PookieMD's Blog: Where Physicians Learn About the Business of Medicine

I went to a noon lunch and learn given by my medical malpractice carrier, and the speaker reminded us that most patients have a 5th grade understanding of medical jargon. He told us to tailor our conversations and handouts to this level of understanding. I had heard this before and have tried to use this as a guide in my conversations with patients.

I was paging through the Annals of Internal Medicine, and there at the back are summaries of articles that can be given to patients.  (I’m not sure why you would want to give a patient a summary of a double blind placebo controlled randomized study, but just in case you do, Annals has it for you!) Anyway, there was a sheet you could tear out and give to patients summarizing “Cost-Effectiveness of Different Types of Evaluations Before Sports Participation in Young Adults.” I quote the paragraph entitled, “What is the problem and what is known about it so far?”

In the United States, sudden death in young people participating in competitive sports occurs at a low rate. Previously unknown heart disease is the leading cause of these deaths. Major medical organizations recommend that young athletes be evaluated for heart disease before they participate in organized sports. The American College of Cardiology and the American Heart Association recommend a medical history and physical examination, with further testing if history or examination is abnormal.  The European Society of Cardiology and the International Olympic Committee recommend including electrocardiography (ECG); this test records the electrical impulses of the heart and provides information about abnormal heart rhythms and other heart conditions.”

Wow. You’d have to be some fifth grader to make heads or tails of that paragraph! If I was a fifth grader, I could care less about the American College of Cardiology and the American Heart Association, as well as the European Society of Cardiology. I might care about the Internal Olympic Committee, if I envisioned myself as the next Lindsey Vonn, but other than that, the entire paragraph would mean nothing to me.

Should I send Annals the hand out from my malpractice insurer to help them make hand out sheets that are actually readable?

Annals of Internal Medicinehas a nice study on the ability of ”structural capabilities” to improve  primary care.  Let me translate: structures are systems implemented in a practice, such as EMRs, paper based reminders, on site language interpreters etc.  They are mechanisms a practice puts in place to improve quality and efficiency of care.

So what works?

An EMR is helpful to bring up scores on some HEDIS measures such as: screening for breast cancer, colorectal cancer, and chlamydia, and diabetic eye care and nephropathy monitoring.  Even at that, it only improved scores if it was a “frequently used multifunction” EMR–meaning that xray reports, labs, med lists, problem lists and specialist notes were ALL on the EMR.  If the EMR was underutilized, or not as functional, it would generate lower HEDIS scores.  So, if your practice is getting an EMR, better make sure you get a highly functional one and actually use it!

Systems to remind patients to obtain necessary screening  improved HEDIS scores, but paper notes to physicians were not helpful.  (Now why is that?  The authors speculate that is may represent practices that have barriers to optimal care.)  Having an interpreter on sight wasn’t particularly helpful either, nor was a multilingual practitioner.

Having frequent (at least quarterly) meetings where quality of care was discussed led to higher HEDIS scores as well.

So simple steps to improve quality of care at your practice:

1. If you are getting an EMR, get a highly functional one that includes multiple functions such as labs, x-rays, medication lists, notes etc, and use it.  Best if subspecialists use it as well.  (Don’t ask me how you are to accomplish that!)
2. Have frequent meetings on how to improve HEDIS measures such as screening for cancer and diabetic monitoring.
3. Send reminders to patients to get their screening done.

Right now, that’s all that has been studied and shown to work.  What works for your practice?

Annals of Internal Medicine (July 21 volume 51, number 2) has an interesting article on trans fats, and an accompanying editorial.

I bring it up because of two things: 1) in this culture of health care reform, we need to look at the low lying fruit and 2) the accompanying editorial is ridiculous.

The New York City Board of Health mandated in 2006 that artificial trans fats be removed from restaurant food.  By November, 2008, use of trans fats in restaurant foods had fallen to 2%.  Trans fats are largely manufactured or modified fats, but naturally occur in small amounts in foods.  Initially, restaurants were urged via an educational campaign to voluntarily remove trans fats from use. Trans fat use in restaurants remained unchanged in spite of the educational efforts.  (Please see my post on “Influencer” as to why education as a mode of behavior change doesn’t work.)

However, once the mandate (and accompanying fines for non compliance!) went in to effect, use of trans fats fell to less than 2%. Now, long term effect on lipid profile has yet to be seen, but it seems a relatively painless step in creating a healthier population.

NOT SO, according to an accompanying editorial by Julie Louise Gerberding, MD, MPH, former director of the CDC.  She states that implementing a nation wide ban on trans fats (as they have in Denmark) is “impractical if not impossible” for several reasons. She claims:

1. Consumers will “inadvertently” substitute foods with saturated fats or higher carbohydrate loads
2. Corn oil is limited secondary to the “strong biofuel market”
3. There is not enough healthy oils and development is too slow to make this viable
4. “Pushing too quickly could do more harm than good, if producers are forced to resort to products high in saturated fats…”

Dr. Gerberding suggests instead that physicians inform and encourage patients to avoid trans fats.  She states that the FDA “urge clinicians to encourage awareness of the important influence of diet on heart health.”

Bull pucky.

Patients do not change their habits because of a once a year “physical” in which physicians urge them to eat better, exercise more, stop smoking, wear their seat belts, wear sun screen, get a colonoscopy, get a mammogram, get a flu shot, get an H1N1 shot, get a tetanus shot, get a bone density, eat calcium, and make sure the guns in the house are stored safely.  They are NOT going to eat less trans fats because I tell them it is bad for them.

Please Dr. Gerberding, use your considerable influence for the common good.  Eliminating trans fats is an easy fix.  Stop pushing it off on clinicians, and stand up for the American public, and for appropriate public health care.