Kidneys Inc.

medicine and nephrology updates and interesting cases by a practicing nephrologist in USA

Archive for the category “Healthcare”

STEPS to improve the experience of being a doctor

I was watching the episode 4 of Satyamaev Jayate (The truth prevails) (for those of you who do not know about it, it is a recently started much publicized talk show conducted by the celebrity actor Aamir Khan in India, addressing various issues that face today’s India). This episode really got the debate going because obviously though it had some truth to it, it was not the complete picture.

As I was thinking through this, I was struck by the fact that doctors are the most vulnerable group in the health care industry, be it in the United States or India. Doctors are at the disposal of everyone else in the ‘hierarchy’ of healthcare industry. Patients can sue them for bad outcomes or even without justifiable bad outcomes, employers can fire them for no reason what so ever, and if they own their own practice, they can get drowned in their own debts with all the ever-increasing overhead costs, and the public can criminalize, ridicule and metaphorically crucify them. It is true there are corrupt doctors, there are greedy doctors, and unfortunately so for the rest of them that are not. I am all for an outspoken criticism when the situation calls for it (like  the criticism of health care that I think is well deserved and long overdue), and recognize that passionately fighting back at the critique is only going to protect the rotten and corrupt parts of the healthcare system. So we should let the spark grow because that is the beginning of the road to a fairer system. However, we should be mindful of what we could do to amend the broken parts on our side.

It is important for us doctors speak up in this is the age of connectedness, age of social media, where every one ought to have a voice. This is a thought process to address the issues that might prove potentially problematic, not just from the legal standpoint, but also from patients’ perspective. Here are some issues that I thought were important ways to address them. This is mostly what we learned during training, but so often forget to practice

Speak up, Team up, Educate, Protect yourself, Support – STEPS

1. Media misrepresentation of doctor-pharmaceutical relationships – This may be different in different countries. My experience says, it is probably a worse problem in India. There have been many regulations to disconnect the big pharma companies from doctors. However, we are missing the elephant in the room, the real and bigger problem, that lies in the high-end ties and relations between corporate lobbyists & ruling powers. Whenever and wherever you see this kind of content, debate the issue, draw the attention to where the real problem is. ‘Mounam sammati lakshanam’. (silence is a sign of agreement) If you keep quiet, it is not considered polite, but counted as guilt. And if you think you are in a slippery slope with a pharmaceutical company, seek help and get out! You will not regret it. Someday, we will have to use the same medications & treatments and we should be able to do so without worries.

2. Doctors are overworked – Bring up such issues in meetings and devise a plan for work hours and schedules. when you cannot work anymore, please stand up and say, “I am done for the day, I cannot work anymore” and leave. It is better for everyone. Although easier said than done, I have to admit. An alternative would be taking at least an hour break, either for some quiet time or a slow lunch which should revive you enough to keep you going for the rest of the day.

3. Doctors have lost trust – Again, bad events, bad outcomes get more publicity and taint the image of doctors in the public eye. Gain trust of your patients. Inform, educate, communicate, obtain consents  — can’t be said enough. Show them their lab values, normal ranges, abnormal ones, graphs of trends, images and point to where the pathology is. Ask them to get an independent second opinion from another doctor of their choice. If it is different, discuss with the other doctor. It is ok if your first opinion was wrong on second thoughts. Do not forget to inform patients about risks, of everything that you do with their bodies. They have a right to know. Tell them what you are going to do, before palpating their breasts, or pressing on their bellies, or even listening to their lungs. Tell them what you find (sounds ok or looks fine) because they will be anxious about what you are going to find. Give them the assurance that you know what you are doing and if you do not know something you will find out. At the end of a visit, always ask if there is any other question you can answer for them. Do not leave them wondering what you are thinking. This may seem too trivial but very important contributors to what patients think of their doctors and how much they trust them, Convey to them that you are only as perfect as them and definitely care a big deal about their health. Remind yourself everyday that you and your patients are in the same team and are not opponents in a game where your win must mean patients’ loss. Work on gaining trust from your patients not by doing what they want, but assisting them with your expertise and help them make the best decisions for themselves. Tell them what they are entitled to know, instead of sugar-coating the talk and giving false hopes for incurable conditions. Keeping them informed of some bitter truths only makes them better prepared to face their struggles.

