Making Time For Patients

"Time, is on my side, yes it is." The Rolling Stones

Unfortunately, when it comes to primary care medicine, time is not on the patient's side.  According to a study published in the Annals of Family Medicine by Valerie Gilchrist, MD and her colleagues, primary care physicians spend nearly a third of their time on non-patient activities.  What's the solution to this time crunch?

The Wide World of Healthcare

Dr. Rich, author of the award winning Covert Rationing Blog, is this week's host of Get Better Health's Grand Rounds, Vol. 7, No.22.

This week's edition of Grand Rounds features an eclectic sampling of bloggers and topics.  It's a great way to get a feel for what's happening throughout healthcare.

A special thanks to Dr. Rich for including my post on aggressive medical treatment.  Enjoy!

The Personal Side Of Personalized Medicine

The stories of Adriana Jenkins and Marty Tenenbaum make a compelling case for the need to develop more targeted drug treatments. But no matter how sophisticated the treatments, their unique stories remind me that care must be delivered with a personal touch, by compassionate and caring clinicians.

Adriana Jenkins, a Boston area public relations professional, died of breast cancer last week at age 41. Soon after her initial diagnosis she participated in a clinical trial studying Herceptin, a drug targeted at a specific cancer mutation. Though her cancer eventually returned, she reflected that personalized medicine had extended her life by at least nine years. In her article, A Dying Wish, Adriana suggested that lawmakers create a law which encourages pharmaceutical firms to develop personalized drugs through incentives such as fast track regulatory review and patent protection.

Cancer survivor Marty Tenenbaum isn't waiting for lawmakers. He's taking on the crusade for personalized medicines himself. In January 2011,Tenenbaum a former e-commerce entrepreneur, launched an online community called Cancer Commons. The online community brings together physicians, patients and scientists so that they can collaborate in creating personalized therapies for patients. Cancer Commons grew out of Tenenbaum's frustration in finding the best course of treatment for his own cancer diagnosis in the late 1990s. He envisions Cancer Commons as a way for other cancer patients to received the same personalized treatment that he did.

The speed at which personalized treatments are developed and introduced will depend on larger issues such as government regulation and improved scientific collaboration. But there's nothing holding us back from personalizing care for all patients, beginning today.

How do you personalize patient care?

Disagreement Over Aggressive Medical Care

Last week, New York Times columnist Pauline Chen argued that aggressive medical care can be beneficial for surgical patients. I agree with her, to a point. Ultimately, though, decisions about the aggressiveness of care should depend on the patient's wishes (or those of surrogate decision makers), after being presented with the advantages and disadvantages of treatment options, evidence about their effectiveness, and the availability of resources and clinical expertise.

Consider one patient's story, discussed at a recent Schwartz Center Rounds session. Do you think aggressive treatment was appropriate?

The patient was an elderly man with dementia who was unable to live independently; however, he was alert and enjoyed the company of his family. When the patient developed a life-threatening abdominal condition, his family was unsure about whether he should have surgery. His wife was opposed, maintaining the patient wouldn't have wanted to continue living in his present state. The patient's oldest son did not want to withhold surgery because this would mean imminent death. The patient underwent surgery but two weeks later was not recovering as expected. Eventually, the family made the decision to withdraw life support.

Dr. Beth Lown, Medical Director at the Schwartz Center, suggested one option would have been for the patient's primary care physician to guide the family through a series of discussions prior to surgery. Specifically, the conversations could have included:

• how to make the patient comfortable
  
• what were the patient's wishes
  
• how to shepherd the family through the process of making a surrogate decision
  

With the decision to pursue surgery, Beth noted that the patient and family should fully understand both the procedure and the postoperative recovery process, including possible complications and estimated recovery time.

How do you engage patients and family members in decisions about the aggressiveness of their care?

Tired of Winter?

After five feet of snow in Boston this winter, I'm ready for a break! This week's host of Get Better Health Grand Rounds (vol. 7, No. 20), Suture for a Living, provides some relief! Dr. Ramona Bates has published some beautiful beach photos along with a wonderful summary of writing from the healthcare blogosphere. Thanks to Dr. Bates for including my post on advance directives and giving me hope that this cold, snowy winter won't last forever!

A Healthcare Nightmare

Stories like Dr. Madeline Biondolillo's keep me up at night. In a chilling account published in the Boston Globe, Dr. Biondolillo wrote about her mother's ordeal after she suffered a heart attack. Her 84-year-old mother survived, but there were several close calls during her hospital stay. As Dr. Biondolillo notes, her mother had the benefit of insiders to advocate and communicate on her behalf: two daughters, a doctor and a lawyer, both knowledgeable about how to work the healthcare system.

In the past, the primary care physician was the patient's health navigator and advocate. Today the primary care physician often doesn't follow a patient over the course of an illness due to the fragmentation of care resulting from specialization and increased use of hospitalists. Our national survey of 800 recently hospitalized patients reflects this trend: 62% said they never heard from their primary care doctor while in the hospital and 29% said they had not met the doctor in charge of their care before entering the hospital.

Perhaps healthcare innovations such as medical homes and accountable care organizations, concepts designed to improve coordination and promote accountability will help; but providers must make a special effort to communicate with each other as well as patients and their families so that patients don't get lost in the system.

Patients and family members should fill the communication gap by seeking out those who help them "navigate the shoals," whether this be through patient advocates at hospitals or representatives within insurance plans. Patients and families will also need to work with their primary care physicians to keep updated lists of medications, allergies, and medical problems, to ask about who is in charge of a hospitalized patient's care, and to insist on "appointment" times to meet with the doctors in charge to get updates throughout a hospital stay.

Following these steps is a good precaution but personally I won't sleep well until we see substantive reform of our healthcare delivery system.

Do you agree with Dr. Biondolillo that accountable care organizations are a way to address the problems in our healthcare delivery system?

Grand Rounds Vol. 7, No. 19 is up at HL7 Standards!

Visit today's issue of Get Better Health's Grand Rounds for an excellent summary of how technology is changing healthcare, including doctor-patient communication. Thanks to host HL7 Standards for including my post on minimally disruptive medicine.