A Canadian Physician, PGY-10.

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The intrinsic injustice of our justice system

I re-read a quote from an article about Aaron Swartz, and it was so beautifully written and insightful that I thought I would share it:

In short, [Swartz's] team seemed to view this as an unjust and broken application of a system to an undeserving man, not recognizing that the system is rigged and unjust and broken from the start. That's common among smart, educated, fortunate people. As I have discussed before, my fortunate clients are the most outraged at how they are treated by the criminal justice system, and most prone to seeing conspiracies and vendettas, because they are new to it — they have not questioned the premise that the system's goal is justice. My clients who have lived difficult lives in hard neighborhoods don't see a conspiracy; they recognize incompetence and brutal indifference and injustice as features, not bugs.

The intrinsic injustice of our justice system

Dangerous Idea: Asynchronous Consultations

I was tagged by Jessica Otte in her Dangerous Ideas post, so I guess it's my turn to post my own submission to the College of Family Physicians of Canada (CFPC)'s "Dangerous Ideas Soapbox" as part of Family Medicine Forum (in 2016, hosted in Vancouver).

This is the part of the conference during which physicians can share radical ideas for change in primary care. Four abstracts are chosen and presented, and the successful ideas are later published in the Canadian Family Physician; see 2015's Dangerous Ideas.

My idea:

We all know technology in healthcare moves at a glacial pace, and the way technology and our lives interact outside of our work has evolved to be drastically different from what happens in clinic settings throughout Canada. The nature of the typical patient-physician interaction hasn’t fundamentally changed in 100 years. But what if we made some common-sense, relatively low-tech changes to how our clinics run? Almost everyone my age or younger keeps in contact with family and friends on a daily basis effortlessly through text and Snapchat.

What is stopping us from communicating with our patients in this fashion, and more importantly what is stopping patients from initiating this type of interaction themselves? I would posit that most healthcare issues are continuous rather than episodic, and that an ongoing, thoughtful conversation with our patients would significantly improve the quality of the care they receive. Texting comes naturally in the modern era to most, and the key to it's explosion in popularity is its asynchronous nature. In the context of healthcare, this means that my time as a physician is used much more efficiently, saving the healthcare system as I fit ongoin asynchronous conversations in between my traditional in-person visits. My patients and I can engage in the conversation when most convenient for each party. We can both take time to think about our questions and answers. The patients have an ongoing and permanent record of our conversation, and subsequently are able to recall 100% of what we discussed, rather than the perhaps ~30% of what we discussed during an in-person consultation.

Now, this isn’t all positive: not all medical problems can be handled over text, and certainly not all patients want to engage with their physicians in this way. But pioneering clinics in the U.S. have seen upwards of half of in-person visits disappear when patients have the option of ongoing, asynchronous care, and this will likely increase as a greater proportion of the population becomes comfortable with the technology. I believe asynchronous care will be a core component of good primary care in the not too distant future, and will be a source of significant healthcare outcome and system cost improvements.

I Just Want to See Patients

Recently, a study came out that declared that the GP incentive payments for complex care, as designed by the General Practice Services Committee (GPSC) here in BC, have failed to improve several markers of healthcare utilization and general health.

Dr. Shelley Ross, co-chair of the GPSC, was quoted in print media defending the GPSC incentive program, stating that two years of data was not nearly enough to draw conclusions:

"There is no doubt that having a family practitioner who knows you, who sees you proactively, who has a care plan for what they want to achieve in consultation with the patients, is absolutely improving care and the patients feel like they are getting better care as well."

What Dr. Ross mentions seems self-evident: having a Family Physician that sees you longitudinally, who has a care plan in place for you, will obviously improve your care (or at least not worsen it!). Unfortunately Dr. Ross has played a sleight of hand here: what she is discussing is proper Family Medicine as we'd like to see it done, but what the study was actually about is billing incentives, otherwise known as "pay for performance". These are not the same thing, and there are much better ways to achieve good, longitudinal Family Medicine. If we're going to spend several hundred million taxpayer dollars, I think we need some evidence behind our programs, and pay for performance has little or no good data to support its use to improve complex care.

