Careful What You Wish For (or, Creating a Monster)

About four years ago I had a meeting with a dear and trusted colleague and a bunch of Vancouver Coastal Health administrators. The chief executive officer and her group said “We have a culture of admission here”. Too many elderly people were being admitted to hospital through the big-city emergency room in Vancouver and they weren’t benefiting. And they were costing a lot of money.

Silence in the room.

I said to the assembled potentiates, “Put Jay (my trusted colleague) and me in that ER and we will turn that around for you in three months.”

“Who’s going to organize it?” they asked, and each of us pointed to the other. Jay it turned out was busy defending our home care of the elderly program and doing a lot of other things, and so making real of my boast fell to me.

The result was “EDiCare”, a unique program with a lot of funding and a lot of flaws. It arranged for me and as many doctors as I could gather together for weekday duty, plus a bunch of nurses spectacularly experienced and qualified at clinical care and dealing with our public health community system, to consult in a little office in a back hall of the huge ER. We started out feeling our way, and slowly convinced the emergency room doctors, nurses, and administrators we meant well, knew how to care for old people in the community, and were pretty good at basic critical care too.

Fast forward four years. About a year ago I left the EDiCare Medical Coordinator job and then quit working in the program altogether, moving outside Vancouver and slowly cutting my practice down as I got ready to retire.

Shortly after, one of my remaining patients in Vancouver got into trouble. She had been in the other big-city hospital with heart disease that nearly killed her about two months ago, and was discharged home still in a bit of heart failure but having survived her near-death experience. I look after a lot of medically sick frail elderly people at home and am pretty good at dealing with heart failure, but with this lady there were too many complicating factors, not enough laboratory support, and a risk that treating her heart failure too aggressively could make her worse. I referred her to a geriatric medicine specialist, and he recommended we admit her to hospital to get her treatment properly organized, and going against my instincts and everything I had been teaching and encouraging my team to do in the emergency room, we sent her in to be admitted.

There is a right time to do the wrong thing and I was pretty sure this was it.

But my team (no longer really mine) and even the hospitalist who would have admitted her thought she was “looking too good” to bring into the hospital. Over the years I had convinced these people to be skeptical of bringing frail elderly people into the hospital because of the risks of admission, and to at least try to get them out of trouble at home. But as I tried to explain I had already tried in this situation and it hadn’t worked out. She needed admission! But the team and the hospitalist sent her home.

My patient hung on in her little apartment still short of breath, still obviously in heart failure, still needing pretty well daily medication adjustment and monitoring with laboratory studies that take two weeks to obtain, a mentally intact person who wants to get better. Eventually we succeeded in getting her on enough medication to control the failure without drying her out. Happy ending but quite honestly much riskier for this dear lady then a week or two in the hospital.

Hospital was what she needed. But I couldn’t do it because of the culture of discharge we had created at the behest of our local administration, convinced in our hearts and minds that for frail elderly people community care is good and hospital care is bad.

And that’s true. Most of the time.

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I’ve moved

For over 10 years my wife and I have lived in two places. We’ve travelled back and forth each week between our home in Roberts Creek on BC’s Sunshine Coast and an apartment in Vancouver, where I’ve conducted my part-time practice looking after homebound frail old people with the HomeViVE program.

A few months ago we gave up our Vancouver apartment and are now full-time “Coasters”, but I’m continuing my Vancouver practice with its 24-hour on-call coverage for the foreseeable future, letting it diminish by attrition. At the same time, I’m looking to establish a home-care of frailty practice here on the Coast, and am gradually learning about the healthcare culture here and hoping I can make a small contribution to it.

My medical-legal work continues as before, centred in Vancouver but confined to Tuesdays.

I realized a few months ago that this is the first time in my life I’ve left Vancouver with no intention of returning, although where we now live is still a virtual stone’s throw from town in spite of the vagaries of BC Ferries. So far Robin and I are happy with the way things are developing, and we love our home and the relaxed atmosphere of this community.

I will try to describe this transition as it develops by posting here, although I have lately neglected a bit in favour of John Sloan’s Reviews, my restaurant and book review website.


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FMF Award Acceptance Speech

A couple of very good friends in Vancouver somehow convinced the Canadian College of Family Physicians and Canadian Geriatrics Society to give me an award for innovation in geriatrics. I don’t deserve it. Here is my acceptance speech at the Family Medicine Forum in Montréal on November 10, 2017.

