time. Exceedingly frequent Paps => increased likelihood of discovering otherwise self-resolving abnormalities that we then feel like we have to do something about because we have a hard time leaving well enough alone as medical providers => possible unnecessary procedures with associated discomfort and risk of future pregnancy complications and whatnot for you.

Seriously, this is a change for the better.

But just because you don’t need a Pap, that doesn’t mean I don’t want to see you! I’d like to check in about loads of other things. Like birth control. And STI testing. And drinking. And SLEEP. And…

*****

Welcome back, patient of any age whatsoever,

It’s so good to see you! It’s always great to catch up.

I’m so, so sorry you ran out of birth control because you thought you needed a Pap to get a refill. First you had midterms, and then you had to cover a bunch of extra shifts at work, and then there was some sort of friend drama you really don’t want to get into, and before you knew it a month or two had passed before you were able to get back to the clinic for a Pap test.

So, first of all, I’m delighted give you a refill today, whether it’s time for you to have a Pap or not. Especially because it sounds like your backup method of condoms and withdrawal haven’t really been working so well, since you took Plan B twice in the last month. Let’s get you back to Plan A ASAP.

Second of all, please, PLEASE don’t let yourself run out of birth control pills again because you think you’ll need to have a Pap test first. I will never, and I mean never ever, refuse to refill your birth control just because you’re overdue for a Pap.

I might ask you about it, and recommend it, and counsel you about why cervical cancer screening is important, and try to brainstorm with you some ways around the possible obstacles you’re facing when it comes to getting one scheduled (fear? timing? money?), but I most definitely won’t refuse to refill your pill just because you haven’t had a Pap. It feels a little like letting someone run out of their cholesterol meds because they haven’t had their colonoscopy yet. Why should one predicate the other? Seriously. No.

I’m not really sure why your last provider told you they wouldn’t refill your pill prescription until you had a Pap. Weird. Maybe you should ask them?

This doesn’t mean I don’t want to see you at all! If you’re on the pill, I’d still like you to come in periodically so we can measure your blood pressure, and touch base about side effects and any possible new risk factors, and so on and so forth. But seriously, if you’re running out, and haven’t been able to see me in awhile, just give me a call.

Please.

#AbxScore: Week 1

yuck

It’s been one full week since I decided to start recording my treatment decisions for nonspecific upper respiratory infections in an attempt to keep myself honest about (and motivate me to improve) my antibiotic prescribing. I know it’s not as exciting as trash cake, but I’ve decided I’m going to try to stick with it for a bit here, since I think it ACTUALLY MIGHT BE WORKING. (With my N of 1. N=me.)

Now, I’m fully aware it’s only been a week. And that week included, um, a four day weekend. Maybe not the most auspicious time to start? But whatevers, after 4 days of tracking my daily #AbxScore, here’s how I fared:

Day 1: The day I decide to start tracking. Because I’m all fired up, my AbxScore=3/3. YES.

Day 2: I’m embarrassed to say I only saw two patients the ENTIRE DAY, and neither of them had a URI. College campus + Thanksgiving eve = ghost town.

Day 3: AbxScore=3/4. Patient #1 had asthma and seriously funky sounding lungs, all the way to the bases. I just couldn’t convince myself that he didn’t have early CAP, despite normal vitals. Z-Pak given. But I rallied, and the following 3 URIs were given heaps of reassurance and symptom management advice.

Day 4, yesterday: AbxScore=6/6. KILLING IT. This was the day where I realized that even if my N remains 1 (ME) this is still worth doing. Because I saw a total of 6 URIs in patients with varying lengths of illness and varying pre-visit levels of commitment to the idea of leaving with antibiotics, and I did it. I DID IT. Even the patient who tearfully told me about the time when she came in with a cold and we “DID NOTHING” and she was sick for months and months until finally she was given antibiotics at home and just like that she was CURED – even SHE left without an antibiotic prescription for 3 days of nasal congestion and sinus pressure.

In a perfect world, obviously, the appropriate number of antibiotic prescriptions of dubious necessity given would be zero. But the reality is that the majority of visits for “bronchitis” (=nearly always viral) continue to end with an antibiotic prescription, so IMHO any reduction in this number whatsoever is an improvement.

Now, I will fully admit that I was already a bit of a striver; all those guilt-inducing missives to prescribers and patients alike over the years about conscientious prescribing were already getting to me, so it’s not like every single one of these URI patients would have left with antibiotics in my halcyon pre-AbxScore days. But if I’m being honest with myself: the girl with the tears, another girl with an asthma history, and a guy with an annoyingly persistent cough probably would have been given a script yesterday.

And now, since I knew I’d have to add them to my total for the day, I found myself that much more willing to a) commit to my diagnosis (is there evidence here of a bacterial infection, really and truly, or isn’t there?) and b) take the extra time to talk to patients about why exactly they don’t need antibiotics, so that we all leave the visit on the same page. Because if they believe me when I tell them that I’m confident antibiotics won’t make them any better, any faster, why would they want to take one?

Most of the time, I think we tend to assume that all patients want are antibiotics, so we “cave” with a prescription. Now, we all know that sometimes, they do. I’m sure I’ll be seeing one later this afternoon, or tomorrow. But often, more often than we think, our patients just want someone to listen to them, explain why they feel the way they do, and let them know what they can do to get better. Because whether or not they “need antibiotics”, viral infections suck big time. Really. And we can acknowledge that reality without writing a prescription that won’t actually make our patients’ mucousy misery go away any faster.

It even worked with the girl with the tears. Believe me, as soon as the crying began, I began to mentally subtract this visit from AbxScore numerator for the day. But after we spent some time talking about the whens and the whys of viral infections and sinusitis and antibiotics and all that, she’d agreed to go with sinus rinses, some guaifenesin, rest, and time.

So there it is. Week 1 down. Progress observed. And if you’d like to add to my N of 1, spread the word.