4. Employers giving you bad feedback based on what they ‘say’ they heard from patients about you. (while in fact it might be a purely administrative decision). It is a more malignant world than you think. An employed doctor does not have any protection against such kind of accusation, even when it is false. Unfortunately employed physicians are also the ones that depend on feedbacks for their future employments and growth in their careers. Do not let this affect you. Regardless of the kind of practice you have, provide patients with a website address (like vitals.com or health grades.com) where they can provide feedback, so you don’t get falsely accused of bad care. And with good feedback, you attract more patients and retain the ones you have.

5. Support your professional community. Do not discuss the perceived medical failures of your colleagues, or any other medical professional in front of patients. Firstly, you might not even have enough information only based on what patients tell you, that the care they received from another doctor was either wrong or unnecessary. Even if you know it is true, your objection has to be brought up with the other doctor and not with the patient. By not doing so, you are setting up a fertile ground that breeds mistrust. This where communication comes in handy, again. Obtain medical records, consult other physicians involved in your patient’s care. The time spent will save you time and even expenses sometimes.

Even after all this, it is not a cake walk being a doctor. It is quite a walk though, and we have to make the most of it!

Healthcare: The insider edition

Doctors inevitably come into spotlight, being at the front end of health care delivery. Sometimes seen as ‘guardian angels’ restoring health and life, other times, greedy minds sucking resources while they carelessly harm and kill patients to fill their pockets. After experiencing, observing, and hearing from others in this profession, I wonder if doctors are given more responsibility than they can handle, often attributed more aura than they deserve and frequently accused of more corruption than they are liable for. This is my attempt to redeem them from their “divineness” and their “evil” and make expectations, speculations and skepticisms a bit more realistic. When I say doctors, I mean, a typical one in the community, having a clinical job or practice, who doesn’t do research, but reads them, pays dues for being a member of medical societies, attends CME conferences regularly. In short, a doctor who is a consumer within the healthcare industry, which form the majority.

Doctors are trained for their skills and are not magicians. It is a science that has to be delivered artfully. Patients get better not because of anyone’s angelic touch or some celestial mediation, but because of treatments and interventions that are tested, tried and known to work. However, the art of delivering leaves a long lasting impression in patients’ minds. These ‘minor’ details are the major differences between top and mediocre hospitals. This ends my argument about the supernatural powers that doctors are supposed or expected to have.

It is an inescapable fact that healthcare ‘industry’ is more similar to other non-medical fields than it is different. However doctors are expected to play a superior role while everything else in the industry isn’t necessarily so. Healthcare is a business where workers have to be paid, professional relationships have to be maintained, the patients have to be happy, the ‘corporation’ should run successfully. There are lots of limitations that doctors work under, making it extremely difficult if not impossible to meet all of the expectations. Held responsible for the fallacies of the healthcare system, doctors see themselves more as victims of it. There are lot of judgmental attitudes and actions that occur based on isolated events. One patient’s angel may be another’s devil. An awesome doctor for a patient may be a colleagues nightmare and with time, it can all be reversed within no time.

Doctors take different roles making it a recipe where conflicts of interest brew in the same pot. One person becomes doctor +business(wo)man + marketing & sales personnel + scientist + teacher in various combinations. It only gets easier to rationalize decisions that a doctor makes under one umbrella if not another. It becomes an inexcusable rationalization when patients suffer. This may seem inapplicable in a non-medical field, because ‘suffering’ in those contexts may be easily overlooked or more indirect.

