The end of (quote-unquote) supervision?

supervision pic

You may already be familiar with how truly, madly, deeply annoying I find the term “supervision”.

I mean, not in its appropriate context, obviously. My daughter, despite being quite precocious for a kindergartener, still requires supervision while using grown-up scissors. My son, who seems to think he’s capable of essentially any physical feat imaginable, needs pretty much constant supervision, since he’s nearly always wrong. Not at all developmentally inappropriate for a toddler, but still. If we want him to survive childhood, supervision is definitely required.

Clearly, supervision has its place. But some problems arise when we start using the word to describe a mandated relationship between a physician and a nurse practitioner. Not the least of which is the fact that I tend to take issue with the intentional misuse of language. It’s kind of a pet peeve.

I wrote something about why exactly I find the word “supervision” so annoying a few months back. (Go ahead, I won’t judge you for clicking.) Afterwards, an NP from another state read it and said something along the lines of “Huh. Supervision? Is that still a thing in some places?”

Yeesh. Why yes. Yes, it is still a thing. In some places. Apparently.

Thing is, I never dreamed that moving to an uber-progressive state would mean I would still be subject to outdated laws that don’t make any logical sense. Maybe that whole no-buying-alcohol-on-Sunday-mornings thing should have tipped me off?

Don’t get me wrong. It’s not like you’d have any idea there were any restrictions on my practice on a daily basis. I go to work and see my patients, order my labs, write my prescriptions, write my notes. Pretty mundane, actually.

Except for this one annoying thing where all my prescriptions have a second name on them: the name of my “supervising physician”.

And even though my “supervising physician” is pretty great, this bugs her as much as it bugs me. And I totally get it. I’d probably be super annoyed too if there were a bunch of prescriptions out there with my name on them that I had nothing to do with writing. Risk exposure much?

Ah well. I’d just assumed it was something I needed to get used to. Just like I got used to the sight of seeing tarps thrown over the beer section at the supermarket whenever I happen to find myself grocery shopping on a Sunday morning. (Actually… nope, still haven’t gotten used to that either.)

But then I finally opened one of the emails that the Massachusetts Coalition of NPs has been sending me to find out WAIT, WHAT? There’s an actual, real-life bill at the State House RIGHT NOW that could fix this?

True story! It’s called HB2009/SB1079, or “An Act Improving the Quality of Health Care and Reducing Costs”. And it’s pretty great. (Even if it could really use a new name.)

I’ve heard that some of the arguments that legislators are hearing against the unfortunately-named bill sound like this:

  • “NPs and CRNAs are not educated enough.”
  • “Patients will be harmed because they don’t know what they don’t know.”
  • “They need continued oversight in order to be safe for patients.”

Here’s the thing, people-who-either-said-these-things-or-wish-they-did. I hate to break it to you, but that ship has left the dock. The train has left the station. The car has left the carport. NPs are already seeing patients and making diagnostic decisions and prescribing stuff – lots of stuff! – on their own, every single day. Whether you like it or not. It’s already happening! You’re too late!

And that’s why I have such a hard time understanding why physicians would be AGAINST removing the supervision language from the books. If my name is going to be attached to someone’s actions, I want to be sure I had something to do with it. But “supervising” MDs? They get all the risk that comes with clinical decision making and prescribing, with none of the power to actually make those decisions. How does this sound like a good deal?

Well, maybe if your income was affected by how many NPs you “supervise”, it would sound like a great deal. As long as that whole risk-under-your-name thing doesn’t bother you too much.

…But wait a sec. If you’re confident enough in the abilities of the NPs you “supervise” to feel comfortable with this level of risk, one might surmise that maybe you don’t actually, deep down, think NPs are all that unsafe after all… which would suggest that all these protests about “safety” may be just a teensy bit disingenuous, no?

In conclusion: this bill rocks, and its time has come. So if you live in Massachusetts and agree with my pointed use of quotation marks around the word “supervision”, please – figure out who your rep is and call, or email, or carrier-pigeon over your thoughts on the matter.

Thank you. That is all.

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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.

**********

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?

**********

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.

The luxury of time

the luxury of time pic

I have had a lovely week.

Really. I mean that. I’m not just talking about the perfectly-grilled steak I had for dinner last night, or the fact that I’ve been lucky enough to find Girl Scouts selling cookies at my subway stop, even though those were definitely highlights.

