By Michael Miller DO, FACOS, FAPWCA
There are many colloquialisms we use to describe a variety of situations. When someone appears to make a real commitment, we call it “full bore” or “going whole hog” or to use the gambling epithet, “all in”. Commitment is an important part of what we as health care practitioners stand for. You have all read ad infinitum, ad astra, ad mortem of my strongest belief that patients must take an equal role in their care. We provide the recommendations, the rationale and the risks (and benefits, of course) and they decide which of our offerings best suits their beliefs, their desires and for better or worse, their purses. The marketing profession has made millions of consumers purchase items they do not need based on the sex appeal of the turn of a phrase, changing a question of doubt into “iron clad”.
The inability to commit to a decision when recommending treatment, and stand proud with it recognizing that it may unbelievably be the wrong one, is a skill all too prevalent in medicine. But lest I be accused of bashing my own profession, for those of you who can remember those Purina Cat chow commercials in which an indecisive cat moved back and forth to his food bowl to the strains of “Chow, Chow, Chow", I refer you to: www.youtube.com/watch?v=bEcmZLDOEXQ (for those of you born after the late 70s). I think of this commercial every time I encounter a situation in which a colleague’s viewpoint changes based on extraneous factors of care. I have adopted the phrase 'Vacillation Fascination' to define those situations in which the patient gets far too many recommendations for care without the physician actually committing to which is the preferred one. Regardless of how many choices one offers, eventually there has to be a scenario in which we Cross the Rubicon, commence the battle and await the fruits of our labors. And so, without further ado, the meat of this month’s questions become…
Why is commitment to a single suggestion/recommendation so often avoided when it is clearly the “best”?
Is it better to offer multiple options even when several are “less than best” just so the patient has choices?
Does use of phrases like “If you were my mother I would” (or other pseudo-altruistic veneers) offer an unfair spin on the best recommendation, or is it simply adding a humanistic touch?
Is there really a limit to how far you should go when caring for a patient with regards to presenting problems? I am not talking about palliative versus curative (versus injurious?) but rather, if everything affects everything in a patient's health, should you pick and choose which labs or physical findings get attended to or not?
Are naiveté, selective attention and/or abject stupidity acceptable reasons for not doing all we can for patients and if so, can you still win an award when they heal in spite of what you did?
Lastly, how many nuts does a blind squirrel really ever find?
My favorite recollection defining my understanding of “definitive” came from my boss, Ben, a venerable Jewish old man who owned a huge clothing empire in Philadelphia in the 1970s. Ben took a liking to me, teaching me how to not just sell suits, but to make friends on many different levels. He enjoyed teaching and teasing and took every opportunity to do both. He once offered to introduce me (Boychik) to a “bee-yoo-ti-ful goil” (remember the Yiddish accent a-la comedian Billy Crystal), from a ”Von-der-ful family vit a lot of money”. “Only von small problem…she’s a liddle bit pregnant”. I could not decide whether to laugh, cry or just get her phone number to make him happy. And yet, while an uproarious joke (at least to him and my manager), it stays with me as a defining moment of how we interpret and comprehend terms like “almost perfect”, or the more germane “almost healed”.
Of course, the attribute of indecision seems to belong as well in the political arena and with the current Scylla and Charybdis presidential race underway (is there a better definition of the lesser of two evils unless you consider that of soft drinks, Coke vs. Pepsi, I suppose), I hungrily await more examples of politically definitive indecisiveness. One story I heard was that after receiving repeated, non-specific answers to his questions, a reporter attempted to get one irrefutable answer and finally, in frustration asked a politician what his favorite color was. You can well imagine his dismay when the response was “Plaid”!