Doctors get overworked (sometimes voluntarily when they have independent practices), become victims of abuse and overuse by hospitals, employers and administrators (when employed). As a result they too become irritable, annoyed, annoying, depressed. They walk on the proverbial tight rope on each side of which are the hot oil of litigation and the fire of cost cutting that is flaring up, with the heat almost singeing their hairs. Professional competition, conflicts of interest shake and wiggle the rope, while the balancing stick has to be held on to tightly. The stick consists of professional ethics, competence, compassion and empathy to patients without getting attached to them, business and communication etiquettes, time management, family, personal growth. It is indeed challenging to become a doctor who is loved by everyone around including patients, colleagues, staff, community and family especially all through their career. But if they do make it to the other end of the rope, there is a well deserved applause waiting. Mostly from self as no one else would be watching. It just takes one bad moment to damage the reputation that has been built over years. For a doctor it is devastating, even if the factual consequences for everyone else are hardly so.

Business of healthcare:

Medical profession requires us to empathize but not get attached to patients. It requires us to treat equally, while the insurance companies are allowed to be discriminatory in their payment. In other words, the system rewards you differently for the same treatment delivered. Doctors do not fix the price for their services, the system does. The cost of physician services vary by specialty and by procedures. Physicians cannot sell themselves to drug companies, but the companies have a strong grip on the whole health care system be it through funding research or sponsoring activities of medical societies.

In a typical private practice, overhead costs are prohibitively high (includes space, computers, electronic medical records, staffing, housekeeping, power and water supply), 70% in one place I interviewed! Moreover, the insurance companies & medicare decide the reimbursement. Again doctors are not as powerful as they appear. Taking care of people who are suffering and making them feel better is an extremely rewarding job by itself. But there is just not enough time to do that rewarding job. If you are scheduled to see 30- 40 patients in a clinic, how is it humanly possible to listen to every patient’s complete story? When our job is to care, where and when does it end?

Relationship with drug companies:

Pharmaceutical companies have customers, clients, prescribers and have strategies not only to survive in the market, but also to grow. General public invests in their stocks and shares. It should be a joint effort of doctors and patients  to not lose track of the common goal of greatest good for the greatest number. IMO, a practicing doctor has very little to do with the drug prices. Here is one hypothetical example of how and why: I work in an inpatient setting only. The hospital uses Dalteparin (Fragmin) for DVT prohylaxis. No matter how many enoxaparin (lovenox) representatives provide lunches, every time I try to prescribe it, it will be changed to the former, because that is what is in the formulary. Same with proton pump inhibitors.

On the other hand doctors who are practicing privately, also see representatives and may have some more control on prescriptions. But again, the prescription has to depend on the insurance. If the insurance covers it, all things being equal, the patient sitting in front of a doctor is a priority over the person who can potentially become one in the future and does not have insurance.

Doctors are also frowned upon for eating at pharmaceutical dinners, because it results in increase in drug prices. We probably are guilty of this. More so probably because it operates at a subconscious level and easy to believe there is no effect.  No matter how much I try to deny their effect, the studies have shown otherwise. In fact, these studies are originally published in the same renowned medical journals that also publish other industry sponsored research. The bigger bargains & deals that go on behind the curtains involving corporations, businessmen, government officials go uninvestigated if not unquestioned. Policy makers make it easy for companies to track prescribing patterns of physicians, dislike ban on gifts more than doctors, while condemning and restricting doctors for accepting them. However, doctors’ communities have been listening to these associations. It has resulted in changes to untangle the knot and free this bias. But still there seems to be no difference in the last 10 yrs. In fact, the problem is only getting worse. Here is probably why:

Coverage of a medication under any insurance, who makes the deal? It is between those companies. And they are probably not doctors.

Meals are not the only venue where doctors are ‘exposed’ to new medications. I have found no medical journal without advertisements from drug companies. I still have to come across a conference where pharmaceutical industry has no role. Severing the connections is not easy, because medications are an integral part of medicine. An essential part of the health care machinery, doctors are more like nuts and bolts and not the ‘driver behind the wheel’ status they are given. The people who are behind the wheel are a handful, some of them are doctors some are not. We are culprits to the extent that we let it tide by us, not because it benefits us, but more because it hardly affects us (unless we become patients) and there are always more immediately relevant patient concerns to worry about. Hence, the check point would be probably more efficient if it is at the FDA instead of at the doctor’s office. What is the point of FDA approving a new ‘alternative’ choice medication if a doctor cannot prescribe it due to its cost? A major fraction of high costs are by the sickest patients who are a small fraction. The major flow of money from drug companies is into a handful of people who for the most part have transparent relationships. I would not be using Xigris (drotrecogin alpha) on everyone everyday. But if no one ever used it, we would never learn anything more about it. Not all medications that enter market thrive. (a new drug is approved by FDA every month on average). They stay only if they work. Here is another important article.