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A Very Interesting Medical Book

I post this here having already put it in my “Reviews” website because I think it’s well worth reading and I take a slightly different message than most reviewers from it.

Kalanithi, Paul. When Breath Becomes Air. Random House, New York. 2016. NF;7/17.

I had a few mixed feelings about this very popular, and very good, book. I hope my swimming against the streams of sickness/death and the American physician isn’t all envy for this fine writer’s success, although nobody would envy his untimely death. Dr Kalanithi describes while trying to maintain humility his superstar status in neurosurgery training and enviable future as one of the best neurosurgeons in his country. No one could avoid emotion and fascination when he tells us he’d looked at hundreds of seriously abnormal x-rays and scans, but the one he now confronted was of himself.

He was a literary guy, encouraged as a child to read. Not only did he do that, but he took to heart the ideas he found in literature and philosophy and had a real philosopher’s curiosity. He even went into neurosurgery as a kind of physical experiment in philosophy of mind, after finding academic literature too political (and is it ever political). And unusually among physicians and just about everybody else, he saw science’s limits:

… Scientific methodology is the product of human hands and thus cannot reach some permanent truth… As strong as (reproducibility and objectivity) make its ability to generate claims about matter and energy, it also makes scientific knowledge inapplicable to the existential, visceral nature of human life, which is unique and subjective and unpredictable.

Wonderful. He was pleasingly Gawande-like picturing a feckless resident who promises to do an extra bit of work for him as a patient and then doesn’t, and critical care subspecialists arguing fine points of care over his dying body in the intensive care unit. He knew the profession is far from perfect.

But if we are looking for perfection, Paul Kalanithi, readers must conclude, came pretty  close. The book is his epitaph. He was a fabulously gifted and industrious young doctor dying (and dead when the book is published) and giving us his “words (which) have a longevity (he does) not.” His girl child is a baby when he dies, and he finished his book with a wise and thunderously moral message to her:

When you come to one of the many moments in life where you must give an account of yourself, provide a measure of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.

When I try to understand my real feelings about this magnificent final act, it’s not Paul Kalanithi himself that keeps me from alternately crying and jumping up and cheering. It’s what he unknowingly embraced when he chose his very difficult career. I’m a doctor too, but one who doesn’t have to exert much effort to lay claim to humility. Lots of people I’ve treated have properly felt anger, sadness, disappointment, and contempt for my work. I was that feckless resident. The good things I’m accomplishing at the end of my career don’t add up to a hill of beans compared to Paul Kalanithi before he even qualified. Not to mention decades of my own arrogance and greed. But my bad performance is mine. I don’t arrogate it, or any of the good I ever imagined myself doing, from something mystical that has been encouraged in society’s imagination.

That imagination continues to see my profession with all its institutions and technology as something to be revered and to tiptoe and whisper in the presence of. It’s not just American. I also see it in an emergency room in Vancouver. Patients there often seem to cast themselves in a real-life version of a movie the final scene of which offers the hospital, doctors, nurses, and masses of incomprehensible machinery as the last rite of passage. But I think this is worse in the United States. Even Paul Kalanithi was rushed to the emergency room and admitted to an intensive care unit on the day he died. Filled with cancer and obviously near death, experts and family were still debating whether comfort care would be appropriate. This, I’m happy to say, would not normally happen where I live.

I also count it a minor shame that that this brilliant polymath young man’s moving book is received as well as it has been partly because of a mystique of medical omnipotence.

Why do I feel this way? It’s got to look as I say like envy. It is, but not entirely. I want medical doctors to be astute, precise, and to struggle mightily to master the necessary skills. But I want us to find our greatest satisfaction from convincing people in terrible situations that somebody who could congratulate himself just for doing a good technical job is also working hard to share their pain. And to find ways for them to stay home at the end and do better in their minds and hearts than default to a chilly falsehood.

I like to think Paul Kalanithi would have agreed. Wonderful book, nearly-unique situation including the skill and determination to write it. 9.4/8.7

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Healthcare Mismanagement

April 2017

I’ve been working in Canadian primary health care now for almost 40 years, and it seems to me that while in many ways we’re making progress, in others we keep making the same mistakes.

At the moment our homecare of the frail elderly program is threatened because of administrators’ perception that it is not delivering return on investment, a legitimate business term being used in a completely un-businesslike setting. I should be clear the I say this speculatively because it’s impossible to find out how much of a threat we are under, what kind of changes are proposed or being considered, whether tuning up the cost or the productivity side of the equation would improve things, and how accurate or reasonable the numbers administrators base their decisions on are.