What Dr. Ross also glosses over here is that, if BC Family Physicians were just paid appropriately to see a roster of family medicine patients, comprehensively, the same goal could be achieved, with significant administrative savings, while decreasing the real risk of burnout. The complexity and opacity of the billing schedule in BC serves as a serious disincentive to young physicians like myself, as it leads to both significant administrative overhead, as well as difficulty figuring out just how much I might get paid, as many of the payments are deferred (i.e. paid yearly). For example, below I've listed just one of the GPSC's many incentive billing codes (G14033):

The Complex Care Management Fee is advance payment for the complexity of caring for patients with two of the eligible conditions and is payable upon the completion and documentation of a Complex Care Plan for the management of the complex care patient until the complex care plan is reviewed and revised in the next calendar year. A Complex Care Plan requires documentation of the following elements in the patient’s chart that: 1. There has been a detailed review of the case/chart and of current therapies; 2. There has been a face-to-face visit with the patient, or the patient’s medical representative if appropriate, on the same calendar day that the Complex Care Management Fee is billed; 3. Specifies a clinical plan for the care of that patient’s chronic diseases covered by the complex care fee; 4. Incorporates the patient’s values and personal health goals in the care plan with respect to the chronic diseases covered by the complex care fee; 5. Outlines expected outcomes as a result of this plan, including end-of-life Issues (advance care planning) when clinically appropriate; 6. Outlines linkages with other health care professionals that would be involved in the care, their expected roles; 7. Identifies an appropriate time frame for re-evaluation of the plan; 8. Confirms that the care plan has been communicated verbally or in writing to the patient and/or the patient’s medical representative, and to other involved health professionals as indicated. The development of the care plan is done jointly with the patient &/or the patient representative as appropriate. The patient &/or their representative/family should leave the planning process knowing there is a plan for their care and what that plan is. Notes: The Complex Care Management Fee was developed to compensate GPs for the management of complex patients who have chronic conditions from a least 2 of the 8 categories listed below. Providing the Complex Care planning visit and billing for the development of a care plan allows access to 5 telephone/e-mail fees (G14079) during the following 18 months. These items are payable only to the General Practitioner who accepts the role of being Most Responsible for the longitudinal, coordinated care of that patient; by billing this fee the practitioner accepts that responsibility for the ensuing calendar year. The Most Responsible General Practitioner may bill this fee when providing care only to community patients; i.e. residing in their homes or in assisted living with two or more of the following chronic conditions: 1) Diabetes mellitus (type 1 and 2) 2) Chronic Kidney Disease 3) Congestive heart failure 4) Chronic respiratory Condition (asthma, emphysema, chronic bronchitis, bronchiectasis, Pulmonary Fibrosis, Fibrosing Alveolitis, Cystic Fibrosis etc.) 5) Cerebrovascular disease 6) Ischemic heart disease, excluding the acute phase of myocardial infarct 7) Chronic Neurodegenerative Diseases (Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke or other brain injury with a permanent neurological deficit, paraplegia or quadriplegia etc.) 8) Chronic Liver Disease with evidence of hepatic dysfunction. If a patient has more than 2 of the qualifying conditions, when billing the Complex Care Management Fee the submitted diagnostic code from Table 1 should represent the two conditions creating the most complexity. Successful billing of the Complex Care Management Fee (G14033) allows access to 5 Telephone/E-mail follow- up fees (G14079) per calendar year over the following 18 months. In order to encourage non-face-to-face communication with patients covered by some of the GPSC incentives, the initial four separate telephone/e-mail follow up fees have been simplified into a single code that will still apply to the planning incentives (Complex Care G14033, Mental Health G14043, Palliative Care G14063 & COPD G14053 which requires a COPD Action Plan). Patients covered by one or more of these incentives are eligible for five telephone/e-mail services over the 18 months following the billing of the qualifying incentive(s). i) Payable once per calendar year. ii) Payable in addition to office visits or home visits same day. iii) Visit or CPx fee to indicate face-to-face interaction with patient same day must accompany billing. iv) G14016, Community Patient Conferencing Fee, payable on same day for same patient if all criteria met. v) G14015, Facility Patient Conferencing Fee, not payable on the same day for the same patient, as facility patients not eligible. vi) G14017, Acute Care Discharge Planning Conferencing Fee, not payable on the same day for the same patient, as facility patients not eligible. vii) CDM fees G14050/G14051/G14052/G14053 payable on same day for same patient, if all other criteria met. viii) Minimum required time 30 minutes in addition to visit time same day. ix) Maximum of 5 complex care fees (G14033 and/or G14075) and/or GP unattached complex/high needs patient attachment fees (G14074) per day per physician. x) G14075, GP Attachment Complex Care Management Fee, is not payable in the same calendar year for same patient as G14033, GP Annual Complex Care Management Fee. xi) G14079 – Telephone/e-mail follow up fee is not payable on the same day. xii) Not payable for patients seen in locations other than the office, home or assisted living residence where no professional staff on site. xiii) Not payable to physicians who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care; xiv) Not payable to physicians working under salary, service contract or sessional arrangements whose duties would otherwise include provision of this care.

