Tuesday, October 31, 2017

How Important is A Mother's Intuition?

A career in medicine wears down the hearts and souls of many physicians.  My pediatric journey has been filled with countless rewarding moments, but also haunting ones as well. By the third and final year of residency arrived, I was unclear as to whether medicine had been the right choice for me at all.  After 11 years of hard work, dedication, and the burden of heavy debt, the destination looked different than I had imagined.  While filled with doubt, one of the most important lessons of my career reeled me back for more:  the necessity of trusting a mother’s intuition. 

When I entered room number 10 in the emergency room, a 6 year old girl was sitting on the bed and her mother was sitting next to the bedside.  When I inquired as to her chief complaint, she answered “something is not right about my daughter and I would like you to do a blood test.”  It was the final day of 10 12-hour shifts in a row and I could not seem to muster even one more ounce of compassion.  “Ok” I replied without giving it much thought.  I sighed, completed a cursory history and physical, and though many years have passed since this night, nothing seemed clinically worrisome at the time.  In all fairness, my closed minded perspective likely got in the way. 

While checking the computer for prior visits, I saw her daughter had a blood count done the previous day.  Yesterday, the result had been normal.  I was incredulous. The pediatric emergency room was very busy that night.   Relaying the story to my attending, he told me to “do another CBC and release her once the result came back normal.”  Returning to the room, I let her know a complete blood count (CBC) had been ordered.  Relief washed over her face.

Reflecting back years later, I would characterize myself as being abrupt, condescending, and dismissive of this mother and her concerns.  I felt justified thinking she could not possibly “know” what I knew as a physician and she was being overprotective.  Let me be very clear, this story is absolutely about a night this physician-in-training learned a hard lesson, one which changed the course of my practice of medicine for the better.

Approximately one hour later, the lab called up to the emergency room with results.  “It’s leukemia”, said the lab technician.  My jaw, and my heart, hit the floor.  “Excuse me, will you say that again please?” I asked, still unable to believe this healthy child was sick.  “Leukemia”, she repeated.  “There must be some mistake. The result of the smear was normal yesterday.”  She replied, “No, we missed it yesterday.”  Apparently, the laboratory director pulled the smear evaluated the previous day, reviewed it, and found immature cells which are characteristic of early leukemia. 

I slowly walked to the exam room wracked with guilt while tears welled up in my eyes and sat down to tell this mother that her beautiful little girl indeed had leukemia. The oncology team planned to admit her that evening and begin the oncologic evaluation and treatment process according to protocol.  I felt terrible; not only for the diagnosis, but also for my glib demeanor while interacting with this mother and her child.  She sighed and said she was relieved to finally know what was wrong with her daughter.  “I am so sorry,” I said.  I was sorry for many more things than I could say. 

This is one moment I wish could be erased from my memory and done again, though differently.   Ideally, I would greet the mother and child with a warm smile, take an extensive history, perform a thorough physical exam, discuss a list of possible diagnoses with mom, and send blood tests accordingly.  I would reassure this mother we would properly evaluate her concerns.

The wisdom imparted to me by this mother has been absolutely priceless.  She taught me the most vital thing physicians do is to take time and listen to the patient or the person who knows their child best.  This unforgettable lesson has stayed with me for the past 18 years.  This “little” girl would be 24 years old today and may already have children of her own; she owes a debt of gratitude to her mother for having the tenacity to push a doubting physician to do her job.    Thank you.     

