Tag: patient care

Blog Posts (8)

July 11, 2016

Does your primary care physician actually provide your primary care?

You’ve just moved to a new city for a new job, and before you can find a primary care practice, you get sick.  So you visit an urgent care center.  The doctor examines you, treats you, and urges you in not-so-subtle (and sometimes judgmental) terms to quickly find and follow up with a PCP.  And so the search begins.

 

Step 1: Consult Google.  Find 150 doctors within 50 miles.  Realize you know nothing about any of the doctors on the list.

Step 2: Ask colleagues for recommendations.  Receive great reviews of 2 doctors.

Step 3: Call the recommended doctors.  None are taking new patients.

Step 4: Realize you have insurance that limits your options.  Scrap your Google search and search on your insurance company’s website for “find available doctors taking new patients.” Results: 3 doctors.

Step 5: Call the doctors listed.  Doctor 1 isn’t taking new patients at all.  Doctor 2 is taking new patients in 4 months.  Doctor 3 may be able to fit you in in two weeks.

Step 6: Give up the search.

Step 7: Symptoms return. Call a PCP office to beg for an earlier visit.  They agree to fit you in in 4 days.  In the meantime, they suggest visiting an urgent care facility for timely treatment. 

 

It has been widely discussed among bioethicists and health care policy experts that emergency departments are overcrowded, urgent care centers are rapidly becoming a substitute for the traditional primary care doctor, and that the number of new physicians specializing in primary care medicine has been declining in favor of other, higher-paying specialties. (See Dr. Wayne Shelton’s blog)  Despite the push for establishing a “medical home” and centralizing care around the primary care physician, demand for urgent care or emergency services is still high.

 

Lack of access to primary care is often blamed on financial issues, especially lack of insurance, but even well-insured patients are affected by the PCP shortage.  A patient may be able to afford the PCP visit, but they either cannot find a practice accepting new patients or, if they are already a patient, may have to wait several days to get a sick visit appointment.  For a patient with strep throat or another easily diagnosable and treatable illness, an extra 4-5 days is too long – the patient suffers longer, risks complications or worsened illness, and must take more time off of work, which can have significant consequences.

 

Faced with this dilemma, why would a patient wait days for their PCP appointment when they could go somewhere else to receive care the same day?  Are patients really to blame for their failure to find a medical home?  If PCPs only see patients for a well visit 1-2 times per year, do they have a comprehensive picture of a patient’s overall health?  Are primary care physicians actually the primary doctors for their patients, or have their offices essentially become a warehouse for patient medical records from other practitioners? 

 

Urgent care centers are rapidly bridging the gap between PCPs and emergency departments, increasing access to care for acute illnesses while avoiding high costs in the ER, but potentially decreasing interactions between patients and PCPs.  Because of this, many patients are left wondering, how can they find comprehensive primary care while still being able to be seen quickly for acute illnesses? Is it reasonable to expect PCPs to be able to provide all primary care for patients, sick and healthy, or do we need to reconsider what is needed for a patient’s “medical home?”

April 11, 2016

Patient Satisfaction and the Possibility of Bad Medicine

In the March 18, 2016, AMA Wire Practice Perspective entitled “When Patient Satisfaction Is Bad Medicine” , Drs. Joan Papp (Case Western Reserve University) and Jason Jerry (Cleveland Clinic) make the argument that the institutional drive for higher patient satisfaction scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questionnaires may be contributing to the opioid prescription drug crisis nationwide. They note the results of an Ohio State Medical Association-Cleveland Clinic Foundation survey 1,100 Ohio physicians:

… 98 percent of the physicians who participated reported that they felt increased pressure to treat pain, and 74 percent reported that they felt an increased pressure to prescribe opioids because of the perverse pain management incentives in the patient satisfaction surveys.

 

Additionally, 67 percent of respondents “agreed that, in general, physicians in the United States over-prescribe controlled substances to treat pain.”

            Drs. Papp and Jerry pointed to HCAHPS questions 2 and 3 specifically that may be a factor:

(1) “During this hospital stay, did you need medicine for pain?” Patients can answer “yes” or “no.” (2) “During this hospital stay, how often was your pain well controlled?” Patients can answer “never,” “sometimes,” “usually” or “always.” (3) “During this hospital stay, how often did hospital staff do everything they could to help you with your pain?” Patients can answer “never,” “sometimes,” “usually” or “always.”

