Quantifying awesomeness

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So, I’ll admit that I tend to think of myself as being a pretty awesome NP. Kind of a rock star.

But I recognize that I might be slightly biased.

My mom, my husband, my kids are all similarly convinced that I, generally speaking, rock when it comes to being an NP.

And they’re, most definitely, totally and completely biased as well. (And more than a little unqualified to judge.)

Isn’t that human nature, though? To think of ourselves as being pretty damn good at what we do? Probably true for everyone, but maybe even moreso for clinicians?

I mean, this job can be hard. REALLY hard. Crazy schedules, crazy patients, crazy admins, crazy insurance companies. If we don’t think we’re particularly great at it, that we’re bringing something special and unique and AWESOME to the table – and I mean even more than that other guy over there – what’s the point?

But we all know that all clinicians are not equally awesome.

Every clinic everywhere has “good” providers and “bad” providers and “okay” providers. It’s not written down anywhere, but when a friend asks a friend who knows some things about who they should ask to see, certain names come up, over and over again, while others are conspicuously omitted.

I’ve been thinking about this topic recently because of a conversation I had with a certain administrative type from a certain clinic this week. While we were chatting about unexciting clinic business, he let slip that roughly half of the patient complaints the clinic receives are consistently about one particular clinician. He then brushed them aside because he thinks of this clinician as being stingy with prescribing antibiotics, so therefore the fact that 50% of the clinic’s complaints are about 1/10 of the clinical staff may not the best measure of the quality of this guy’s work. Besides, he sees A LOT of patients. Very, very quickly. No drama. Admins love a high volume:drama ratio.

Hmm.

Zoom out.

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There’s currently this great experiment underway to figure out how to measure which clinicians are particularly good at what they do, and to reward those who are the MOST AWESOME in an effort to inspire everyone to be even MORE AWESOME than they may already be.

On one level, this makes perfect sense. Why NOT pay more money for better care? Why not reward high quality? Isn’t that how the rest of the world works?

But measuring quality in health care isn’t the same as counting how many widgets an assembly worker makes, or how many five-star Yelp reviews you get.

Briefly, a probably-incomplete rundown of what seem to be most common approaches to quality measurement in healthcare:

a) Volume. How many patient visits can you squeeze into X minutes? Easy to measure – the greater the number, the greater the reward. In a fee-for-service environment, the reason for this relationship is obvious: more visits = more cash. But even outside the FFS world, this idea – that part of what makes one clinician better than another is how on-time they run, or how soon a patient can get an appointment – is a pervasive one. And who knows, maybe it should be. Access matters, right?

b) Patient satisfaction. How happy was your patient with the perceived quality of the care provided? If health care was just like any other consumer-oriented business, this would make 100% perfect sense.

BUT. Studies show that patients may not always be the best judges of the actual quality of the care they just received. Scores go up when providers hand out more antibiotics and more narcotics. Scores go up when providers order more expensive tests and procedures. Satisfaction matters, but so does averting a post-functioning-antibiotic future, avoiding the unintentional promotion of opioid addiction, and keeping medical costs from bankrupting the nation.

c) Adherence to clinical guidelines. How many patients got a flu shot this year? How about a Pap smear, or a mammogram? Hard to see what could be wrong here. Lots of people who know lots of things spent lots of time creating those guidelines. Flu shots are good. Early detection and treatment of cancer is good.

But what about shared decision making? Does judging clinicians based on their adherence to guidelines, above all else, result in strong-arming patients into taking medications, or having tests performed, or whatever it might be that they don’t want, or can’t afford, or may not even be considered appropriate care in 5 years? (cough mammograms cough)

Having a conversation with the patient and discussing guidelines, and the evidence behind the guidelines, in a shared and mutually understandable language is always a good thing. But is it possible that overreliance on adherence to guidelines as a marker of quality misses something?

d) Measuring outcomes. How many of your patients’ LDLs, blood pressures, and A1Cs are within normal limits? This, also, seems reasonable. Considering that part of our job (most of our job?) is to try to make these things better, it makes sense that we be judged on how well we do.

But we also all know that controlling chronic illness is harder in some populations than others. Access to care matters. Wealth matters. Community norms and expectations matter. Does rewarding clinicians who can show better outcomes unwittingly drive them away from caring for more at-risk populations?

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Back to this unpopular-with-the-patients clinician. Sure, he’s decent at avoiding prescribing antibiotics for colds. But I also happen to know he’s not great with the interpersonal skills. He also doesn’t bother to spend much time explaining what he’s thinking and why – to anyone, really, about anything, let alone his diagnostic and care plans with his patients. So you can consider me completely unsurprised to learn that he receives a far-greater-than-average number of “He did nothing!” complaints than the average clinician.

