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Always Trust A Mother’s Hunch: My Experience With a Sick Baby and an Untrusting Doctor

A recent post on KevinMD.com caught my eye. The piece was written by Niran S. Al-Agba, MD, a pediatrician, who was reflecting on a distressing moment during her third year of residency. On a busy night in the hospital, a mother requested a re-do of her 6-year-old daughter’s blood work, which had come back normal the previous day. Al-Agba ordered the new test at the advice of her attending but remembers feeling like the mother was being overprotective. Exhausted, she wasn’t feeling very compassionate that night.

However, the mother’s hunch that something wasn’t right proved correct. The lab had missed something in the first test and the girl actually had leukemia. Al-Agba, understandably shaken, returned to her patient to break the bad news.mother child-1298137_1280

“It was during this trying time I learned one of the most important lessons of my career: the value of trusting a mother’s intuition,” she writes.

That really struck a chord in me, and triggered a memory of an experience I had years ago after the birth of my youngest son. I was living in San Francisco at the time and my son was barely a month old. When he started vomiting after eating, I recognized the signs immediately: pyloric stenosis. My oldest son, then 5, had experienced the same symptoms and underwent surgery to fix the problem when he was 6 weeks old. The condition was in my husband’s family; his brother had the same thing 30-plus years earlier.

Pyloric stenosis is a narrowing of the opening leading from the stomach to the small intestine. The enlarged muscle surrounding that opening prevents normal digestion and often leads to projectile vomiting. It is sometimes hereditary and usually develops in boys in the first couple months of life. Surgery involves making a small incision in the enlarged muscle so food can empty into the intestine. While it’s traumatic to witness your newborn undergoing surgery, the procedure is almost always successful nowadays and resolves the problem permanently. But it has to be diagnosed and treated right away.

The whole experience was fresh in my mind when I went to the doctor with my youngest to get a diagnosis. My husband was away at the time and I had my other son in tow. Like any new mother, I was sleep deprived–perhaps more so due to dealing with the vomiting. I explained the issue to the doctor on duty, including the genetic link, but her response was noncommittal. “Babies spit up,” she said. “This could be just normal spitting up. Why don’t you try ipecac and come back in a few days if it gets worse.”

Her attitude infuriated me. I felt patronized and dismissed. I knew the difference between spitting up and projectile vomiting–babies with intact digestive systems don’t project the contents of their stomach halfway across the room, landing with a loud splat against the wall. Plus, I had been through this before.  The doctor wouldn’t budge, though, seeming to regard me as another overanxious new mother. So I asked to see another doctor. I was, she reluctantly admitted, entitled to a second opinion.

The upshot is that my son received the diagnosis and was admitted to the hospital the same day. (Remembering the sight of his tiny body hooked up to IVs and the sound of his desperate cries still makes me feel physically ill, but it all worked out in the end). I know now that this doctor was probably just young, and perhaps in a similar state of exhaustion as Al-Agba during her residency. But I’ve never forgotten the experience and it has colored my interactions with doctors to this day.

What I learned that day was to trust my instincts, ask questions, and demand answers. While I’ve encountered some thoughtful, intelligent physicians over the years, I believe that taking care of my health is ultimately up to me. I do my research and seek out facts. The doctor’s opinion is one voice of authority to be weighed along with others.

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My sons: all grown up.

So, when something “just doesn’t seem right” about my children or me, I pay attention to that gut feeling and tell my physician in a spirit of shared decision making. That shouldn’t undercut the knowledge and expertise of my doctor but actually help him or her make a correct diagnosis. Isn’t that what patient-centered care and shared decision making–those frequent buzz words in medicine–are all about? Reflecting on her experience that day, Al-Agba says she learned the “importance of listening to the person who knows their child best, their parent.” I couldn’t agree more.