A friend and colleague in the Midwest USA has recently sold a company he started based on principles similar to our homecare of the frail elderly program to a huge US health insurer for dozens of millions of dollars. US dollars. The idea that being available for frail patients 24 hours a day, seeing them at home, forming a relationship of trust with them, having a care plan conversation, and showing up when they are in crisis saves money seems to me founded in common sense. To say nothing of its being better care. Famously venal and hardhearted American business interests get the message, whereas our supposedly kindly and open-handed Canadian managers don’t.

So let me generalize about healthcare management from my experience.

The rare really capable healthcare managers I’ve worked with have an instinct for good clinical work. They form personal trusting relationships with the best clinical people, and include them in brainstorming and planning. When they encounter lazy or incompetent clinical people, they get rid of them. There arise out of this programs that work for everybody.

Sadly more often I see healthcare managers who default to an adversarial attitude with clinical people, presuming like industrial revolution overseers that we are lazy and will minimize work unless kept under threat of sanctions and always being made to feel we aren’t quite doing enough. Out of this kind of thing arise programs fraught with labour-management conflict, dissatisfied clinical people, and blunted outcomes.

These less effective managers substitute numbers for accurate instinct about what works for clinical people but more importantly for patients. Statistics. These are famous for being crystalline and unarguable, but are well known among anyone who has spent any time with them for being plastic and for serving any interest through sophisticated selection.

So it is at the moment with our homecare of the elderly program. An administrator recently emailed me about a related program in the emergency room that the physicians were only 50% effective at identifying and paying attention to proposed family practice admissions. And this, she told me, represented an “opportunity”. My physicians in that program are absolutely 100% effective at identifying those patients and discharging them back to the community if at all possible. The administrator involved has never spent a day shadowing the doctors she is evaluating, and teeters between listening to capable clinical people and making decisions based on numbers that don’t make any sense.

Decisions here, it seems, are based on whichever ill-defined buzzword is turning heads in administrative circles. At the moment it’s called “medical home”. To the extent that there is a definition of that, I can say with confidence that the only program meeting that definition in this city is our homecare of frailty program. But that doesn’t matter. It will be months before I become aware of whatever latest buzz now interests local administration, by which time our program could be gutted and scattered.

It’s enough to make a Canadian long for the economic realities of healthcare south of the border. For all its abuses and expense, at least decision-making eyes are reliably fixed on the bottom line, and where, as we have in home care of frailty, a program can improve care and at the same time save money, American business jumps onboard and buys it. Here we strangle its resources, constrained only by yearly budgets and preferring appearance to both economic and clinical reality.

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A Fool and His Money

I work with a multidisciplinary emergency room team that tries to stop unnecessary hospital admission of frail old people. Again and again at the busy Vancouver General emerg family doctors who go on holiday without replacement, won’t make house calls, or whose office phone number prompts a recorded “go to the nearest emergency room” outside office hours are a reason frail people turn up there and end up admitted, for no good reason.

Nobody can blame our hard-working capable emergency room docs for wanting to admit a confused poorly-mobile old man who turns up in the middle of the night dehydrated, urine full of pus, suddenly unable to get to the bathroom. Typically how he was functioning and how confused he was before this recent change, how much help he was getting at home, and whether his family doctor is involved in his care at all just aren’t accessible and a “short admission to sort things out” seems the only safe option. But getting that sort of person back out of the hospital too often turns into a multi-month-long nightmare. An expensive and dangerous real-life nightmare.

The General Practice Services Committee (GPSC) in BC has for many years now tried to reward “full-service” family practice through dozens of fee items for primary care of patients with lots of chronic conditions, mental health problems, and frailty. In particular it pays hundreds of dollars for each “attachment”, which means taking on a difficult new patient and being responsible for their care.

You’d think this kind of incentive would result in cost-saving as well as better care as “full-service” doctors get rewarded for avoiding expensive futile hospitalization, referrals, over-investigation, and over-prescribing. Interestingly, a recent paper by UBC epidemiology researchers suggests maybe not.

Looking only at the incentive payment for patients with two or more chronic conditions, researchers found no change in primary care access or continuity, and an increase in hospital admission associated with the extra $240 million paid to doctors for billing these incentives between 2007 and 2013. The authors commented “policy-makers should consider other strategies to improve care of this patient population”.

You think?