Not for nothing, but I’m also known for being stingy about prescribing antibiotics. And yet I consider it a point of pride that even my most pre-visit-antibiotic-committed patients leave their visit agreeing with me that their nasal congestion is viral.

I don’t actually have any answers here. I feel like each of these quality measurements dances around an aspect of care that matters, but also somehow misses the bigger point. It feels like there’s got to be a way to measure and reward the intangibles.

Any ideas?

Blame the EMR

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Another day, another article blaming EMRs (electronic medical records) for the sorry state of medical documentation today.

The latest, “We are in the age of copy and paste medicine”, blames EMRs for the fact that medical providers are producing useless, inaccurate clinical notes because it’s easier to copy and paste a previous note’s history/review of systems/exam/whatever into your current note than it is to actually write a new note.

I can’t deny that EMRs make it EASIER to create useless notes. But the EMRs aren’t the ones creating these notes.

Clinicians are.

It’s time to stop blaming EMRs for our crappy documentation, and do something about it.

What can we do about it? We can START WRITING BETTER NOTES.

Sure, maybe this means it takes another couple minutes to finish your note. Do I find note-writing to be one of the most onerous tasks of my day? UH, YEAH. It’s a pain, it’s tedious, it sucks. But it’s part of my job.

I owe it to the patient, who took the time to come in and share their story with me, to write that story down somewhere. I owe it to my colleagues, who might see that same patient when she comes back in a week, to write down what I saw the first time around. I owe it to my future self, who might see the patient for a follow-up visit in 6 months, to write down my current and prospective plans for managing that patient’s care.

Back when computer illiteracy was a thing, and a decent percentage of health care providers were still technology novices, there was an argument to be made about how EMRs made life oh-so-hard. I’ve actually lived this: My first job as an NP was with an office where the implementation of an EMR, and the (questionable) decision to adopt temporary-but-actually-permanent schedule reductions for our more slow-to-adopt providers, resulted in the financial ruin and closure of an otherwise thriving primary care practice. That. Sucked.

But today? When the majority of Americans own a smartphone? When nearly 3/4 of Americans have a broadband connection at home? The argument that COMPUTERS ARE HAAAARD doesn’t really hold water.

So yeah. Copy-and-paste notes are terrible. Illegible template-based notes are terrible. Agree, agree, agree.

But we’re not powerless here. Like any form of technology, the EMR is just a tool. It’s up to us to decide how we’re going to use it.

You don’t like your colleagues’ templated, copy-and-paste notes? Tell them. Maybe they don’t realize how bad they are. Maybe being called out will inspire them to start creating less useless notes.

You don’t like your own templated, copy-and-paste notes? Don’t write them. Every EMR I’ve worked with has a free-text function.

The first step in recovery is admitting you have a problem.

The sooner we all admit that we share at least as much blame in producing lousy notes as the EMR developers do, the sooner we can start fixing the problem.

When “good” isn’t good enough

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Dear parents-of-college-students: before you decline your kid’s college health insurance plan because you have “good insurance”, please check to make sure that “good” will be good enough.

Recently, a patient came to see me with a history of recurrent ovarian cysts. She presented her story like it was old news, since this has been happening to her since she was 14 – or in other words, since well before she left the comfort of her parents’ home for the big wide world of college.

Her issue is that three or four times a year, she experiences what she describes as several weeks of progressively intense unilateral lower abdominal pain, culminating in severe pain (which she assumes is from a cyst rupturing) that eventually resolves on its own, with the help of lots of pain meds and missed class. 

Generally speaking, she manages things on her own, but yesterday, the pain was worse than usual. Her prescription NSAID wasn’t cutting it. She’d missed a midterm. I had a few questions: who does she normally see for this? When was the last time she’d had a pelvic ultrasound or any other imaging? Was there a plan to change her birth control pill, which she was ostensibly taking to keep things like this from happening? Was it time to dig a little deeper, to see if maybe something else was going on?

Well. It turns out that she hasn’t seen a health care provider (besides our college clinic) in years. Why? Because she grew up in New York. Her parents continue to live, and work, in New York. Their insurance allows her to be seen by providers in New York, and to have labs, and imaging, and procedures, and pretty much anything medically-related she might ever need, in New York. I’m sure it’s very “good” insurance – in New York.

If she actually lived in New York, well, that would be just fine, wouldn’t it?

BUT SHE DOESN’T.

