Annie medicine…

Posted on Thursday 21 April 2016

Annie [above left on the day she arrived] was a retirement present from my practice partners [2003]. Her first friend, Studly, [above middle] lives down the road, but eats and sleeps here [going home for the odd holiday]. Woofie, above right, showed up after a year or so as a stray, taking up full time residence after being shot in the chest [mistaken for a Coyote we think]. Annie has an electric fence encircling about an acre of our property because she is just not highway·savvy, while the other two are free range denizens of the hood. Annie waits patiently at the edge of her domain while the boys go on their morning and evening walk-abouts.

Thirteen years have passed, and things are a little different now. Annie has bilateral hip arthritis, and [untreated] lays around moping. But she can return to her old frisky self with a single dose of aspirin a day. It’s remarkably effective, but getting her to take it is another matter entirely. She often turns her nose up at the liver flavored Nutri·Vet doggie aspirin, even when sealed inside of a Greenie [a pill pocket designed for such purposes]. So over time, we’ve learned that:
  1. if: we don’t feed the dogs automatically in the morning
  2. and if: we wait until Annie starts lobbying to be fed [by head butting my leg]
  3. and if: she hasn’t seen me preparing the aspirin bomb [broken up pill sealed in the Greenie]
  4. and if: we give her the bomb slightly reluctantly as a treat in response to her demands
  5. then: she sucks it down with relish
  6. and then: we feed the dogs
Any break in the chain, and we’re in a forced drugging situation [not conducive to good inter·species relations]. forced drugging is okay for a one shot heartworm pill or maybe a short course of medication like antibiotics for a discrete illness, but not for everyday meds. So every morning, the background issue around here is "Has Annie been bombed?"

Little question that this is a story about how old people spend their time and about my lifelong attachment to dogs, but I have another agenda in the telling. In medical school and during the first part of an Internal Medicine residency, I think I had an algorithmic view of medications. This medicine is for these things. And that medicine is for those things. This is the dose for this med, etc. But then then came the clinical part of my Fellowship with our Rheumatology Group. Since many of those diseases are of unknown etiology, and the treatments are often empirical, things were very different:
    em·pir·i·cal  /ëm-pir-i-kãl/
      adjective: empirical
      based on, concerned with, or verifiable by observation or experience rather than theory or pure logic…
At first I thought I’d fallen in with a bunch of lunatics. On rounds, we’d spend forever retaking the history and repeating the exam. Then we’d retire to the ward conference room and have a long discussion about treatment, and about what parameters we’d follow to judge the effect of the treatment, whatever it was [and sometimes it was nothing, as in benign neglect]. I was used to the  speed-dial ER mindset, and this seemed like a lesson in what it was like to have OCD in a war zone. Every treatment was a therapeutic trial [emphasis on every]. With every medication trial, we were seeking a therapeutic window in terms of dose. But after a time, I came around to see the wisdom in that way of thinking. We were using medications on the toxic end of the spectrum with crippling chronic diseases and the only solid proof was in the unique response in any given patient. It was a good lesson for all of medical practice. I never got over that way of thinking [and never plan to]. When I got to psychiatry, it was a natural fit [unknown etiology, significant toxicities, chronic course, proof in individual results, benign neglect option, etc].

Back to Annie. This aspirin choice came after trials with several other anti·inflammatories [GI problems] and some concoction being pushed by our vet called Zoom [poor results]. With the aspirin, ½ an adult aspirin worked [~160 mg]; a baby aspirin didn’t [~80 mg]; so on to the 120 mg doggie aspirin which also worked – at least for now.

While this little tale of Annie’s treatment has an obvious moral-to-the-story, its moral only really works in a Marcus Welby, M.D. world [Marcus Welby was a long-running television program about a doctor who devoted 24/7 attention to the patient of the week, with no other apparent cases or duties] – a world in which every case is an Annie. In case it’s not clear, my topics here are modern medical practice and treatment guidelines – obviously too big for a single post [maybe too big for a single blog]. But here’s a viewpoint piece from the JAMA that frames some of the issues:
by Donald M. Berwick MD
JAMA. 2016 315[13]:1329-1330.