Interestingly, it is the nutritional aspects of wound care that seem to be the most overlooked part of our care. My own Miller Care Group organization has made a full commitment to aggressive nutritional assessment and management of all our patients. My new associate, new NP and my staff have been re-educated on current nutritional concepts and every patient gets a nutritional vetting at the same time their wound orders get initiated. Fortunately, CMS has a specific set of guidelines regarding nutritional intervention and so, we happily follow the Yellow Brick Road to the land of Anabolism as a routine part of our practice in wound care and lymphedema.
As I write this, I am finishing a visit to Shanghai, China where I participated in a conference on burns and wounds with the top specialists there and several “foreign invitees” including myself. It should come as no surprise that they face the same wound problems we do and though some of their dressings and techniques differ a bit, a bedsore in China looks exactly like one in Indianapolis. Their attention to the nutritional status of their patients, for better or worse, matches our own based on my experiences in training and talking with them. In other words, the spectrum of how their health care practitioners react to abnormal nutritional assessments are identical to ours as they run the gamut from passionate repletion based on specific protein/caloric calculations to the generic “more shark stomach with every meal” (actually not bad but you really need the abalone sauce!) And so, regardless of the locale, attention to detail seems consistently inconsistent.
Cases in point
I received a call to see an 89-year-old retired judge at home due to progression of his pressure-based tissue injuries. The Primary House Call Doc had used the several mandatory courses of antibiotics, no pressure relieving surfaces, several antiquated wound treatments and finally, with much urging from the Home Health Care nurses agreed to a wound consult. I met an alert, slowly responsive but oriented gentleman who exceeded the definitions of chronically ill and debilitated. His daughter provided me an excellent history of worsening wounds and progressively poorer oral intake. He supported my conclusion of GI dysfunction by complaining of nausea, cramping and loose stools with eating. Luckily and unbelievably, the Primary House Call Doc had drawn labs two weeks prior and so, the need for an additional stick was unnecessary. A simple request for a copy of the CBC and CMP resulted in his assistant telling me “Doctor said everything was “pretty normal“ and that if we still wanted a copy, it could be faxed. To my mind, “pretty normal” is a term that means, “they had to be good or I would have done something and I don’t remember doing anything”.
Another week of unrequited lab requests resulted in the labs being redrawn at my request. The CBC showed a low absolute Lymphocyte count and the Albumin was 3.0 with a Total Protein level adding insight into what “pretty normal” meant to that doc. Though I had previously run the gamut of nutritional options with the daughter regarding PPN and a PICC line as distinct possibilities, I called her with my recommendation, gave her my rationale and then advised the doc of the same. Either out of ignorance, misinformation, or paranoia of being recognized as “missing the boat”, the primary doc launched into a diatribe first with me and then with the family of the dangers of PPN both real and imagined and how just increasing the number of cans of protein drink per day would do the same thing. Never mind that this plan of three months had been as successful as a Lady Gaga tour date at the Mormon Tabernacle. More, when I called his attention to the worsening condition and the abysmal (and certainly not “pretty normal”) lab values, He stated, “Michael, almost everybody I see has labs just like that”. Never mind that his house call population consisted of the most severely debilitated and so my response of “so what’s your point?” was met only with disregard for science and compassion thus ultimately relegating his viscera to the Bed of Procrustes (Trust me, not a story to tell your kids at bedtime). I called the daughter, advised her that we had respectfully disagreed, advised her of my and “Doctor’s” opinions and that the choice was hers to make. My argument to them both that malnutrition is not an expected nor accepted condition was met with no response, though “full bore” wound care orders were agreed to. Even the home health care nurses could not fathom the persistent lack of concern for nutrition from a doc who normally chased the most picayune lab value like Wile E. Coyote after the roadrunner.