 

Unless patients answer “always” to these last two questions, the hospital is considered an “underperformer” by Centers for Medicare & Medicaid Services (CMS) and may be financially penalized.

            With these survey results, one may reasonably wonder if a “cultural paradigm of overly aggressive pain management … exists and will continue to be a barrier to efforts to address the opioid epidemic.”

            Drs. Papp and Jerry offer three suggestions that might help: (1) Perhaps CMS should consider giving “partial credit” for responses for HCAHPS questions 2 and 3? It is very difficult clinically to “always” relive acute and chronic pain. (2) In the introductory question attention is directed toward “medicine”; there are many other pain modalities such as ice packs, improved positioning, physical therapy, and surgical intervention, that are not addressed. (3) Perhaps CMS should use “discomfort” rather than “pain” in the questions? As worded, there is little room for patients and doctors reflecting on other pain control options for rapid pain relief.

            The opioid prescription drug crisis in America is real. During the month of March 2016 alone, a great deal of attention has been directed to the problem. The U.S. Senate recently passed S.B. 524, the Comprehensive Addiction and Recovery Act (CARA) to provide “money for various treatment and prevention programs for a broad spectrum of addicts, including those in jail. It also strengthens prescription drug monitoring programs to help states and expands the availability of the drug naloxone, which helps reverse overdoses, to law enforcement agencies.”

The Massachusetts and Wisconsin legislatures enacted laws establishing new prescribing rules and allowing for the better disposal of controlled substances. And the Centers for Disease Control and Prevention (CDC) published their Guideline for Prescribing Opioids for Chronic Pain with advice for primary care clinicians not dealing with end-of-life or palliative care situations. Even so, much still needs to be done to improve pain control while minimizing risks of addiction and abuse. All the more reason to align as many forces as possible – including a revision of the CMS HCAHPS patient satisfaction questionnaires – to maximize best practices in prescribing opioids.

 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

February 12, 2016

Pain Relief is an Ethical Issue

When patients lack capacity, physicians look to family and friends to step in and provide consent for treatment on behalf of the patient.  These surrogates, whether they were appointed by the patient as their health care agent or become health care surrogates by default under state law based on their relationship to the patient, have the right to receive information related to the care and treatment of the patient and have the corresponding responsibility to make health care decisions for the patient based on either the patient’s previously expressed wishes or her best interests.  What they don’t have, however, is the right to control and direct every minute aspect of the patient’s care in the hospital.  It would take several blog posts to discuss the conflicts that occur between surrogates and health care providers because of this (such as DNR orders, barriers to discharge, and demands for certain medications, to name a few), but perhaps the most concerning example of surrogate over-reach is the issue of inadequate pain management.

The use of pain medication can be difficult for both patients and providers, especially with the rate of opioid abuse in this country.  Patients and their families are often afraid of the possibility of addiction, while physicians are reticent to prescribe narcotics for fear of misuse.  Whether or not a patient is a “drug-seeker” is a common question that arises when physicians are deciding what to prescribe.  However, in the context of terminal illnesses – particularly at the very end of the illness – the shift in focus from curative to palliative care highlights the need for sufficient pain control in the face of nearly intractable pain.  It is in this context that denial of pain medication, or poor pain management, is most clearly an ethical issue.

I have often heard complaints from health care providers about how surrogates have refused to consent to pain medications, or insist that physicians give lower doses than medically appropriate.  When I ask how the provider responded to such requests, all too often the answer is, “I followed their direction.”  We are so used to turning to surrogates for consent for every treatment and procedure, but is it really within the surrogate’s authority to consent to or refuse pain medication?   Assuming there is no advance directive from the patient opposing adequate pain medication, do surrogates have the right to refuse it?  More importantly, is it ethical for physicians to withhold adequate pain medication at the direction of a surrogate despite obvious signs of pain in the patient?