Phew! Think of the time wasted here in self-audits and clinically unnecessary documentation, just to ensure you're billing appropriately. Billing codes are not (and should not be) the incentive to do proper complex care; our training is.

How would I like to see this fixed? BC could attract many young physicians like myself by offering a fair compensation package that does away with the dozens of complex billing codes, and pays me to look after a cohort of patients longitudinally. I want to do proper Family Medicine, but the fee schedule doesn't enable that currently. Preferably, I would like the government to say ""we'll pay you $X/month to look after Y patients, comprehensively." I can dream! Until then, BC will continue to hemorrhage younger physicians.

99 Topics

I've recently started concentrated study for the Canadian Certification in Family Medicine (CCFP) exam that I'll be writing in April this year, and as part of my study I've decided to create a "99 Topics" podcast. I learn best when listening on the road (lots of driving to do in Saskatchewan!), so I hope other residents and medical students might find some use out of what I have to say. I plan to in time cover all 99 topics required for the exam.

Feel free to follow along and suggestion content changes or corrections as we go. You can find the podcast at http://99topics.drbouchard.ca.

Hacking Health

This evening was a Hacking Health Cafe held in my current nearest city, Saskatoon. I was asked to present on a topic, and I chose a topic close to my heart as I work toward the end of my residency: Failures of EHR (or EMR in the current Canadian nomenclature). Slides are below, feel free to use and reuse!


Smartie Houses

I'm off on a new adventure, this time in Canada's Arctic. I'll be working and training as a medical resident in Inuvik. I'm really excited to experience the far north of my country, to learn in a remote environment, and to see the local sites and sounds of Inuvik. For the entire month of June the sun will be up — it rises in mid-May, and doesn't set again until July. I'm hoping to keep this blog updated on my adventures — more to come in the days ahead!

FOAMED grand rounds

I gave a presentation on #FOAMED and the Free Open Access Medical Education movement for our hospital grand rounds today. The slides might require a bit of context, but may be still be of interest to some of you, so have at!

The top 20 studies of 2012 for primary care

Tim Leeuwenburg on Kangaroo Island in South Australia discusses an excellent summary in American Family Physician this month of the top 20 most relevant studies of 2012 for primary care.

After more than a decade of follow-up from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, there appears to be no mortality benefit to screening asymptomatic men for prostate cancer.

The top 20 studies of 2012 for primary care

Supervised injection sites: Prejudice should not trump evidence of benefit

Insite opened in Vancouver in 2003 as a response to devastating twin epidemics of HIV and drug overdoses. A large body of peer-reviewed research, published in leading medical journals, has documented the various benefits of the program, including reductions in syringe sharing and fatal overdoses, and increased uptake of addiction treatment. Three separate studies have found Insite to be cost-effective. Meanwhile, the feared negative consequences of opening Insite have failed to materialize. Although concerns persist that supervised injection facilities attract crime and increase drug use, research undertaken in Vancouver has shown that such fears are unfounded. The results of several studies suggest that disorder associated with public injecting has declined. The rigorous scientific evaluation of Insite, as well as the evidence derived from the 90 other supervised injection facilities internationally, support increasing these services as part of a comprehensive response to drug use and its associated harms.

Keep up the good work Insite! Here in Saskatchewan I know physicians are campaigning hard for a similar site to be set up, but I'm doubtful it will happen anytime soon due to the enormous amount of red tape that is already required, with likely additional hoops to jump through being added by our current Conservative government.

Supervised injection sites: Prejudice should not trump evidence of benefit

UK Health Check contradicts best evidence

According to a 2012 Cochrane systematic review and meta-analysis, periodic general health checks do not reduce morbidity or mortality (BMJ 2012;345:e7191). "Since health checks probably increase the number of diagnoses, the absence of benefits suggests overdiagnosis and overtreatment," states the paper. "Current use of general health checks is not supported by the best available evidence."

