The Business of Medicine Should Not and Can Not Replace Care and Compassion

Compassionate CareWell over a year ago I advised my 80 something year old patient and her children that due to progression of her Parkinson’s disease, and her frail nature, she needed a higher level of assistance and care if she wished to remain in her home.  She was extremely unsteady walking and several courses of physical therapy had not improved the situation. The patient was feisty and would only allow help to come for 4 hours per day despite having a long term care policy that paid for significantly more.  She lost her balance recently, fell and landed on her back. She could not get up or get to a phone or her alert bracelet and was found seven hours later on the floor by her aide arriving for work.  In the Emergency Room x-rays revealed several acute fractures of her vertebrae that accounted for her severe pain with movement and inability to stand, bear weight or walk.

I hustled over to the ER and examined her and called the interventional radiologist to see if he could perform a procedure called a kyphoplasty that would cement the fractures and remove the pain. It was early Friday afternoon and the traditional back specialists were unavailable until the next day.  The radiologist came promptly, was professional and very pleasant explaining that he could do the procedure but because she took a baby aspirin for prevention of stroke, he would not perform it until the aspirin wore off in 5 – 7 days because of fear of excessive bleeding around the spinal cord.  He suggested we send her home with pain medications and round the clock assistance or keep her in the hospital until the aspirin wore off and he felt comfortable performing the procedure.  He was courteous and a credit to any profession. 

Since the patient was in great pain with any movement, I chose to admit her to the hospital while we sorted things out.  I admitted her as an inpatient because she is extremely elderly and frail with medical conditions that led to this injury which an expert had just told me required surgery to fix. She could not walk or transfer to a chair or wheelchair to get food, water or get to the bathroom. She had no arrangements for additional help at home to assist her. She could not, in my professional opinion, go home safely at this point.  

The next day I was making rounds late in the day for me at noon, reviewing the situation with the patient and her son when the physician’s assistant (PA) for the back surgeons, Andy, walked in and introduced himself. They had not seen her Friday evening or Saturday morning and this was their first contact with the patient.  My consult request and phone call had been quite clear. I wanted to know how they viewed the injury and what options did they feel were best to fix the problem. I additionally asked them how their approach would differ, if at all, from the approach of interventional radiology.  I had seen Andy around the facility and said “hello” but never formally met him so it was an introduction for me as well. 

“Hi, my name is Andy, and I work for Doctors Y and Z.  We have a little problem with your insurance.  You have a Medicare Advantage plan and we are not part of that plan. Most of the time, about 95% of the time, we eventually get paid for our services but we need to know how we will get paid for performing a procedure on you to fix your back before we proceed further. In these situations we usually ask the patient to pay the bill up front ($1000 – $1200) and then we submit the charges to your insurance company. If we get reimbursed from the insurance we return the money to you.”  

I took a deep breath and wondered if maybe I was overreacting to the brusque inappropriate presentation to a groggy senior who had been given a narcotic 30 minutes before for pain and was really in no condition to listen to any presentation or sign away informed consent.  I cut Andy off in the middle of a sentence and reminded him that I had requested an opinion. The son, an attorney by trade took up the fight and reminded the PA just how inappropriate his initial remarks were and that in this case money was not a problem but the manner of dealing with an elderly confused patient was.  I played mediator at this point and got the PA to explain that his employers had done several thousand of these procedures and handled many more complications than most interventional radiologists and that their success record spoke for itself.  He outlined a slightly different approach and once we got him talking about the reasons for his invitation onto the case, justified calling his group.

I am all in favor of physicians being paid for their professional services. This could have been handled differently by calling me first and informing me that they had concerns about payment and insurance and letting me address the issues. It could have been handled far gentler by answering the questions asked first and suggesting options and then reviewing the problems with the insurance. Had the gentleman performed a history and or exam rather than rely on the ER PA’s evaluation the day before, he would have seen that the patient was not in a position to comprehend what he was saying or sign for a procedure.  

This is not a criticism of PA’s or Nurse Practitioners. It is a criticism of any practitioner who does not answer the questions asked by the referring physician or question the referring physician about payment before arriving for the consult if they have questions about getting paid for their time and expertise.

The post script is that the son wisely chose to use this group based on their talents and experience and put aside the rude and insensitive communication by the PA. The surgery went well and the patient will go home after spending three nights in the hospital. 

There is still one obstacle to overcome. The hospital ignored my written order to make her status inpatient and made her status observation which will prevent her from receiving any post-surgery therapy or care which is paid for by her insurance. I will fix that. Keeping the phone number on my phone contact list of the Office of the Inspector General who investigates Medicare irregularities opens doors in situations like this. It does not change the fact however that as practitioners we need to be much more thoughtful when we discuss financial issues before medical issues if we wish to continue to be considered a profession rather than another business.

Metal Joint Replacement – Should Allergy Testing Be Done First?

As our physically active baby boomers age, more and more of them are facing the need for joint replacement. We run, golf, bike and attend exercise class all in the name of fitness and cardiovascular health.  As a result, many of us have bodies that are becoming beat up and worn.

There have been numerous articles discussing the large increase in knee and hip replacements in active 50 year olds who wish to continue to be as active as they were prior to joint replacement surgery.  An article appeared in this week’s MedPage online journal about a small Italian study conducted regarding chronic pain in “successful “metal joint replacements in the lower extremity. Most of us know someone who had a perfectly unremarkable uncomplicated knee or hip replacement who is now suffering from unexplained pain at the surgically repaired joint site.  X Rays show perfect alignment. CT Scans and MRI scans show perfect surgical alignment. The patient remains in pain.