Tuesday, October 17, 2017

Do Physicians Deserve Our Mercy? #silentnomore

This past week a video went viral when a woman complained about the lengthy wait time at a clinic.  On video, we see the physician asks if the patient still wants to be seen.  The patient declines to be seen, yet complains patients should be informed they will not be seen in a timely manner.  The frustrated physician replies, “Then fine…Get the hell out. Get your money and get the hell out."  While we do not witness events leading up to the argument between doctor and patient, we do know staff at the front desk called the police due to threats made by the patient to others. 
Based on the statement released by Peter Gallogly, MD, he is a humble, thoughtful, and compassionate physician who was very concerned for the safety of his staff, which he considers “family.”  Physicians like Dr. Gallogly do their best to serve patients, ease their suffering, and avoid losing ourselves to burnout at the same time. Every human being deserves our compassion, kindness, and clemency.  Patients and physicians must accommodate each other when possible.
Do physicians actually deserve our mercy when necessary?  Yes, they do.  I should know.  The kindness shown to me by my patients over the past month has been unparalleled, leaving this physician thankful beyond words. 
My father has been a practicing pediatrician in our community for 47 years.  As I type these words, he is dying in a hospital bed.  We have worked side by side for the last 16 years.  It is difficult to make it through the day, desperately hoping to hear his voice one last time in the clinic hallway.  He was carrying a full patient load before an unexpected cardiac arrest ended his career.  The patient load doubled overnight; it is a burden I am carrying alone.
Many families have brought their children, grandchildren, and great-grandchildren to us for more than 40 years.   We have seen them through the darkest moments of their lives, at their most vulnerable, and brought them into the light.  Now, our patients must guide me through unimaginable heartache and grief. 
Long wait times can be terribly frustrating.  Punctuality has long been a personal obsession. Lately, I have been unable to keep up; patients with appointments are waiting more than two hours to be seen.  Every new encounter begins with an apology for tardiness followed by an update on the condition of my father.  Most families are aware of my overwhelming task -- running a practice built for two when I am but one physician.  Not a single parent or child has complained, yelled, accosted, or threatened.  Each family has shown me desperately needed mercy.
Over the last twenty-one days, patients have provided 15 home-cooked meals.  Some have assisted by car-pooling my children or taking care of them when my presence at a last minute hospital care coordination meeting was required.  Others have simply offered a helping hand, by filing charts, running errands, or landscaping the grounds.  This is the physician-patient relationship as it was meant to be, simple, beautiful, and perfect. 
Yesterday, after apologizing yet again, a mother reassured me she would wait as long as it took to have her child seen, hugged me tightly, told me to take a deep breath, and offered me her chair to rest.  She reminded me to take care of myself.  In the next room was a grandmother who has been patronizing our practice since 1977, when I was barely three years old.  She offered billing services free of charge and emphasized how grateful she was for the loving care provided for two generations to her family.  
The clinic my father established is a place where mutual admiration between physician and patient has existed seamlessly for a half century.  Magic happens when patients walk through our doors.  The next time your physician is running late, consider the challenges they might have faced that day.  Accommodating their delay will be treasured more than you can possibly imagine.
Medicine is not a hospitality industry.  Patients are not customers and physicians are not restaurant wait staff.  We gave up our youth to become educated, skilled, and compassionate.  Saving the life of human beings is not equivalent to ordering a hamburger and having it served your way.  Physicians genuinely work hard to serve patients at their most desperate hour.  Remember, we are also human beings, who unequivocally need and deserve your mercy.      

Tuesday, October 10, 2017

Building Better Metrics: Immunizations and Asking the Right Question?

As policy experts cling to pay-for-performance (P4P) as an indicator of healthcare “quality” and shy away from fee-for-service, childhood immunization rates are being utilized as a benchmark.  At first glance, vaccinating children on time seems like a reasonable method to gauge how well a primary care physician does their job.  Unfortunately, the parental vaccine hesitancy trend is gaining in popularity.  Studies have shown when pediatricians are specifically trained to counsel parents on the value of immunizations, hesitancy does not change statistically. 

Washington State Law allows vaccine exemptions on the basis of religious, philosophical, or personal reasons; therefore, immunizations rates are considerably lower (85%) compared to states where exemptions rules are tighter.  Immunization rates are directly proportional to the narrow scope of state vaccine exemptions laws.  Immunization rates are used to “rate” the primary care physician despite the fact we have little influence on the outcome according to scientific studies.  Physicians practicing in states with a broad vaccine exemption laws is left with two choices:  refuse to see children who are not immunized in accordance with the CDC recommendations or accept “low” quality ratings when caring for children whose parents with beliefs that may differ from our own.   

The more willing a physician is to care for those with differing philosophical, religious, and cultural beliefs, the more CMS metrics will discriminate against our open-hearted approach.  Reflecting upon my medical school admissions interview, my open heart and mind are some of the reasons for entering medicine in the first place.  As I contemplated my tumbling quality indicators by continuing to see children regardless of immunization status, I stumbled upon some ICD-10 code gems: 

  • Z28.0 -   Immunization not carried out because of contraindication
  • Z28.01 - Immunization not carried out because of acute illness of patient
  • Z28.02 - Immunization not carried out because of chronic illness or condition of patient
  • Z28.03 - Immunization not carried out because of immune compromised state of patient
  • Z28.04 - Immunization not carried out because of patient allergy to vaccine or component
  • Z28.09 - Immunization not carried out because of other contraindication
  • Z28.1   -   Immunization not carried out because of patient decision for reasons of belief or group pressure
  • Z28.2  - Immunization not carried out because of patient decision for other and unspecified reason
  • Z28.20 - Immunization not carried out because of patient decision for unspecified reason
  • Z28.21 Immunization not carried out because of patient refusal
  • Z28.29 - Immunization not carried out because of patient decision for other reason
  • Z28.8  - Immunization not carried out for other reason
  • Z28.81 - Immunization not carried out due to patient having had the disease
  • Z28.82 - Immunization not carried out because of caregiver refusal
  • Z28.89 - Immunization not carried out for other reason
  • Z28.9 - Immunization not carried out for unspecified reason

Surprisingly, ICD-10 and the advanced coding technology might have had some unanticipated benefits.    If a physician uses vaccine refusal codes appropriately, the patient in question should be removed from the denominator being used to calculate immunization rate for a given clinic or physician. 