So why is this practice so prevalent in Canada then? I'm genuinely interested in arguments for and against - throughout my training here I'm hoping to reconcile common practice with best evidence so I can decide how to apply this in my own practice.

UK Health Check contradicts best evidence

Just an average day here at Sherpaa...

My OBGYN is having trouble getting my prescription approved. I've been on my OCP (oral contraceptive pills) for 8 years, and my insurance company says they don't cover it.

[…] There's a number that the pharmacy usually has to call to get prior authorization for coverage for medications. I can't get through to your insurance company or the pharmacy at this time.

[…] I got prior authorization for a 90-day prescription of your OCP. I called Duane Reade, and you're good to go. You can go ahead and pick them up. I changed it to a 90 day supply with three refills. There will be a $0 copay. Your OB's office tried for prior authorization yesterday, but they didn't have information about your medication history. Btw, I have a 100% batting average for getting prior authorizations. Have a great vacation.

Jay Parkinson sees this as a demonstration of the strength of his new company Sherpaa, but to me this is a perfect demonstration of just how dysfunction American healthcare is, and it makes me mad and sick to my stomach at the same time to think about the hundreds of millions of people that have to suffer this. In Canada or Australia, there is no need for a company like Sherpaa. This isn't a demonstration of good healthcare, or good medicine, it's a demonstration of using experience in healthcare bureaucracy to battle bureaucrats at their own game.


Just an average day here at Sherpaa...

Finally, done.

Medical school is finally over, and yet it feels very anticlimactic. I've been looking forward to this for so long (and for so many reasons) that I thought it would be this momentous event (at least in my head) - instead it feels like just another day. When I think about it though, it's a day when I get to use the title "doctor", and a day when I start earning money rather than spending it, so definitely worth it. I'm looking forward to having responsibility for my patients; to being challenged to succeed and to learn; and to building a life together with my soon-to-be-wife as DINKs (Double Income, No Kids). Here's to the future!

Why childhood vaccinations are worthwhile

Below is a short, disorganized note I wrote to a friend who wasn't a fan of childhood vaccinations. I thought I would put this out there for critique and hopefully a productive public discussion:

Before I begin, please note that unfortunately access to most online medical journals isn't free. Please let me know if you'd like a copy of any of the papers I've cited.

When reading the latest news headlines espousing either pro- or anti-vaccination studies, it's important to look behind the news article to the study itself. In the medical field, we call this "evidence-based medicine" - research is evaluated as it is reported, and how we practice medicine changes based on how strong the evidence is for or against a particular practice. A small study including patient interviews is unlikely to change practice widely, whereas a large randomized and controlled trial including 10,000 patients is likely to change our practice as a profession. One fairly recent example of this is the Cochrane review on oral anticoagulants (i.e. Warfarin) versus anti-platelet drugs (such as Aspirin) in those with Atrial Fibrillation (i.e. an irregular heartbeat) for the prevention of the stroke. The idea is that an irregular heartbeat can cause blood clots to form in the heart, that then "break off" and travel to the brain, causing a stroke. The Cochrane Review, which is essential a study-of-studies on a particular subject, showed that drugs such as Warfarin are about 1/3 more effective than Aspirin in preventing stroke. This study included 8 randomized trials, and over 9000 patients, and although most physicians were already giving Warfarin to patients with an irregular heartbeat, this study confirmed that this was indeed the "best medicine" for the patient. For more on evidence-based medicine, this link covers the different "levels" of evidence that are important when discussing vaccination research.

Because the MMR (Measles, Mumps and Rubella) vaccine seems to be the primary target for anti-vaccine groups and the main concern for worried parents, I'll discuss the evidence for the MMR vaccine briefly. We're fortunate that in 2008 the Cochrane Library published "Level 1++" evidence on the topic - a meta-analysis of all published trials regarding the MMR vaccine.

Their published objective:

  1. To review the existing evidence on the absolute effectiveness of MMR vaccine in children (by the effect of the vaccine on the incidence of clinical cases of measles, mumps and rubella).
  2. To assess in children the worldwide occurrence of adverse events, including those that are common, rare, short and long-term, following exposure to MMR.

This "study-of-studies" started very broad in trying to identify adverse outcomes of vaccination - they started with 5000 articles. They narrowed this down to 139 articles on the subject since 1966, and after selecting only retrospective and prospective studies on the subject they had 31 published articles to review.