The skinny is – doctors should avoid prescribing expensive medications when cheaper alternatives are available. But what about the clinical trials showing an expensive medication as a better choice? Some examples, Carvedilol for beta blocker, Sevelamer for phosphate binding, now the bicarbonate form better than the previous chloride form… . Once FDA approved, there are studies to expand the indications of a medication. And then another study follows through showing how the new medication caused more harm (epogen for anemia in ESRD) The lawyers wait in the waiting room. The vast community of doctors use the results, but a handful of them produce them. How do we maintain quality and transparency in such research? If not published journals (inundated with drug company advertisements) what else do we rely our medical decisions on? For one, I agree that it would be a welcome change (and we should speak up for it) if drug companies were more transparent about the research. The articles published do have to disclose any relation between the authors and pharmaceutical industry.

A slightly different story when it comes to choosing diagnostic studies. Patients have to informed about risks of procedures, benefits, alternatives etc. This article will explain in detail how this operates.

It begins to almost look like a conspiracy against doctors where the professional and personal integrity are put to vigorous testing and the whole system is designed to fail you at every step.

Some numbers to get an idea:

There are currently 1.5 million doctors in US and as per the data available about money flow from doctors to drug companies, about 17,000 got paid. This would be about 1.1%, distributing the amount among themselves with only about 300 or so distributing about half of it. Some of it goes into research, some into consultancies, and a minute fraction into meals. IMO it would be a judgmental error to call a doctor unethical/immoral or greedy because he/she consumes meals offered by a drug company. What is more important is what went on before the drug company had its new drug FDA approved. I wonder if an engineer or an accountant working in a company making medical equipment or soft ware for electronic health records would be equally culpable for accepting & giving freebies in the form of gifts, travels to market and sell their products. Because like everything else, the costs get transferred to the consumer, which in this case are hospitals and practices.

I will be the devil’s advocate for a moment and wonder, why hospitals and cannot get subsidized rates on land, their equipment, transportation and other resources they use. Why are not insurance companies held responsible for making huge profits without doing a penny’s worth of research. Would it be a bad idea to channel a percentage of their profits into the government so medicare can keep its treasury full to help the sick, old and poor?

Why is manufacturing PET scanners, dialysis machines, surgical equipment, performing special blood tests so expensive? Aren’t these companies as responsible (for public health) as pharmaceutical industries? Doctor- drug company relationships- do they deserve this incrimination? Ultimately, most industries connect to and impact health care costs, even if remotely and indirectly.

We cannot deny that unethical, greedy people exist in the field of medicine also and one rotten apple stinks the basket. One mishap and now everyone is required to remove their shoes (and most everything else) at the airport security.

Medical liabilities: Currently doctors are personally* responsible for most lawsuits, isolated again. Liability insurances in some states are prohibitive for even sustaining a practice. While it is not impossible for the doctors mistake alone to cause a bad outcome, more often than not, it is not the case. There are always a series of holes that have to align for something to fall through. It would be a welcome change if doctors can emancipate themselves from the fear of frivolous lawsuits, and this I believe can play a major role in cutting costs of health care. I emphasize *frivolous* because there is always fear of the other extreme where doctors behave recklessly in complete absence of lawsuits.

A good and strong healthcare system is an asset to our society. Since health care industry is weaved intricately into a capitalistic, free market based economy and doctors belong to the work force of this huge industry, isolating only one profession & one industry for the costs at the other end is not only unfair, but biased. Somewhere along the way the major burden and blame of its malfunction seems to be unfairly shifting on to the doctors’ back. Doctors are not as powerful as they are portrayed. This is not to seek permission for unacceptable or reckless behaviors from healthcare professionals, but to seek acknowledgement of how ‘human’ most doctors are, how they are the part of the callous and inflexible system, more as pawns, less as players. And how like most people, they too are constantly battling to eliminate their deficiencies. Doctors are losing the little power they have by remaining silent about all the unfairness and misinformation. It is difficult and impossible to solve these problems by tightening a few screws here and there. What we need is a system wide approach that includes everything that touches healthcare to decrease costs and doctors would be more than willing to become a part of it.