I know, I know. Parents have a hard time thinking of their grown-up kids as no longer living with them. Sure, they’re away at school, but that’s just temporary. Their permanent address is still here with us, at home, right?

Hold up. If your college kid wants to keep listing your house as their permanent address while they’re bouncing around between dorms, sublets, and friends’ couches, living the typically transient life of an undergrad, that’s all well and good (after all, those parking tickets have to be sent somewhere).

But they need to have medical coverage in the place where their physical body actually spends the most time. If you live in California, but your daughter goes to school in Arizona, the place she needs coverage is Arizona.

You might be thinking something like this:

“I’m not worried. We just schedule her routine care while she’s home on break.”

Great, but what if she needs care that’s non-routine? What if something happens in the middle of the semester that might not meet criteria for being rushed to the ER, but really warrants being evaluated by a gastroenterologist, or a cardiologist, or whatever-ologist this week or the next, rather than months from now when she happens to have a few days off from school?

And what about that time – that not-too-distant time – when she stops coming home every summer or spring break? When she gets an internship, or a part-time job, or decides to take classes over the summer? How do you expect her to be able to get even routine, preventative health care if her insurance doesn’t allow her to have Pap tests performed in the state where she lives 95% of the time?

“Well, our insurance is pretty good. I’m sure she’ll be covered.”

Really? You might be surprised. One way that insurance companies trim costs is to limit where you can access care, so even if you’ve been pleased as punch with your plan’s low co-pays, and local provider network, and coverage for fun stuff like acupuncture, you can’t assume it covers anything beyond emergency care once you – or your dependents – leave the state.

Back to my patient from New York. Our options were limited to this: ER or no ER, since emergency care is all that her plan covers here in the state of Not-New-York. Beyond bringing her to an ER, my hands were tied – I couldn’t run labs; I couldn’t order an ultrasound.

Even though she was in pain, she didn’t want to miss yet another midterm. So against medical advice, she refused to allow us to transport her to the ER down the road, and instead returned to her dorm room, clutching her lower right side, with strict instructions to call the campus police to bring her to the hospital if things got worse overnight.

Had I been these parents, had this been my daughter, I would NOT be okay with this state of affairs. I would insist that we find a plan somewhere, somehow, that allows my daughter to access medical care where she actually lives. And I would insist a whole lot harder if she had a chronic or recurrent medical condition.

If, despite my best efforts, I couldn’t find a plan for our entire family with decent in-state and out-of-state coverage, I’d look really, really closely at the plan offered by my daughter’s college before checking the little “waive school insurance” box hidden somewhere within all that orientation paperwork.

So. My humble request to the college parents of America is this: if you’re planning on waiving out of the health plan they’re offering through your kid’s school, please, please, PLEASE read the fine print, or pick up the phone and sit through the terrible hold music until you get a human being to talk to, and find out whether your plan covers medical care – specialists, labs, imaging, etc. – in the state your child is about to move to.

Those insurance premiums aren’t cheap. So make sure they’ll pay for the care your family actually needs.

Let’s talk about…

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Did you know that 1/3 of all routine health maintenance visits with teens don’t include ANY discussion of sex or sexual health? Like, NONE?

And in those visits that do, the conversation lasts an average of 36 seconds?

I’ve been told I’m a fast talker. But if I tried to cram everything sex-related that I wanted to talk about into 36 seconds, I’d sound like an auctioneer on Adderall – and I’d STILL be providing my patients with lousy and inadequate counseling about their sexual health.

So, health care providers, what’s the deal? Don’t pretend it doesn’t occur to you that your teen patients might be having, or at least be thinking (constantly) about having, sex. It hasn’t been THAT long since you were a hormone-fueled adolescent yourself, has it?

Nope. Providers aren’t avoiding The Talk because it doesn’t occur to them. They’re avoiding it because it feels uncomfortable. The sense that you’re asking someone you barely know to discuss the most intimate details of their life feels vaguely icky. Far easier to ask a few general questions about how your patient has been feeling, chat about their plans for the summer, maybe (just maybe) ask about smoking, sign a few forms for school and send them on their way.

It used to make me feel uncomfortable too. But changing the way I thought about taking a sexual history and talking about sexual health with patients made things a little easier.

1) First of all: Get over it. You need to get used to talking sex with your patients. ESPECIALLY if you’re caring for teens and young adults. There’s just no way to do this job well without it. I’m not saying you should feel like you have to talk condoms with every patient who comes to see you about their runny nose… but you and I both know your patients are coming to you with more than runny noses.