Becoming a Patient-Centered Medical Home

In 2011, one of Kansas-based St. Luke Medical Group’s major payers approached the 18-office multispecialty group about joining a new quality initiative. The insurer would pay participating practices a monthly per-patient fee for coordinating the care of its members provided that each practice qualified as a Patient-Centered Medical Home (PCMH).  Read more at Physicians Practice…

Tools to Help Hospitalists Spot Delirium

An excerpt of my article from the March ACP Hospitalist:

Delirium is common among older hospitalized patients and can lead to poor outcomes. HoweACPH delirium coverver, the condition is often missed during rushed morning rounds. Patients may seem simply sleepy or physicians might catch them in a good moment, despite fluctuating periods of delirium.
The 10-item Confusion Assessment Method (CAM) is often recommended for diagnosing delirium, but although a recently validated short version, the 3D-CAM, takes only 3 minutes to administer, even this may be too time-consuming for busy hospital practice.

“One of our challenges as hospitalists is that the methods of diagnosing and validating delirium in research trials don’t work very well in daily practice,” said Ethan Cumbler, MD, FACP, medical director of the Acute Care for the Elderly service at the University of Colorado Hospital in Aurora. “In general we don’t have 30 minutes to complete a dedicated cognitive assessment, so what practicing hospitalists really need is a rapid assessment tool.”

Recently developed screening tools that can be administered quickly at the bedside have the potential to provide that. A 2-item tool that asks patients to name the months of the year backwards and the day of the week, for example, accurately identified 93% of delirium cases in a study published in the October 2015 Journal of Hospital Medicine (JHM).

More user-friendly screening tools may encourage clinicians to routinely screen for delirium and raise awareness about the signs and symptoms, which include inattention, disorganized thinking, and altered level of consciousness. However, experts caution that every test has both advantages and limitations.

“When there is limited time, a brief assessment makes sense, but realize that you may sacrifice some diagnostic accuracy,” said Jin H. Han, MD, MSc, associate professor of emergency medicine at Vanderbilt University in Nashville, Tenn., who studies delirium. “These newer brief methods are appealing for hospitalists, but they have not been validated in large studies.”

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Revenue Cycle Management: Preventing Claim Denials

Preventing denials requires careful documentation but physicians don’t always make the connection between poor documentation and declining revenue. As a result, some offices get stuck in a downward spiral that’s difficult to reverse without a coordinated effort between the front and back office.

Revenue cycle management experts I spoke with had some great tips for reversing that negative trend. Here are 5 worth noting:

Communicate. Physicians, nurse practitioners, and physician assistants should receive frequent, direct feedback about the quality of their documentation. Whether your billing staff is medical revenue cycleon-site or you work with a third-party, you need to know how often and why your claims are denied. Consider having regular staff meetings or online discussions focused on billing and coding.

Test for coding competency. Perform a baseline assessment of providers’ coding skills and repeat it twice a year to make sure everyone is up to speed.

Invest in training. Both newly hired and established providers should undergo regular training and refresher courses on coding and documentation. Remember: poor documentation + inaccurate coding = denied claim (and lost revenue).

Show them the money. Complying with coding audits and attending educational seminars should be tied to financial compensation and/or bonuses.

Use technology. “Scrubber” tools embedded in your practice management system search for coding errors and generate reports on recurrent problems–consult them regularly to avoid repeating common errors.

 

Please see the longer version of this column that I wrote for Physicians Practice.

 

 

 

 

 

 

The Hospitalist’s Role in Post-Acute Care

From my article in the April issue of ACP Hospitalist

As he pulled into the hospital’s parking garage before work on a recent morning, hospitalist Ryan Greysen, MD, thought about one of his patients slated for discharge that day, a middle-aged man recovering from a major stroke. The stroke had caused dramatic and sudden changes in the man’s cognitive and functional abilities, and he was about to undergo an extensive period of rehabilitation in a skilled nursing facility (SNF).

“I did the best I could to ensure a really good handoff to the receiving MD but, ultimately, I wondered, ‘Why isn’t it easier for me to remain connected to this patient and his family?’” said Dr. Greysen, a hospitalist at the University of California San Francisco (UCSF) medical center.

Photo by Thinkstock


Photo by Thinkstock


 

It’s a familiar dilemma for many hospitalists. When seriously ill patients are discharged to SNFs for rehabilitation or ongoing care, physicians might like to spend more time on the discharge process, but they’re often forced to hand off some of the details in order to focus on other patients and new admissions.