While respect for autonomy is a bedrock principle in our society, and we would certainly honor the informed refusal of pain medication by a patient with capacity, this respect for autonomy does not mean we necessarily honor the directives of the patient’s surrogate to the same extent as we would the patient herself when it comes to pain control.  Without explicit direction from the patient, certain basic assumptions are made about what the patient would want: namely, relief of pain and suffering.  While questions of withdrawal of life-sustaining treatment or palliative surgery may properly be left to the surrogate, the provision of pain medication is assumed as part of basic care for the patient in accordance with the principle of nonmaleficence.  We have an obligation to do no harm to patients, and to the extent possible, to relieve suffering.  While the side effects of opioids should certainly be considered and discussed with the patient’s family, particularly as it may affect the patient’s awareness or respiration, if other palliative approaches are not sufficient to address the patient’s pain, these side effects should not preclude the use of pain medication.  Interventions aimed at pain relief should be given in the overall best interests of the patient, considering the risks and benefits.  Especially at the end of life, providing comfort to the patient should be of utmost importance, even if the surrogate objects.  When pain relief is an ethical issue, it is not an issue for the surrogate alone to decide.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

October 16, 2015

If I Were Running the Place

<p style="font-size: 11.2px; line-height: 19.04px;"><span style="font-size: 11.2px; line-height: 19.04px;">I have a riddle for you.  Start with six attorneys; add three management consultants, three financial executives/advisors and a couple of bankers. Sprinkle in, one each, clothing store chain CEO and entertainment retail chain CEO. Add executives from a supermarket chain, a construction company, and a paper products company. Fold in a hedge fund manager, real estate executive, and an accountant. Finish with a reputation management expert and exactly one educator and one physician. What have you got? Perhaps you have the membership of an exclusive club, perhaps a class reunion of an exclusive prep school. No not these.  I will not make you guess any more. What you have is the Board of Directors of a large academic medical center which includes a major teaching hospital and a medical school. This academic medical center educates medical students and physicians, graduate students in science and other health professions. This teaching hospital is a major health care provider in the state capital of a large northeastern state. The academic medical center is the leading biomedical research organization in the region.</span></p> <p style="font-size: 11.2px; line-height: 19.04px;">The Board of Directors is fully responsible for the governance of this large and complex organization. This organization has a mission to educate, to conduct biomedical research, and to provide patient care services. I was expecting to see that this list of directors would include expertise from renowned educators with national reputations. I was expecting to see a list containing outstanding biomedical researchers who discovered knowledge which made the world a better place. I was expecting leaders from the field of healthcare and medicine. But that is not what I found. I was surprised.</p> <p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;">Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
October 5, 2015

Elective or Life-Saving? Catholic Hospitals and the Ban on Tubal Ligation

<p style="font-size: 11.2px; line-height: 19.04px;"><span style="font-size: 11.2px; line-height: 19.04px;">A Catholic hospital </span><a style="font-size: 11.2px; line-height: 19.04px;" href="https://www.rt.com/usa/315359-catholic-hospital-denies-sterilization-request/">came under fire recently</a><span style="font-size: 11.2px; line-height: 19.04px;"> for stating that it would not permit doctors to perform a tubal ligation during a c-section scheduled for October.  According to news reports (including an</span><a style="font-size: 11.2px; line-height: 19.04px;" href="http://www.thedailybeast.com/articles/2015/09/23/a-catholic-hospital-says-it-s-evil-for-me-to-get-my-tubes-tied.html">article written by the patient herself</a><span style="font-size: 11.2px; line-height: 19.04px;">), the pregnant patient has a brain tumor, and her doctor have advised her that another pregnancy could be life-threatening.  Her doctor has recommended that she have a tubal ligation at the time of her c-section.  While my knowledge about this hospital, this case, and the participants is limited to what has been reported in the media, it raises an interesting question: in our pluralistic society, where conscientious objection is respected while maintaining a patient’s right to a certain standard of care, is it ethical to allow a religiously-affiliated health care institution to refuse to provide certain treatments it finds morally objectionable?</span></p> <p style="font-size: 11.2px; line-height: 19.04px;"><span style="font-size: 11.2px; line-height: 19.04px;">As background, the Catholic Church has historically been outspoken on bioethical issues and has a strong and robust bioethical teaching.  Catholic hospitals are governed by the </span><a style="font-size: 11.2px; line-height: 19.04px;" href="http://www.usccb.org/issues-and-action/human-life-and-dignity/health-care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifth-edition-2009.pdf">Ethical and Religious Directives for Catholic Health Care Services</a><span style="font-size: 11.2px; line-height: 19.04px;"> (ERDs), a document promulgated by the United States Conference of Catholic Bishops (USCCB) that clearly articulates the bioethical policies that must be followed in a health care institution based on the Church’s moral teachings.  It explains the Church’s teaching against direct sterilization as a method of birth control based on the </span><a style="font-size: 11.2px; line-height: 19.04px;" href="http://plato.stanford.edu/entries/double-effect/">principle of double effect</a><span style="font-size: 11.2px; line-height: 19.04px;">.  “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution.  Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.” (Directive 53).  In other words, if the sterilization procedure directly treats a pathology, it is licit; if it is used as a form of birth control to prevent a pregnancy, even if that pregnancy would be life-threatening, it is not licit.</span></p> <p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;">Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
September 4, 2015

