Better to Best: Thoughts on Global Health Care Systems

If only this was the perfect solution…

Posted in Medical School (General), Patient Quality and Safety by reshmagar on August 9, 2011

A while ago, many of my friends in med school posted this article from the The New York Times Health Blog – lauding the innovative method the doctor used to counsel her patient about their medications. To summarize the article, the author, a physician had a visit with one of her usual elderly patients who was chronically ill with diabetes, hypertension, and high cholesterol. Like many who are chronically ill, the patient had over time been prescribed a slew of medications which he brought to the visit and was confused as to when to take each of them. Turns out he was unable to read the pill bottles as well as the directions the doctor had written out for him the visit before. To solve this dilemma, the author worked painstakingly on a new set of directions;

Mr. M and I opened up his pill bottles. We extracted a pill from each and taped it onto a piece of paper. I drew a sun next to the ones that needed to be taken in the morning, and a moon next to the ones for nighttime. He left my office with sheet of brightly colored pills, a rainbowlike guide that I hoped would offer him access to the quality medical care he surely deserved.

I first came across this article posted on Facebook by some of my friends stating that this would be a great way to tackle non-compliance amongst patients. From my last rotations in psychiatry and Ob/Gyn, I frequently see patients struggle to take their medications at appropriate times for a variety of reasons – sometimes they just don’t like the way the medicines make them feel or feel like they don’t need them or other times, they are unable to access them due to loss of insurance or funds. I read the article hoping to find new insight into this topic only to find an interesting anecdote on patient health literacy and a good method for the patient described in the article.

Regardless, I do agree with the author’s approach to her patient in that she actually spent time to explain the medication regimen. During my first year of medical school, I worked with an Urgent Care Center physician who taught me from day one the importance of not only writing out instructions for the patient and explaining the treatment plan to them but also the need to spend time asking the patient what they understood the regimen to be. In the hospital setting and in other clinics, time is precious and often, patients leave with a stack of discharge instructions with paragraphs regarding their condition and medications as well as prescriptions they have to pick up on their own time. We often at our hospital triage see repeat patients who failed to follow-up with us as directed or pick up their medications causing their medical condition to exacerbate. They return often more sick than necessary and a new treatment plan has to be created. Some are even admitted.

In looking at the problem of health literacy, there are certain pragmatic factors to take into consideration to ensure that patients upon leaving the hospital understand their treatment. For many doctors, time is a limiting factor. In most medical practices including primary care practices, follow-up appointments last approximately 15 minutes. In this time, not only does the doctor have to address any immediate concerns that the patient has, but they also have to ask questions to ensure that they are no other health issues going on the patient may be unaware of as well as a modified physical exam. Usually, the physician also spends a minute or less going over any results and their recommendations.

Additionally, physicians often schedule patients back-to-back which means that any additional time taken with one patient going over medications takes away time from subsequent patients. With the impending shortage of primary care doctors, it is not possible right now to take on less patients. The Affordable Care Act will provide much-needed health care to millions of new patients who will all require a primary care doctor. In line with this, however, there are provisions to build more community health centers but no clear provisions to increase the number of primary care doctors. Until there are more students going into primary care and more incentives to do so such as a salaried position or less overhead costs in a private practice, doctors will probably not be able to spend an extra 15-20 minutes with patients who have complex chronic diseases along with other social issues such as being illiterate. At least, not on a regular day.

During gynecology, one of my attendings set aside one day per week for a chronic pelvic pain clinic where she tailored care for each patient that included long sessions with each person along with regular emails and phone calls. Perhaps, this is the solution in primary care we need. A day set aside for the most complex patients to spend longer amounts of time to construct a comprehensive plan. Rather than being sent to a chronic care specialist, patients who see their primary care doctor more often will get regular check-ins to ensure they understand the plan completely.

Another solution proposed has been to hire a nurse or other practitioner who after each visit will sit down with the patient to go over their treatment plan and check-in with them. This, I also do not see as realistic. With rising overhead costs from the lightbulbs and toilet paper in the practice to paying the billing specialists and receptionists and more and more primary care doctors closing their practice due to these costs, it seems unlikely that hiring someone else to sit down with patients after their visit is a sustainable solution.

Today, I start family medicine. I have no idea where I am going to be placed but I do wonder if I will encounter a similar situation to the one detailed in the New York Times health blog. I would like to think that I will spent the extra time needed but what if my attending expects me to finish the visit within a certain period of time (which has happened) before moving onto the next patient? Then what solution will work then? Will I allow the patient to walk away with a confused look on their face and a statement along the lines of “Well, if you have any questions, feel free to call or email. Okay?” That makes me uncomfortable especially after recently realizing that I am more at peace immediately constructing a flowchart plan and wanting to actively try the best algorithm as soon as possible. I am not comfortable with expectant management usually…but I guess, we’ll see what happens with this rotation.

Does anyone know of solutions to this that have worked that they’ve seen implemented? Any input on this would be much appreciated.

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