Constant conflict roils the health care landscape, including issues related to the Affordable Care Act, electronic health records, payment changes, and consolidation of hospitals and health plans. The morale of physicians and other clinicians is in jeopardy. One foundational cause of the discord is an epic collision of 2 eras with incompatible beliefs.

Era 1
Era 1 was the ascendancy of the profession, with roots millennia deep—back to Hippocrates. Its norms include these: the profession of medicine is noble; it has special knowledge, inaccessible to laity; it is beneficent; and it will self-regulate. In return, society conceded to the medical profession a privilege most other work groups do not get: the authority to judge the quality of its own work. However, the idealism of era 1 was shaken when researchers examining the system of care found problems, such as enormous unexplained variation in practice, rates of injury from errors in care high enough to make health care a public health menace, indignities, injustice related to race and social class, and profiteering. They also reported that some of the soaring costs of care were wasteful — not producing better outcomes. These findings made a pure reliance on trusted professionalism seem naive. If medical professionals were scientific, why was there so much variation? If they were beneficent, how could they permit so much harm? If they self-regulate, how could they waste so much?

Era 2
The inconsistency helped birth era 2, which dominates the present. Exponents of era 1 believe in professional trust and prerogative; those of era 2 believe in accountability, scrutiny, measurement, incentives, and markets. The machinery of era 2 is the manipulation of contingencies: rewards, punishments, and pay for performance. The collision of norms from these 2 eras—between the romance of professional autonomy on the one hand, and the various tools of external accountability on the other—leads to discomfort and self-protective reactions. Physicians, other clinicians, and many health care managers feel angry, misunderstood, and over controlled. Payers, governments, and consumer groups feel suspicious, resisted, and often helpless. Champions of era 1 circle the wagons to defend professional prerogatives. Champions of era 2 invest in more and more ravenous inspection and control…
I was trained in an Era 1 world, one where medical morality and standards were meant to be an inside job. And whether by design or good fortune, I spent my practicing years in a domain that was close enough to welby-esque for this discussion – as a sole practitioner, on no provider panels, with time enough to practice Annie medicine. So I have a big bias on both of these topics [modern medical practice and treatment guidelines]. But as my daughter, a practicing child psychologist, puts it, "Dad, you could never get away with the way you did it now!" While I expect she’s probably right, that doesn’t change what I think one bit. I still think the Annie model of  personalized  individualized medicine is the right way to do things.

But I absolutely can’t argue with Dr. Berwick’s point about the pollyanna idealism and the dark side of Era 1. I wouldn’t even argue that it was those other doctors who didn’t do it right. Medical Care isn’t the Wild West. It’s an essential profession that needs oversight and discipline – not cowboys and entrepreneurs. And I realize that because of my own experience, what I see in modern medical practice and in treatment guidelines is the pollyanna idealism and the dark side of Era 2. But unfortunately, there’s plenty to see.

So I guess this post is my COI declaration for my future comments about modern medical practice and treatment guidelines
    Bernard Carroll
    April 22, 2016 | 3:55 AM

    I trained in Era 1, too, and I like to think we internalized the values of beneficence, respect for boundaries, disinterested commitment to patients, and avoidance of public display. To betray patients’ confidences was unthinkable. Physicians in Era 1 were all too conscious that they did not possess full understandings of disease mechanisms or of therapeutic choices; medical encounters were human interactions rather than data transactions. The imperfect physician offered his best advice to help the patient, though much was left unsaid in these interactions about quantified risks and prognoses – patients expected the physician to sort through the complex probabilities and to act in the patients’ best interests. In return, patients wanted ongoing care and attention from the physician, validation of the sick role, and freedom to raise any intimate subject with the physician. When things went badly, patients and their families accepted that with resignation, while we physicians did our best to learn what lessons we could from the poor outcome. Recognizing that we all were fallible, we generally refrained from piling on when a bad outcome occurred in someone else’s practice.