Wondering why the incentives weren’t working and what strategies might be more effective, I emailed the Medical Services Plan (MSP) to ask whether “full-service” primary care includes availability of a physician 24 hours a day and seven days a week.

It doesn’t. MSP told me, “There are no specific requirements attached to these GPSC fees with regard to out-of-office hours coverage” and referred me to the GPSC for further information. Vancouver Coastal Health recently looked at the proportion of Vancouver family physicians who provide 24-hour coverage and it was around 40%. I spoke to an associate registrar at the BC College of Physicians and Surgeons who was unhappy about this since the College practice guidelines mandate 24-hour physician availability. He commented the College isn’t in a position to do much because they only find out about off-hours vacancy if there is a complaint about a doctor.

I’ve had lots of conversations with colleagues who have no problem directing patients to emerg outside office hours and who bill GPSC incentives on every patient who qualifies. And I see first-hand in the ER how many unnecessary expensive hospital admissions of frail people happen because the patient and their family can’t get ahold of anyone on call for their GP at night.  Would we give better care and save more money if we offered elderly patients in crisis a primary care community alternative to the emergency room?

Damn straight, in my opinion.

I’m getting old myself, pushing 70. When I started practice 40 years ago unpaid 24-hour coverage was simply assumed. In 1980 a self-respecting city family physician would no sooner leave a patient without a doctor to call at night than ignore a breast lump or tell a 50-year-old with chest pain to take an Advil. But today’s practitioner (quite properly I think) expects not to be bothered during time off, or at least to be paid for being exposed to urgent calls in the middle of the night. I believe we are dreaming if we think we can return family practice to the dinosaur model of care I grew up with.

Maybe there is another, better way. Money on the order of dozens of millions per year paid to doctors for taking on care of difficult complicated people if “care” just means putting the patient’s name on a practice roster could be redirected. Willing capable family doctors could be paid to take night and weekend call, given access to EMR of practices being covered, report contact to the patient’s family physician, and still be rewarded fee-for-service for home visits, with some of that money.

I’ll see if the GPSC will talk to me about trying to get a bit better bang for their buck.


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Policy and People

I ran across a recent review in the New Yorker by Canadian journalist Malcolm Gladwell, commenting on The Death of Cancer, a book by Dr. Vincent DeVita. Dr. DeVita is a leading cancer specialist in the United States who has developed groundbreaking chemotherapy regimens which are still in use. This very influential physician advocates in his book one side of a difficult controversy that we see all the time in healthcare: should we insist on treating patients according to guidelines based in best-quality research studies, or should we encourage physicians to be “creative” and use intuitively reasonable but unproven treatment strategies?

In some ways this controversy is an example of a more abstract question: should we be focusing in healthcare on the individual patient, or on a population of which the patient is presumed to be a member? In my practice caring for frail elderly people at home I find, because my patients never seem to fit into labelled-box categories, I nearly always end up favouring the “individual” side of that question. As far as insisting on guidelines versus trying out unproven treatments is concerned, I am forced almost daily to be creative about what kind of treatment I offer my frail elderly patients.

I think though that it’s easier to make a case for that kind of practice with someone in their 90s, an example of the famous heterogeneity principle in geriatrics. Not only does this old person not not quite fit the definition of any study population, he or she is pretty much completely unique, and often needs a unique solution to a unique problem. But what about 30-year-olds with HIV, 40-year-olds with breast cancer, or 60-year-olds with heart attacks? They are much more like the others in their group and likelier to benefit from a treatment that has been proven to be effective in big studies of very similar people. And of course “borderline” situations exist. An 80-year-old with new heart disease who drives a car, runs a business, and has never been sick a day in her life, or an eccentric young cancer patient whose beliefs preclude standard care? What about them?

My solution has turned by default to giving my patients a choice. Many of them have to delegate that choice to a substituted decision-maker, but it’s still the patient’s (not my) choice to make. Once I take the time to let them know the potential risks and benefits of guidelines-based care versus some once-off treatment I believe might help (and if I’m careful not to spin the information I provide) each patient can think over the options in their own circumstance and with their own biases and preferences.

This could be a way out of the dilemma Dr. DeVita discusses. Evidence-based care, clinical guidelines and hospital policies and procedures need to be recognized and treated as suggestions, not tyrannical laws of practice. It is after all the patient who suffers or enjoys the real consequences of what we do and don’t do, not me, my reputation, an institution I work for, or a regulatory health authority.

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