“As hospitalists, we try to provide really good care for our patients as they’re leaving the hospital, but we wind up feeling stuck and frustrated because often we’re working against a system that’s not set up to work that way,” said Dr. Greysen. “We unintentionally but understandably get disengaged.”

Over the past decade, hospitals have implemented multiple successful interventions aimed at reducing preventable readmissions, but those reforms have largely focused on systems rather than individual physicians, noted Dr. Greysen and Allen Detsky, MD, PhD, in a perspective in the October 2015 Journal of Hospital Medicine.

As a result, hospitalists often lack the guidance and support they need to fully engage in postdischarge planning.

In addition to lack of time, hospitalists often have too little information about post-acute care options to make informed decisions, said Leora Horwitz, MD, MHS, FACP, associate professor in the departments of population health and medicine at New York University School of Medicine. Until recently, it has been difficult for hospitalists to access details on the type or quality of care provided at the different facilities to which they routinely refer patients.

“We have historically done a poor job of understanding the differential outcomes at various nursing homes,” said Dr. Horwitz, who studies transitions of care. “Tracking outcomes and giving feedback to community facilities is relatively new, and it could make a real difference in the kind of care patients get.”

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Biggest Loser Study Sends Hopeless Message But There’s More to the Story

Recently the New York Times published a long article about the contestants from the Season 8 of “Biggest Loser.” The timing the article was tied to a new study, published in the journal Obesity, in which researchers followed the contestants for 6 years after the end of the show to monitor how their weight loss affected their metabolisms and ability to keep pounds off. What they found “shocked” them, according to the Times.

At the close of the show, the contestants’ metabolisms had slowed dramatically, which is normal after significant weight loss. However, the rates did not stabilize and in fact lowered further as people gained weight. In the words of the Times, “It was as if their bodies were intensifying their effort to pull the contestants back to their original weight.” The article goes on to interview the study’s author and several other experts with impressive credentials. Some of them try to bring up other points of discussion but the writer sweeps everything into a neat conclusion: there’s no hope for the obese. Nature has sentenced you to be fat forever. You might as well give up. She even includes a quote from one expert who says that the obese “can’t get away from a basic biological reality.”

At this point, I’m picturing every significantly overweight person in America crumpling in despair. Every diet they’ve tried has been a failure and these experts are revealing why: it’s impossible. The NYT suggests that this might make people feel better in some way because they’ve been released from the guilt associated with overeating (it’s genetic). However, I doubt this revelation makes anyone feel a lot better.

In my opinion, this is irresponsible journalism. Sure, the reporter interviewed experts and quoted studies in scientific journals. But she also leaves out some pretty important points and questions. Most obviously, how does the “Biggest Loser” format affect these results? The contestants lost an astounding amount of weight in an extremely short time, not to mention under contrived circumstances in an unnatural setting. They focused on weight loss 24/7 for 30 weeks in full view of millions of TV viewers. And they were competing against each other for a big cash prize, making the stakes even higher.

According to the Obesity study authors, “the extreme and public nature of this weight loss intervention makes it difficult to translate our results to more typical weight loss programs.” No kidding. this seems apparent but is brushed aside by the NYT as a minor point never to be fully explored. But consider just how extreme this “intervention” was: one contestant featured in the article, Danny Cahill, went from a massive 430 pounds to 191 pounds in just 30 weeks. While on the ranch, he spent 7 hours a day exercising, burning between 8,000 and 9,000 calories, the NYT notes. After returning home, his regime got even more intense as he tried to lose as many pounds as possible in the 4 months leading up to the final weigh-in. To quote the Times,

“Mr. Cahill set a goal of a 3,500-caloric deficit per day. The idea was to lose a pound a day. He quit his job as a land surveyor to do it. His routine went like this: Wake up at 5 a.m. and run on a treadmill for 45 minutes. Have breakfast — typically one egg and two egg whites, half a grapefruit and a piece of sprouted grain toast. Run on the treadmill for another 45 minutes. Rest for 40 minutes; bike ride nine miles to a gym. Work out for two and a half hours. Shower, ride home, eat lunch — typically a grilled skinless chicken breast, a cup of broccoli and 10 spears of asparagus. Rest for an hour. Drive to the gym for another round of exercise.”