    With the arrival of Era 2, eminence-based medicine supposedly was replaced by evidence-based medicine. All that really happened, though, was that process replaced substance in the clinical encounter, while financial exploitation of commodified patients replaced beneficence towards the suffering patient. The third parties (payors) hijacked the two-party clinical encounter, and money now shapes every aspect of clinical medicine. This was done under the pretense of evidence-based medicine, though the people who really set the agendas nowadays have no medical training. They surely have internalized no medical professional values. They did not hesitate to enforce discriminatory provisions against patients with pre-existing conditions when they could get away with that. They did not hesitate to discriminate against patients with psychiatric diagnoses. Why did they? Just because they could, not to mention their unseemly personal enrichment. As Roy Poses and Scot Silverstein tell us week in and week out on the Health Care Renewal weblog, they extract value from the system rather than add real value. As if that isn’t bad enough, the mandates to adopt clumsy electronic health records have gutted clinical encounters in primary care. I say that from personal experience as a patient: process truly has replaced substance. Yet if we look around today there is still plenty of “unexplained variation in practice,” there are still “rates of injury from errors in care high enough to make health care a public health menace, indignities, injustice related to race and social class,” and, boy, is there profiteering!

    Are we better off in Era 2? Hell, no! Worst of all, we shot ourselves in the foot by promoting the illusions of standardized process and standardized outcomes. These did not improve our understanding of disease mechanisms or of therapeutic choices – just look at DSM-5 and the treatment of depression. But patients have bought into these illusions, too, and they now demand nothing less than standardized outcomes – all the more so because they sense that “the system” doesn’t really care about them except as commodities to be managed for maximizing profits.

    James O'Brien, M.D.
    April 22, 2016 | 11:37 AM

    I’d break down Era1 into Era1a and Era1b.

    Era1a was medicine before Medicare, pre-1965. When insurance was called “hospitalization.” Before hospitalization, catastrophic care was really managed by friendly societies. Accountability for routine services was by the invisible hand, not insurance review. Doctors were accountable and didn’t make as much as in Era1b. There was certainly quackery as there always has been. This is well documented in books such as Charlatan and during the early 1900s which was the golden age of medical scams, but at least that was paid by the mark and not the taxpayer or by ever increasing premium on everyone.

    Era 1b was from about 1965-1985. This was an era when physicians were billing anything for everything and getting away with it. Before mangled care, which was a necessary response to 17 year olds being hospitalized six months for conduct disorder and other excesses not limited to psychiatry. As Mickey pointed out, psychoanalysts at the time thought maybe insurance should pay for a full 5-10 year, 5x a week psychoanalysis, and the math obviously doesn’t work.

    The critical fallacy of the eras after 1a is the facile delusion that routine services should be based on an insurance model. In era 1a the only victim of medicine without evidence was the patient, and even though charlatans proliferated they victimized the wealthy by and large (Google Kellogg). The poor didn’t have the luxury of being duped.

    The ACA furthers the utterly unworkable idea that routine services are to be paid by pooled resources that will call insurance but that is really prepayment of services. Imagine if your homeowners paid for painting and remodeling. This will bankrupt the country before Medicare does. Next year ACA premiums are going through the roof.

    April 22, 2016 | 1:54 PM
    Bernard, James,
    James O'Brien, M.D.
    April 23, 2016 | 4:47 PM

    Medical price inflation will either be contained by:

    1. aggressive rationing (see Era 2,3)
    2. prices being too high for the patient who says no (Era 1a)

    There is no choice number three. Choose 1 or 2.

    This is basic behavioral psychology. Humans will seldom say no if it doesn’t hurt them in the pocketbook.

    It’s frankly amazing that it took 20 years for mangled care to appear after the free for all Era 1b of charge and collect anything you want.

    April 26, 2016 | 1:53 PM

    give pills hidden in Trader Joes plain cheddar cheese spread. Make sure it’s plain. The horseradish option causes huge stinky farts

    April 26, 2016 | 2:09 PM

    Good idea! I eagerly await Trader Joe’s opening a store here in the mountains. On my next foray into Atlanta, I’ll definitely give it a shot…

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