Lest I be accused of limiting my venomous injections regarding “definitive” into only wound care folly, my newest antithesis of joie de vivre is the current Federal mandate for all practitioners to be EHR (Everybody Hates Regimentation) ready with a large bunch of green carrots for the successful and a whittling away of compensation for the slow and unwilling. An astute physician friend of mine, well known for his unwavering common sense and meticulous attention to detail (perhaps that is why he is quadruple Board Certified) has taken up this war cry merely out of boredom. He works for a hospital and so has been able to avoid his own Sword of Damocles by allowing the hospital to mandate universal usage of its system for all employed physicians. Nonetheless, he has scrutinized the available literature, articles and expert opinions and thus far has been unable to find any real evidence that mandated EHR usage will improve care, decrease costs or improve outcomes. He is convinced that the underlying rationale is that more bureaucrats need to be hired and EHR is a convincing way to generate more data that needs to have done with it whatever it is that bureaucrats do with data. More, part of the mandate is that practices that use Medicare guidelines as their primary target for utilization must demonstrate that the ERx (prescribing) component of the EHR is being used correctly. This is accomplished by sending ten prescriptions for Medicare patients to pharmacies electronically by June 30th, 2012. The kicker is that it is not enough to merely do so. Despite using an EHR system that (1) must have a high level of compliance with Federal guidelines and (2) pharmacies that have their own set of guidelines and (3) also must demonstrate compliance with the same guidelines as the EHR, there is apparently no way to definitively demonstrate that you have done so unless you provide proof of the proof of these prescriptions to CMS by filing a claim (also electronically) that lists the patients insurance number, their diagnoses for which the prescription was written and the code G8553 which pays nothing but means “Hey, I gave this person a drug”. And so, a system designed to assure accurate tracking of information itself needs its accuracy verified so that the action you took to get paid is verified by yet another action for which you don’t get paid. And if you fail to do the ten prescriptions, then you will get paid less unless you don’t get paid. Then you will be penalized for not getting paid. Unless you tell them you prescribed the ten prescriptions, (even if you didn’t as without the proof you can’t get paid), you still can provide the proof that you did…SIMPLE ! To this I ask the universal conundrum buster…Who’s watching the watchers?
My final extra-spection on “definitive” concerns the proposed security and veracity of these same ERx systems that come part and parcel of the EHR. You may remember my blog on why narcotics and other controlled substances probably should be legalized due to the laughable success rate the US has had interdicting and stamping out this problem. Our attempts to legislate stupidity have resulted in more wasted man hours, more money foolishly spent and more lies told on security clearance forms than a teenage boy trying to avoid getting a summer job. And yet, despite the assurances of real-time prescriptive accuracy and that the DEA, FDA, all pharmacies and those with prescribing rights are all in sync, you still must hand write a prescription for Class II controlled substances. Since these EHR systems parade HIPAA compliance like Senator John Edwards paraded his nuclear family beliefs, I can only assume this is an attempt to make sure we do not forget how to write out a prescription should the power go out. Safe, secure and accurate except for narcotics and stimulants. Why would anyone worry about Coumadin or antibiotics being prescribed erroneously? And so, a system designed to be completely accurate to assure the infallible transfer and tracking of patient data and activities winds up with training wheels.
What happens when the irresistible force meets the immovable object? Can you suck and blow at the same time? How can you be a little bit pregnant? Our ability to settle time and again for almost, nearly, and close instead of reaching for the definitive stars means that our care will always be “OK”, “pretty good” or even “not too bad”. As hard as it sounds, we need to say what we mean and mean what we say. I am not recommending you be a harbinger of doom threatening amputation for every lower extremity wound on your first evaluation so that in the event there is a problem, you can always state categorically “I told you so”. Nor should you proudly proclaim that you will provide the patients a healed wound without the opportunity to spend some time with them, their history and some time observing their tissue response to your ministrations, if only to provide them a verbal security blanket. The balance between committing to an outcome and committing to doing all that you can to reach that outcome sits on a very thin line. Can we do it? I am almost 100% sure.
Until we ramble together next time…
About The Author
Michael Miller DO, FACOS, FAPWCA is the Founder and Medical Director of The Wound Healing Centers of Indiana and IndyLymphedema, as well as a clinical consultant, teacher, inventor, and published author.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.