2) Create a little script for yourself. Practice it. The less time you spend in the visit fishing around in the dark abyss in your mind for the next question, the less opportunity there is for the awkwardness to expand and grow to fill the void left by your silence. Know that the more you do it, the easier it gets. Pinky swear.

3) You may think that the fact that your patient isn’t bringing it up means they don’t want to talk about it. Unlikely. More likely, they’re feeling just as uncomfortable as you are, yet they also have a million sex-related questions and thoughts and worries, and they’re just waiting for an excuse to pretend to reluctantly be dragged into a conversation about it.

4) From your perspective, you’re asking about morbidity and risk factors: exposure, prophylaxis, pregnancy risk, infection risk, symptoms. But think about it from the patient’s perspective: what you’re really asking about is relationships. The guy who asked them out once and texts every once in awhile just to keep them hanging on. The girl they dated for a whole semester until they broke up, and now she’s dating your best friend…but they might have hooked up again that one time a few weeks ago. Framing the history as a series of stories allows your patient to tell you what’s going on in a familiar language, as well as providing you with context that you just won’t get with a few yes or no answers.

5) The more presumptuous and judgey the questions (“You’re using condoms, right?”), the less likely it is that you’ll get the full story, or that your counseling will make much of an impact. Is actively shutting down an open, honest conversation actually worse than no attempt at all? Well, probably not. But this isn’t a race for the bottom. (No pun intended.) You can do better.

Any other suggestions? Were you as surprised as I was by the results of this study? What do you think we can do as health care providers to improve these numbers?

More than an absence of No

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The chief complaint varies: “STI testing”, “pregnancy test”, “GYN problem”. It’s not until I enter the exam room and see my patient, eyes downcast and voice in a near-whisper, that the real reason for the visit becomes clear.

Apparently, it continues to be open season on questioning the legitimacy of the sexual assault epidemic. This time, it was the Wall Street Journal that decided the world needed yet another article blaming women for their own rape. So brave, WSJ! It’s about time someone stood up for those poor accused assailants.

I mean, it’s not like assault survivors have had their trauma minimized and dismissed for years – er, decades – wait, no, EONS now or anything. “She was drunk, so she was asking for it” is today’s “she was wearing a short skirt, so she was asking for it”, which is really just another version of “she’s female, so she’s always, somehow, asking for it”.

In case you missed it, the numbers around rape in college are pretty insane: approximately 1 out of every 4 to 5 college women will experience sexual assault at some point while they’re in school. Numbers like this are hard to ignore; a incidence rate of 20-25% must meet epidemic criteria by pretty much anyone’s standards. But rather than saying “holy crap, we need to do something about this”, some people prefer to respond to these numbers by questioning their legitimacy, citing evidence that assaults involving college students often involve alcohol — ergo and therefore = not-rape.

If you’re one of these people, a question: have you, or anyone you know, ever actually been to college? You know, that place where day-that-ends-in-Y is cause for celebratory drinking? Where the next generation’s ingenuity is expressed through the laborious construction of elaborate snow-carved beer pong tables? Where it’s often harder to find an event WITHOUT alcohol involved than with?

In other words, yeah, binge drinking in college is a legit problem. I’ve seen more injured wrists and broken collarbones than I’d care to admit due to the ubiquitousness of college alcohol use. But part of being a young adult living on your own for the first time sometimes means figuring things out the hard way – like how to consume alcohol responsibly, without the puking and blackouts. Today’s monster hangover paves the way for tomorrow’s dignified glass of Malbec (or three) with dinner. We’ve all been there. I know I have.

Which is why I see myself in the eyes of my patients. The ones who come to the clinic after a night where yeah, maybe they had too much to drink, but that didn’t mean they planned, or deserved, to wake up too-early the next morning, dawn not quite ready to breach the horizon, in an unfamiliar room, clothes and hours unaccounted for. In pain.

There is no amount of alcohol, no level of intoxication, that justifies assault.

If you think that the real epidemic is one of morning-after-regret-turned-false-accusations, spend some time with me at work. Look in my patients’ eyes as they struggle to tell their stories. And know that you, and others like you, are part of the reason that most of them will never file a formal report, no matter how many ways I talk to them about their rights, and resources, and recourse. All they can handle, in that moment, is a modicum of damage control: please, just tell me what I can do, what I need to do, to be okay.

Today, all I can offer is damage control – antibiotics, EC, labs, lots of counseling. But tomorrow, I’m hoping for more. I’m hoping I’ll stop waking up to rape apologia in the mainstream news. I’m hoping that the socially accepted definition of consent will shift from an absence of “no” to an enthusiastic “YES!”