No, this week was something special. This week, I was able to be the health care provider I always want to be, the kind I always aspire to be, the kind I hope I’ll be able to be on any given day. With every patient.

Except I typically have at least 3 patients waiting and OH WAIT another double-booked emergency visit between me and this shining ideal. But not this week!

Why? Because as a grown-up woman, I’ve found myself once again completely, swooningly in love with that unique college tradition known as Spring Break. While most of my patients spend the week in exotic locales, enjoying all-inclusive cocktails and remembering what it feels like to experience above-freezing temperatures (MUST BE NICE), I get to stay behind inside the endless polar vortex, holding down the clinic-fort and taking care of the students who are opting out of paradise in order to spend their week sleeping in and catching up on House of Cards.

But that’s okay. My week may not have involved jell-o shots, but it did involve something even more delicious: time.

The clinical schedule was relatively light, but steady. Functionally, this meant that I was able to spend about twice as much time with each patient as usual.

Functionally, this meant that when I thought this one patient and I had reached a decision point, only for the patient to stop and ask to explore, from the beginning, a completely different possible option, I didn’t internally groan and look at the clock.

Functionally, this meant that when another patient continued to send me wordless signals that she was still worried that Something Serious might be going on beyond being unlucky enough to catch a third cold this winter, I dug a little deeper and asked, and listened, and talked until the signals indicated relief.

Functionally, this meant that when a different patient decided to “oh, by the way” me as our visit was ending with a completely unrelated, and much more complicated, symptom of concern, I asked her to tell me more with a warm smile. And I meant it.

It made me fantasize about an alternative reality: one where I’m empowered to spend as much time with each patient as the patient needs – as much time as we both might need – to feel confident that I’ve done everything I can do on that day, in that moment. Fewer patients might be seen. Which means the clinic might need to hire more providers. Which, I’m quite certain, won’t be happening any time soon.

Spring Break can’t last forever. The party has to end sometime.

But the memories last forever.

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.

One hot potato

20140221-182240.jpgI love science.

Today, Dr. Awesome*, myself, and an NP student were discussing something called “hot potato voice” – specifically, whether use of the term is limited to patients with peritonsillar abscess, or could also be used to describe patients with particularly gnarly cases of tonsillitis.

Imagine you decided to stick a few jumbo-sized marbles in the back of your mouth.

Or, if you will, a potato. Maybe even a hot one.

Then, imagine yourself trying to pretend like there’s nothing amiss when your friend, mom, the cashier at Starbucks, whoever decides to chat you up about the weather.

Not so easy, right?

Trying to talk when you have one or two enormous, angry tonsils sounds kind of like that. (Except with more pain and sadness.)

For some reason, at some point in time**, the term “hot potato voice” started being used to describe this super special sound. So much so that nowadays, it’s just one of those things health care providers do without thinking much about it.

As NP Student and myself are going back and forth with some uninspiring blahblahblah, Dr. Awesome consults Dr. Google and finds this:

Mahmood F. Bhutta, George A. Worley, Meredydd L. Harries (2006). “Hot Potato Voice” in Peritonsillitis: A Misnomer. J Voice, 20:4, pp 616-622.

I love everything about this.

I love that someone was sitting in their office one day and said, “What is UP with ‘hot potato voice’? Puh-lease! I’d bet good money (that I don’t have, since I’m a voice researcher) that someone with an ACTUAL hot potato in their mouth wouldn’t sound anything like these people with peritonsillitis.”

I love that this person didn’t let their contempt for “hot potato voice” end there, and instead started digging through the existing literature to discover that WHAT!? Has NO ONE bothered to prove what people with actual hot potatoes in their mouths sound like??

Sounds like a knowledge gap right there! IRB TIME.

Next thing you know, you’re taping and analyzing and comparing voice recordings of people with peritonsillitis with those of healthy subjects (aka you and your pals from the lab, who are presumably as amused by all this as you are) holding whole microwaved potatoes in the back of their mouths.

Et voila. Legit, published, peer-reviewed research proving that you were right all along. NOT THE SAME. (Drops mic, walks away.)

Thank you, hot potato skeptic. Thank you for making my day, WAIT NO my entire existence, a little brighter.

*not her real name. BUT IT SHOULD BE.

**disclaimer: not a medical historian. Clearly.

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?