My suggestion for people who are skeptical about their doctors, this website might help to know more and thus help in making informed decisions.

I once had a patient with terminal cancer, with a huge abdominal malignancy, at risk of bleeding, with an extremely poor prognosis if I have to word it optimistically. The family requested air transfer to another facility, due to fear of road travel causing rupture of the mass.

Always explore other options, get second opinions. Ask your doctors if a cheaper alternative is available, be it an investigation or a medication, regardless of whether or not your insurance covers them. What you choose as a patient for yourself will affect other people who can become patients, somewhere else, some other time. It is very difficult for doctors alone to decrease the healthcare costs, when there is no consent from patients, when there is fear of losing license to practice medicine for not using an expensive alternative.

Green dialysis

Some stats & facts

Average american family 400 gallons of water a day

Dialysis uses tremendous amounts of water — 32 gallons (120L) required during a typical dialysis session. Water purified by reverse osmosis prior to entering dialysis machines & water rejected by reverse osmosis goes down the drain.

7.13 billions gallons of potable grade A water wasted per year, with high salt content being its only problem. After desalination, it meets standards set by WHO & united nations food and agriculture organization for use in irrigation & landscape.

All the water, if saved and used, is enough to supply a city as big as salt lake city

It has already been done in Australia. more details in this link

http://www.renalbusiness.com/articles/2011/03/making-dialysis-green.aspx

Some more facts from the Australian Pilot Project

The RO water, better than drinking water wasted at 1100ml/min. It also fell within all national and international requirements for drinking water.

This otherwise rejected water was stored in tanks. They supplied the central sterilization department, the rest was used for cleaning, gardening, laundry and toilets.

The australian practice also adapted solar power that powered the reverse osmosis machines and also the dialysis machines. The cost of setting all this up turns out to be lesser than conventional expenses (electricity and waterbills) in the long run. It even becomes an income generator, once the cost is paid back.

The morality and rationale behind rationing “the beans”. Egalitarian or utilitarian?

here is a regular periodic meeting in all transplant centers, when doctors, nurse practitioners, transplant coordinators, social workers get together and ‘decide’ which patients in their center are eligible to get a kidney transplant and which ones need have to be removed from the waiting list. This important decision depends on a multitude of factors including but not limited to criteria such as time on waiting list, co-existing co-morbidities, social and family support, financial and employment status of the patients, insurance coverage, mobility and functional status of patients. Although pre-emptive transplantation is the ideal one, we are still far away from its realization, merely due to demand-supply discrepancy. Currently, age is not a factor for denying a kidney transplantation and donor kidneys are allocated on a first come first serve basis. Simply put, having age as a criterion would amount to ‘age discrimination‘. The OPTN/UNOS (Organ procurement and Transplant Network/United Network of Organ Sharing) committee is proposing a change that prioritizes younger patients, allocating younger kidneys to younger recipients. I think this will decrease* the ‘age discrimination’ as well as organ-recipient age discrepancy. Sounds like a paradox?.. Read on.

The number of patients on the kidney transplant waiting list, continues to increase sharply, growing 6 percent in 2008, and reaching more than 77,000 by 2008. Only about 17,000 end up getting transplants every year. The waiting time also continues to rise, varies geographically with a median duration being bat 3-4 yrs and could be as high as 8-9 yrs in areas like new york. Now with aging population and better healthcare technologies, lifespan of people with ESRD (End Stage renal disease) is getting longer and so is the waiting list for donor kidneys. This is mutifactorial:

The median age of the prevalent ESRD population has increased 3.2 percent since 2000, reaching 59.4 in 2008.