This allows immunization rates to reflect “quality” while accounting for factors outside the control of the primary care physician.  Vaccine exemption laws must be considered confounding variables when using immunization rates as a quality metric; eliminating confounding variables purifies the data set.   This is a simple concept, so why are metrics being collected by CMS not controlling for caregiver refusal when it is mandated by law?  Accuracy is the point of collecting data in the first place, right?  If you believe CMS is interested in accuracy, then I have a bridge somewhere to sell you on the Olympic Peninsula.

ICD-10 codes already allow for regional specificity; a physician in Washington State has codes when a patient is pecked by a chicken (W61.33) or bitten by a cow (W55.21); there is even a code when a one is struck by an Orca Whale (W56.11), an event more likely to occur in Washington than Idaho.  If we can code for injuries sustained when our water skis catch on fire (W91.07) after a civilian boat collided with a military watercraft (V94.810) while waterskiing on the Puget Sound near the Naval Undersea Warfare Center Keyport, then we certainly should be capable of controlling for confounders which do not reflect the “quality” of care a physician provides.  

Claude Levi-Strauss, once said, “The scientific mind does not so much provide the right answers as ask the right questions.”  Immunization rates are clearly NOT an accurate quality indicator.  Maybe it is time for policy experts and physicians to question what constitutes the provision of high-quality health care in the first place.  Only then, can this country move in the right direction. 

Friday, October 6, 2017

What do Playground Slides and Golf Carts Have in Common?

Statistics on childhood injuries from playground slides and golf carts were presented this weekend as a part of injury prevention efforts at the annual meeting of the American Academy of Pediatrics.  Injury prevention has long been a focus for pediatricians as it is an important element of child advocacy.  As a result of injury prevention efforts, bicycle helmet use has become almost universal across this country, sports gear has been adjusted to be more protective, and even automobiles come with factory-installed airbags, LATCH systems, and backup cameras.  The next frontiers for injury prevention are playground slides and golf carts.  

Backyard playground slides are a rite of passage for most small children.  This past summer, one little patient of mine was injured on a slide in her backyard while playing naked with her three sisters.  Unbeknownst to their mother, the four decided to hose down the slide in the effort to increase their sliding speed.  When that was not adventurous enough, they put gravel at the bottom to “liven things up” even more.  The middle toddler was brought in after sustaining a gluteal laceration containing small pieces of gravel.   While cleaning the wound and removing pieces of gravel with small tweezers, the mother was lamenting the fact that her daughters were so fearless.  I smiled, reassuring her this is what children do – push the envelope.  

Playground slides injured an estimated 352,698 children less than 6 years of age between 2002 and 2015.  A recent abstract, “The Mechanisms and Injuries Associated with Playground Slides in Young Children:  Increased Risk of Lower Extremity Injuries with Riding on Laps,” evaluated playground slide injuries in more detail.  According to the data, the riskiest age for injury is 12-23 months.  36 percent sustained fractures, mostly involving the lower leg.  The most common mechanism of injury is when the child’s foot catches the slide edge while sitting on the parents lap.  

Understandably, parents believe assisting children on playground slides is protective but the number and nature of injuries sustained tells a different story.  If parents were made aware of this potential for injury, the chance they would stop going down slides with their children is highly likely to change. Educating parents about the risk of playground slides can be clear, effective, and likely to generate changes for pediatricians and parents.

Golf carts are increasingly becoming popular in small communities across this country and a recent study: “Golf Carts and Children:  11 year Single State Experience,” has demonstrated the possibility of  sustaining injuries which are fairly significant.  Researchers collected information from a trauma center in Pennsylvania and identified 108 children between 2004-2014 injured by golf carts.  On average, children were 11 years old and hospitalized between 1 and 26 days to recover.  

While golf cart injuries are not necessarily common, the injuries can have significant sequelae.  Admission to the ICU was necessary 36 percent of the time.  More than three-fourths of children studied sustained a fracture and 44% of those were skull fractures, which were actually more common than fractures of the extremities.  For those sustaining head injuries, 27% had concussions, and 25-30% had intracranial injuries with associated bleeding.  

In closing, injury prevention is something near and dear to the hearts of most pediatricians.  As the world changes, so must our conversations with the parents of young children.  Based on these two abstracts presented at the AAP annual meeting, I will incorporate reminding parents to stay off playground slides with their children, and ensure their children are 16 years of age before being allowed to drive a golf cart independently while maintaining speeds of less than 10 miles per hour.  While childhood injuries will continue to be a rite of passage, pediatricians have the opportunity to reduce those with long-term consequences, such as skull fractures and intracranial bleeds. Educating parents   will go a long way toward ensuring the next generation grows up to make their own mark on the world in the future.