Are Primary Care Providers Providing Primary Care?

<p class="MsoNormal" style="font-size: 11.2px; margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 11.2px;">I initially set out to write a post about lack of access to primary care physicians, but the more I explored the topic, the more I realized that the issue is not only that access to PCPs is limited, but that the medical model of primary care itself has changed.</span></p> <p class="MsoNormal" style="font-size: 11.2px; margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 11.2px;">It has been widely discussed among bioethicists and health care policy experts that emergency departments are overcrowded, urgent care centers are rapidly</span><a style="font-size: 11.2px;" href="http://registerguard.com/rg/news/local/33331415-75/ccundoctored-sidebar-hedliney-herey.html.csp">becoming a substitute for the traditional primary care doctor</a><span style="font-size: 11.2px;">, and that the number of new physicians specializing in primary care medicine has been declining </span><a style="font-size: 11.2px;" href="/BioethicsBlog/post.cfm/what-we-can-learn-from-medical-students-about-the-need-for-health-care-reform-in-the-u-s">in favor of other, higher-paying specialties</a><span style="font-size: 11.2px;">.</span><span style="font-size: 11.2px;">  </span><span style="font-size: 11.2px;">Still, many insurance plans require regular visits with a PCP and only cover specialty services if the referral is made by the patient’s primary doctor.</span><span style="font-size: 11.2px;">  </span><span style="font-size: 11.2px;">Specialists and urgent care clinicians also insist that patients follow up with their PCP after treatment and make sure that their records are forwarded.</span><span style="font-size: 11.2px;">  </span><span style="font-size: 11.2px;">Despite the push for establishing a “medical home” and centralizing care around the primary care physician, demand for urgent care or emergency services is still high, and getting into a practice or getting a timely appointment with a primary care physician is difficult.</span></p> <p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.04px; font-size: 12px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.04px; font-size: 12px;">Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
May 14, 2015

Why Do We Over Treat Patients in the U.S.?

<p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">As a clinical ethics consultant and bioethics professor for many years, it still amazes me that one of the most common problematic features of our healthcare system is the tendency to over treat patients to the point of causing harm and wasting financial resources. The question is, why?</span></p> <p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">The question, why do physicians generally over treat patients in the U.S., must be approached in light of the fact that we spend more per capita and more overall, about 16% of GDP, on healthcare and get far worse outcomes than do countries like Canada and Western European countries who spend far less of their GDP on healthcare. But to be fair, before we blame physicians entirely for making poor judgments about treatment options, it is important to keep in mind that the U.S. is big, diverse nation with complex social and economic issues where creating efficient systems of healthcare is both practically and politically challenging. Also the U.S. spends more on medical research than most other countries, which still benefits patients everywhere. But what is most uniquely American is an economic system designed by politicians first and foremost for creating wealth for investors and that provides, generally speaking, efficient markets for consumer goods and services. But, whatever the virtues of American capitalism in creating efficient markets, it does not hold true for healthcare.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;"> </span><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 11.1999998092651px; line-height: 19.0400009155273px;"> </span></p>
April 10, 2015

Ethics in the Age of Ebola

by Joseph J. Fins, M.D.
It now seems a lifetime ago. The first case of Ebola had come to the Western hemisphere and taken the life of Thomas Eric Duncan at a Dallas, Texas hospital.