Is it any surprise that this man was so sick of diet and exercise when it was over that he collapsed in exhaustion? That he was more than ready to give in to a few food cravings?

But weight loss isn’t hopeless. There are diet plans out there that work. I’m not saying they’re easy or quick but they exist. This whole area is given short shrift by the Times. One expert, David Ludwig, MD, director of the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital, tries to insert some perspective, pointing out that the results, “shouldn’t be interpreted to mean we are doomed to battle our biology or remain fat. It means we need to explore other approaches.” But those other approaches are barely mentioned and definitely not explored by the Times.

I have not personally experienced intensive weight loss but I’ve witnessed it in people close to me. Someone told me that a similar article that appeared in the Times a few years ago put him off trying to lose weight for a while because obesity seemed to be preordained. However, he’s since successfully lost weight on a high-protein, low-carb diet. There is evidence that cutting out sugary, processed foods and eating a diet rich in protein, vegetables, and healthy fats helps improve weight and health. And when you cut out the unhealthy carbs, you feel less hungry. I’m not advocating a particular diet here, just pointing out that there are options. It still takes work to plan and stick to a diet and make sure you’re getting all the right nutrients. But it is possible to cut calories without feeling constantly hungry–something that the Times article suggests is impossible.

Consider these facts from scientific studies:

  • “A very low carbohydrate diet is more effective than a low fat diet for short-term weight loss and, over 6 months, is not associated with deleterious effects on important cardiovascular risk factors in healthy women.” — from the Journal of Clinical Endocrinological Metabolism.
  • “Compared with an Low Fat Diet, a Low Carb Ketogenic Diet (LCKD) was found to result in significantly less hunger and negative affect” and “there is evidence that an LCKD leads to a stabilization of blood glucose levels; this stabilization might reduce craving for food as well as an improvement in energy levels.” — from Obesity. (The ketogenic diet has been found to lower glucose levels and improve insulin resistance and has been used successfully to prevent seizures in children with epilepsy. You can read more about it here.)

Many other studies explore this topic. The point is not whether one is right or wrong but that other relevant, scientific evidence on weight loss exists.

The Times article is not factually wrong. It is an accurate report on a recent study and includes comments from well-qualified experts. But it leaves things out–important things that could influence how someone feels about their ability to achieve a healthy weight. The impact is significant when an article like this appears in a widely read and respected news publication. I hope those struggling with weight don’t see it as a reason to give up–because this is definitely not the last word on weight loss.

 

Revenue Cycle Management: The Front Desk

Your first chance to avoid a denied claim happens when a patient walks through your door. It might start with seemingly inconsequential errors, like leaving one letter out of a patient’s name, but those small mistakes get compounded as they move through the coding and billing process. Down the road, that one missed letter could end up costing hours of precious staff time and significant delays in getting reimbursed for that visit.

The key is making sure your front medical office revenue cyclestaff is well-trained and prepared to gather all necessary information before, during, and after the visit. That means being diligent about verifying insurance coverage and becoming familiar with different policies in order to educate patients.

Consider these tips for avoiding front-end mistakes that can cost you down the road:

Verify insurance in advance. Ask the patient about their insurance coverage when you schedule the visit, follow up several days before their appointment, and re-confirm  when they arrive in the office. Double check their phone number, address, and other personal information.

Follow up on errors. Coding and billing staff should alert staff at the front desk about any frequent errors that are causing denials so they can modify their procedures accordingly.

Be clear about costs. A cost estimating tool integrated into your practice management system can generate a quick estimate of patients’ financial responsibilities for upcoming services or procedures. These are often available through insurers.

Talk to patients. Knowing the details of a patient’s visit upfront will help you schedule it appropriately. For billing purposes, keep preventive services, such as a mammogram, separate from procedural visits, such as skin tag removal.

Think of time as money. Front desk mistakes, however small, aren’t just annoyances because they ca lead to multiple delays. When a denied claim arrives, someone has to spend time investigating the reason, correcting the error, and resubmitting the claim. And if it takes longer than 90 days, that money could be lost for good.

For more information, check out a a longer version of this column that I wrote for Physicians Practice.

 

 

 

 

 

 

 

 

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