The study released by Italian researchers’ discusses allergic contact allergy being the cause of the continued pain. The individuals evaluated are allergic to the metals in the artificial joint. In the study subjects were patch tested in advance of joint replacement. Those showing allergic sensitivity to metals contained in the prosthesis received a hypoallergenic product instead. They did not develop the unexplained pain and discomfort and had a great outcome. While the study was small and the results preliminary, it raises the question of whether allergy patch testing prior to elective joint replacement should, and will, become the norm in the future.

There Is A Malaise Among Us

In my professional life, and on this blog, I have complained bitterly about the orthopedic surgery department in my community changing from physicians to technicians to “consultants” as they now prefer to be called.  These same physicians once aggressively sought out hip replacement patients to admit to their surgical service where they would provide admission, discharge oversight and care.  Now, these “consultants” see the patient before surgery, operate and then turn their patients’ post operative care over to their nurse practitioners, physician assistants and technicians as well as hospital based and employed internists or, the patient’s own medical doctor.

The “consultants” will no longer admit the patient to their surgical service, insisting that the patient be placed on the medical service and, they have taken steps to relinquish their skills in post operative and post surgical wound and general care. They see the patient before surgery, in the OR and several weeks later in the office to check on bone and appliance alignment and to remove the surgical sutures.   I am told the impetus for this change in the orthopedic role is cost and liability and based on specialty specific recommendations of consultants.

Over time, I have seen the post surgical stay reduced from 10 days down to less than four days. Patients no longer go directly home from the hospital.  In most cases, they are sent to skilled nursing homes for rehabilitation and strengthening. I have written about how these overregulated and inspected homes are spending so much money on personnel to keep them in compliance that they can’t afford to staff the facilities to provide skill, nursing and care.

With nighttime patient-to-nursing ratios of 40 residents to one nurse; how can anything get done each shift?   I have written about the conveyor belt / revolving door between recently discharged post hospital patients and the hospital Emergency Department using the 911 system and diverting emergency EMTs from true emergent issues to being a transportation corp.

An article in the Journal of the American Medical Association finally added some credence to my observations. Researchers looked at the subject of Medicare age patients receiving primary hip replacements and hip replacement revisions between 1991 and 2008.  They looked at over 1.4 million primary hip replacements and 348,000 hip replacement revisions. When looking at first time hip replacements they found that mean length of stay dropped from 9.1 days in 1991 and 1992 to 3.7 days in 2008.  This resulted in 20% fewer patients going directly home from the hospital and a 17% increase in patients going to skilled or intermediate care nursing facilities by 2007 and 2008.

The good news is that the overall death rate at 30 days declined from 0.7% in 1991 to 0.4% in 2008.  The bad news is that the rate of readmissions rate for complications of the surgery within the first 30 days rose to 8.5% in 2007 and 2008.

When we look at look at hip replacement revisions, the length of stay declined from an average of 12.3 days to 6 days. In hospital mortality declined from 1.8% to 1.2% but 30 day mortality increased from 2% to2.4% and 90 day mortality from 4% to 5.2%.  Fewer patients were discharged to home in 2008 than 1991 with a resulting increase in transfer to skilled and intermediate nursing facilities by about 17% at the end of the study dates.  When hospital readmission rate was looked at for revision of hips the readmission rate increased by 2007 and 2008 significantly

This data is about real human beings. It means we have not figured out the correct length of hospital stay for this procedure. It may mean that we have reduced the expense for the hospital stay while increasing the expense to the system, patients and family in other areas of health care accounting.

With regard to revisions of hips, more people are dying and more people are coming back to the hospital for readmission than in the past.  Maybe the orthopedic surgeons need to spend more post operative time attending to their patients directly for a longer hospital stay before transferring them to the care of others at a nursing home?

The topic is intensely personal to me especially as we approach Mothers’ Day. During the time of the study my Medicare age mother dislocated her hip repair repeatedly. Each time she was brought back to the operating room, given a whiff of anesthesia and the artificial ball joint was forcibly pushed back into the socket. She would awaken, be given a day or so of rehabilitation and oversight by the surgical assistants and mid level providers and then sent back to the skilled nursing facility for strengthening and rehabilitation before returning home. After each episode her orthopedist would tell me how much force and pressure and strength were required to push that hip back into the socket.

On one of those admissions the hospital physical therapist became alarmed by the fact that the involved leg appeared to be two inches shorter and externally rotated on the last day of therapy. She was having difficulty walking and bearing weight.  She called the surgeon who sent one of his staff to see her in her room prior to transfer. That staff member had never met her. He told her that our hospital physical therapy department was “notoriously inaccurate in measuring limbs.”  He didn’t examine the limb or order an x-ray but transferred her to the nursing facility immediately.

Upon arrival she could not stand up and bear weight. The receiving facility physical therapist requested a hip x-ray. The x-ray showed that she had been discharged from the hospital with the hip still dislocated. The ball could not stay in the socket because the pelvic bone had been fractured during one of the attempts to push the ball back in place.

My mom refused to go back to the same hospital or surgical group and was transferred to another center of excellence for extensive reconstructive surgery.  She has never ever walked independently again.