The results of this study showed that there are adverse (bad) effects of the vaccine, but that they are very rare and generally not serious. They were unable to show that the vaccine was effective as a whole (because there is no specific research on this topic to date), but noted that other studies have show that each component of the vaccine is effective individually. For example, there is Level 2+ (a.k.a. "good, but not great") evidence showing that the Mumps component in the MMR vaccine is at least 88% effective when both required shots are given. The effectiveness rate for Measles in the MMR vaccine is similar.

According to the CDC, almost 3 in every 1000 people infected with Measles will die - stated another way, the mortality rate from Measles infection is about 0.3%. In the current vaccinated Canada, incidence of Measles is in the tens per year, which means that the chance of dying from Measles is 3/1000 x 20/35,000,000, or essentially negligible. Rates for other vaccine-preventable diseases are roughly equivalent (pertussis ("whooping cough") is quite a bit more infectious), so this begs the question of "why vaccinate?", if there is even a slight chance of adverse effects.

This is certainly a reasonable question, that I would counter with three points:

  1. The only reason that your children have a negligible chance of contracting these life-threatening infections is because most parents in Canada have chosen to vaccinate their children, reducing the incidence of infection significantly. With Measles, for example, rates have gone from greater than 90% to virtually nil. Pre-vaccination, your children would have had a 30,000-fold increased chance of dying from Measles than in a modern day plane crash - post-vaccination, all we have to worry about is the plane crash.

  2. There is a small proportion of children who cannot receive vaccinations because their immune system is compromised (for example, in early childhood cancers, genetic defects, or other serious illness), and rely on herd immunity to protect them from these deadly diseases. By not vaccinating children that are able to handle the vaccines and become immune, we put these sick children at risk.

  3. Although definitive evidence of the risks of adverse effects has yet to be carried out for most childhood vaccines (I hope it does eventually!), the dearth of credible case studies demonstrating serious adverse effects over the 200+ years of routine vaccination is strong evidence in itself of their safety. Remember that still, to this day, we have relatively poor evidence for the causative link between smoking and lung cancer - what has changed the consensus opinion is the long time period and the very strong correlation between the two. Conversely, I am unaware (and certainly haven't heard differently in medical school) of any correlation, strong or otherwise, between childhood vaccinations and an increased risk of adverse effects. As you would know, the single "peer reviewed" study done on the link between autism and the MMR vaccine has been fully retracted by The Lancet and 10 of the 12 original authors of the paper.

One last comment: while researching this further I have found a rather disturbing trend in anti-vaccination groups to lend an undue weight to case reports and anecdotal evidence supporting the link between vaccinations and adverse effects. Remember that there are "levels" of evidence, with case reports and other anecdotal evidence making up the bottom, or least reliable, level. Just as I (and the Cochrane authors) have discounted case reports in demonstrating the safety and efficacy of the MMR vaccine, so too does the anti-vaccine movement need to rely on unbiased and controlled trials. To date I have yet to see any of the studies cited by the Vaccination Risk Awareness Network that meet this criteria.

Concerns about immunization safety often follow a pattern. First, some investigators suggest that a medical condition of increasing prevalence or unknown cause is an adverse effect of vaccination. The initial study, and subsequent studies by the same group, have inadequate methodology, typically a poorly controlled or uncontrolled case series. A premature announcement is made of the alleged adverse effect, resonating with individuals suffering the condition, and underestimating the potential harm to those whom the vaccine could protect. The initial study is not reproduced by other groups. Finally, it takes several years to regain public confidence in the vaccine. Adverse effects ascribed to vaccines typically have an unknown origin, an increasing incidence, some biological plausibility, occurrences close to the time of vaccination, and dreaded outcomes.

— From Wikipedia: Vaccine Controversies

The squeeze - WhiteCoat's Call Room

Work in emergency medicine long enough and you get good at figuring out what patient's medical problems are just by their appearance.
He had a pasty color as he was wheeled through the door. Anemic for sure. His abdomen was swollen. Liver failure is my guess. Probably GI bleeding. But he also had the blank stare of someone who was focusing on something other than the world around him. He needed help and he needed help in a hurry. His blood pressure was low. His respirations weren't keeping up with his oxygen needs. His focus was on getting enough air into his lungs. He was able to communicate in short sentences between his quick breaths.
"Can't breathe."
"No chest pain."
"Do everything."
The squeeze - WhiteCoat's Call Room