The adjusted incident rate of ESRD has grown 9.4 percent for patients age 75 and older, to 1,718 per million population in 2008, while the rates for those age 20–44 have increased by only 5.5 percent,

The adjusted rate of prevalent ESRD for patients age 65–74 has increased 25 percent since 2000, while the rate among those age 75 and older has grown 31 percent, to 5,266. Among those age 20–44 and 45–64, in contrast, growth has been just 11.0 and 17.5 percent, respectively. Meanwhile, the relative scarcity of donor organs is getting worse, despite measures taken to expand the donor pool as the number of organs available is not catching up with the number of waiting eligible recipients.

It is important to note in this context that the pediatric age group has a separate waiting list to avoid long waiting time as the outcomes are maximized both from medical and economical standpoint. These approaches, in my opinion, has apparently created a ‘donut hole’ in the list of patients waiting for a donor kidney. It seems like younger patients, who are neither too young to be in the pediatric group, nor too old enough to have accumulated a long waiting times were being pushed down the long waiting list. They are being denied kidneys that would provide them (and the kidneys) more additional years when compared with a similar older recipient higher on the list. Moreover, older patients have a higher chance of dying with a functioning transplanted kidney. The DWF (death with functioning graft) can be as high as 38% and amounts to about 42% of the kidney transplants. In some ways this situation is similar to the blood group and HLA matching discrepancy that made it harder for the O blood group ESRD patients to get a donor kidney and lengthened their waiting times. Also I can see this as an extension of the ‘pediatric allocation concept’. A 30 y old is relatively a ‘pediatric when compared with a 70 yr old.

Recent proposal to consider age and hence overall ‘predicted life years’ is the most drastic of the changes that have been made, in the last 25 years, to the algorithm of choosing recipients for the available kidneys. The new change is aimed at maximizing the outcomes for both the recipient of the kidney and the kidney itself. This is a good approach because

-The sooner an ESRD Patient gets a kidney, the better the outcomes are

-The longer the graft survives, the longer the patient survives

-The younger the recipient, more likely he/she will outlast the graft, and when that happens, they still have blood vessels and peritoneum in a good shape to last long enough

-It results in more patients with ESRD staying away from dialysis thus decreasing the budget deficit of medicare, which is the main coverage provider for patients with kidney disease

However, being a major and a fairly comprehensive shuffling of criteria by UNOS, major ethical, political, medical debates over the rationale of rationing will soon follow. More interesting would be to know what happens to the existing list where the older patients already predominate the higher parts of ‘the list’. With my quick research, I found out that a separate group will be formed for the youngest of the waiting list, so the younger kidneys are more likely to end up in younger patients. And the rest would follow in real time.

While this change is very appropriate where there organ scarcity and government is spending for the care of recipients, it raises an important question about healthcare that should be, by principle, equally distributed and equally available to everyone. If implemented, the same effect is bound to trickle down other aspects of health care, like end of life care, therapies for malignancies and end stage heart disease. The infamous “death panels” come to mind. But no matter what name they are given, such panels are important for healthcare, where everyone is fighting for a bite.

Some questions arise that cannot be left unaddressed. Medicare only pays for patients for a limited period for post transplant medications and one of the major reasons for failed transplants is non-adherence to those much needed medications, due to prohibitive costs. Should we then prioritize rich recipients over poor ones? Patients that are/were more productive over the unemployed?

While trying to get away from discrimination, do we end up doing just that? Can judgment based on sound scientific evidence and strong statistical data be accused of being discriminatory? Should we stratify both recipients and donor kidneys based on characters to form multiple short waiting lists?

Health policies are made based on population studies and statistical analysis, emphasizing greatest good for the greatest number. Rightfully so, because, when there are way too many people wanting the cake, some one has to decide, who benefits the most by having it, based on available scientific evidence. But more importantly, whoever gets the power to decide will take the blame for playing god.

The policies based on outcomes or consequences are more meaningful than those based on principle without support.

While I am writing this, a random thought flickers and I wonder if there is an end to our dependence on donated organs.  Is there an implantable metallic kidney in the future, ending this rough battle for the ‘beans’?


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