Frustrating Patients

My attending and I have a pretty good relationship. Good enough that we can have a back and forth about politics (typically a no-no in the world of medical education and "professionalism"). He tends to point out my leftist tendencies and I point out his right-winged nuttiness. After 3 weeks of working in his clinic, which serves a rather impoverished part of the state, I can see his point of view.

Nearly half his patients have their healthcare covered by the state. This is great, but it seems like those same patients tend to do the worst at taking care of themselves. I don't mean eating right and exercising. I could understand if they didn't have the resources to do that. I mean they ignore doctor recommendations, then get an exacerbation of their disease, get admitted and have a hospital work-up that costs tens of thousands of dollars, get better, then go back and ignore every recommendation made to them. It's frustrating for a physician when a patient who is unemployed (and has no trouble with transport or any responsibilities at home) misses important appointments repeatedly or a patient who has all their medications paid for not taking them. Yes, some patients with good insurance also fall into this pattern, but from my admittedly short experience so far, it's a nearly universal pattern with those that are under the public health plan (and my attending agrees). One assumption I could make is that they have trouble following recommendations because they have a lot of other problems in their lives, but it's hard to tell if that's the case.

No, fear not dear readers (both of you), I'm not becoming a Republican (though my attending keeps on telling me that it's a matter of time). Rather, I think that there needs to be a shift in healthcare resources. Covering expensive medications and procedures is great, but I'd rather give those up for increased education of patients and more access to social workers. Preventative care looks great on paper, but in the real world, it only goes as far as patients know to take it.

Refill on the Vics

So two weeks into a non-academic community setting, I've learned what the real world is like. I'm not so surprised by fact that there are a lot of patients who are addicted to narcotics. I'm more surprised by how there are so many doctors that are feeding their addiction. It's so easy for a patient to find a doctor that will prescribe them some heavy-duty narcotics without too many questions that things that I learned in med school like counseling, pain contracts and limiting refills just plain doesn't work. If legitimate doctors to try to manage their patients' chronic pain without overly relying on narcotics they risk losing the patient and likely the patient's other chronic medical conditions won't be taken care of. Or, they can just write the refill to bring them back and make sure that they have their diabetes, high cholesterol, heart disease, asthma, etc. under control. It's a hard decision to make, but many of the patients in this area just won't see a doctor unless they need their pain meds refilled.

Slow Start

So, I'm officially a doctor. July 1st was supposed to be a mind-numbing experience where I get thrown into the medical system, overwhelmed with things to do and actually get to feel like I'm making a difference in people's lives. Unfortunately, I feel like I've gone back a few years. I start with a primary care rotation. Primary care is not my thing, but I can appreciate the value of health maintenance and getting to know patients and I was looking forward to actually acting like a primary care doctor. To my surprise, I find out that all I do is shadow a physician while he sees his patients. It's worse than 3rd year. At least then I got to see patients beforehand. The clinic I'm at doesn't have electronic records, so I can't even read about the patients. I go in not knowing what's going on and about 30 seconds later come out not knowing what happened. The physician knows his patients and doesn't really need to go into the details that I would have needed in order to diagnose and treat (actually, I'm a little wary of how quickly he goes through patients). It's a complete waste of time. All I can say is that at least I get paid for it.

Bad science in clinic

I was very disappointed by my recent preceptor, who's pretty good with practicing evidence-based medicine (even when it contradicts the current trends), at recommending an unproven treatment to a patient. We had a patient with reflux disease who was well-controlled with a proton-pump inhibitor (PPI). He suggested that acupuncture might be a good alternative. Then went on to describe this study, in which patients who failed standard therapy with a PPI were randomized into one group that received a double-dose of PPI and another group that received acupuncture in addition to the standard dose. Surprise, surprise, the acupuncture group got better. This is a terrible study that is doing nothing but comparing apples to oranges. First of all, if patients failed standard therapy, the chances of failing a double dose is pretty damn high. Second, where is the control for acupuncture? How do we not know that the acupuncture group is getting a placebo effect? They could have easily placed needles in the wrong places as a control. Third, this doesn't even apply to the patient we were talking to, she was responding to PPIs. Overall, terrible advice by an otherwise well-informed doctor. At least he described the methods to the patient. Luckily, the patient preferred sticking to her trusty PPI.

The one thing I learned from the paper: In the UK, GERD is called GORD (gastro-oesophageal reflux disease).

In the donut hole

Ms. X is a 80-something year-old woman with congestive heart failure, high blood pressure, diabetes, rheumatoid arthritis and asthma (among other things). She on about 15 medications that adds up to nearly $4000 a year. Unfortunately, this falls right in the middle of the famous donut hole of Medicare Part D (the prescription coverage part of medicare). I never really thought much about it until I saw how this affects Ms. X. Here’s Medicare Part D’s payment schedule from 2010:

If your drugs cost between $2830 and $6440 per year, you get no coverage, but if your drugs cost more than $6440, you get 95% of it covered by medicare. This makes absolutely no sense to me. I was wondering how the hell this came about and it turns out that it’s the consequence of two separate coverage plans (one clearly made completely independently of the other). There’s Medicare initial drug coverage that covers 75% of all drugs on the formulary from $310 to $2830 (there’s a $310 deductible). Above $2830 there is no additional coverage by Medicare’s initial drug coverage. However, if you have to spend (out of pocket) more than $4550 (that’s your prescription drug costs go over $6440) Medicare’s catastrophe coverage kicks in. At this point, Medicare pays 95% of anything that goes over. Medicare does have an “Extra Help” program that includes coverage of the donut hole, but you have to make less than $16245 a year to qualify (not really much). Ms. X is a widower who rents an apartment in town. She has an income of about $18000 a year. She makes too much to qualify for the extra help. She can’t really afford to pay an extra $60-$80 a month that the extra “gap coverage” insurances cost. Now, I don’t spend much money, but I know that you really can’t do much on $18000 a year, especially if you have numerous chronic medical problems. Ms. X has gotten to the point that she is not eating well, she’s not filling some of her prescriptions and has even resorted to taking her son’s albuterol (he has private insurance) for her asthma.

Luckily, the healthcare reform package that recently passed will start closing this donut hole, but it looks like it won’t be until 2020 before the gap is completely closed. I’m not sure why it should take 10 years to fix it. I’d bet that none of the people who set this system up or who decided that it's ok to wait 10 years before closing the gap have an 80 year-old grandmother who steals their albuterol.

Burnt out

It's official, I'm totally burnt out with 3rd year of med school. The primary care rotation is pretty relaxed, but I just can't get myself to study much or do any of the mind-numbing busy work that we are assigned. I'm glad I don't have something more intense like internal medicine or surgery scheduled now. Luckily, it looks like I'll have a pretty chill 4th year (though I'm not looking forward to taking Step 2 of the boards) and I'm looking forward to the adventure of applying for residencies.