Because eventually, I’m hoping that the gradual elimination of rape culture (eternal optimist that I am) will mean that I get to spend more time focusing on the more mundane aspects of a career in college health: strep tests, ankle sprains and contraception.

Letting your garden grow

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“I’m sorry, I haven’t shaved.” Delivered sheepishly, with a cringe.

Le sigh.

I know it’s been awhile since I was in college (I mean, not THAT long <cough>), but let me just say that the scorched earth look was uncommon back in my day.

However. I like to think of myself as a hip old. I read Jezebel. I tweet. So I get that the social mores of grooming from my day are a thing of the past. It’s all about the prepubescent look now. Got it.

Or is it?

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There are upsides to this trend of complete hairlessness. Well, um, so there’s one. Crabs, a.k.a. pubic lice, that notorious entity of teen nightmares, is practically nonexistent today, rendered obsolete by a wave of wax and razor blades (wow, so that’s not a completely terrifying image). When I finally saw my first case ever last year, I was actually a little excited, with that thrill that comes with the discovery of a rare and endangered creature. I know, I know. JUDGE.

But the quest for bare skin doesn’t come without a price. Razor burn, ingrown hairs, folliculitis, microtrauma from waxing and shaving, and oh so much more… And, I dunno, all those many hours dedicated to lady area maintenance that could be redirected towards…saving the whales? World peace? Kardashian marathons? Take your pick.

I’ve heard the back and forth – it’s all porn’s fault! it’s my choice, and it’s hygienic! – but I can’t help but feel as though this trend is working against us ladies more than for us if you feel as though you need to apologize for being a smidge grown out when you come see me for your Pap.

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But. BUT! There are signs that the pendulum might finally be swinging the other direction.

Recently, those leading arbiters of classy, American Apparel, created a window display with mannequins wearing both domestic-construction spandex-cotton blend and full bush. Bold move, AA.

Seriously though, pubic hair’s been all over the news lately. (Pun not intended! I mean it, now THAT would be unhygienic.) You might have missed the articles in Slate and The Guardian, but you can’t deny the legitimacy of the New York Times. If the gray lady is deigning to write not one, but two, pubic hair trend pieces, you know it’s both a legit happening and maybe a year or two behind.

So there you go, ladies. Feel free to shave or not shave, wax or not wax, but please, at the very least, know that regardless of the choice you make, you should never feel the need to apologize for it.

The A Word

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Hey, health care providers:

It’s time to get comfortable talking about abortion.

I mean it. And not just the women’s health care providers.

Nope, what I mean is this: You, me and every generalist we know should get comfortable talking about abortion.

Why? For one, because it’s really, really common. Nearly one-third of all women in the U.S. will have had at least one abortion by the time they’re 45. So if you choose to remain willfully ignorant about what to tell your patient when she comes to you with that unexpected positive pregnancy test, looking for a medical professional to talk to her about her options, you are failing her you’re unable or unwilling to provide her with the comprehensive, respectful, judgment-free evidence-based care she deserves.

If your options counseling begins and ends with awkwardly and wordlessly handing over the phone number for a women’s health clinic, I’m talking to you. If you continue to associate Plan B with “RU-486” (and you’re still calling it “RU-486”), I’m talking to you. If you have trouble getting your mouth to form the word “abortion”, either to patients or colleagues, I’m talking to you.

Because NOT being able to talk about abortion with the familiarity and comfort with which we discuss a million other medical conditions and procedures relegates abortion to this hidden, unspoken corner of medicine and society, reinforcing the concept that abortion is dangerous and rare. Which – HELLO – it’s not. Not even a little bit.

(And all of this makes it easier for activists with too much time on their hands to continue making progress in their increasingly successful push to marginalize abortion access out of existence.)

So.

If there’s even a remote possibility that your clinical role includes caring for patients with a uterus, being willing and able to talk to them about abortion when they need you to MUST be part of the package.

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Here’s an initial, too-brief list of online educational resources for health care providers seeking to learn more about medication and surgical abortion. If you know of others that you think need to be added to the list, can you send them my way, pretty pretty please?

http://www.guttmacher.org/sections/abortion.php – the penultimate org/website for abortion and access trends and data

http://www.arhp.org/professional-education/medical-education-opportunities/archived-webinars – ARHP’s on-demand webinars, several of which review medication abortion and award CE/CME

http://www.prochoice.org/education/resources/index.html – NAF’s list of educational resources for health care providers

Much thanks to Chelsea Polis (@cbpolis) for:

http://www.teachtraining.org/

https://exhaleprovoice.org/pro-voice

(Happy belated birthday, Roe. Here’s hoping you’re around for at least another 41 years.)