Each Patient Counts: Massachusetts Medical Society Weblog

Annual Education Program -- Patient-Centered Medicine: Bringing Health Care Home

"It is now conceivable that our children's children will know the term cancer only as a constellation of stars."

Certainly, a bold and ambitious statement for former U.S. President Bill Clinton to make, but with the current explosion of numerous efforts to create a more patient-focused health care system, experts say this idea really could be conceivable.

Today's speakers at the MMS Annual Educational Program discussed unique, patient-centric efforts that are changing the way physicians, patients, and families can work together to create more comprehensive and thorough health care.

By using computer software and the Internet, said Mike Magee, M.D., director of the Pfizer Medical Humanities Initiative and the first speaker of the program, physicians, patients, and families can come together to more effectively communicate and develop treatment plans. Physicians can now monitor patients through webcams, provide quick answers and advice for patient queries, even create computer-based games that test for patient mental clarity. All of these things, claimed Dr. Magee, can provide a buffer against associated patient risks, allow the patient to remain in the comfort of his own home, and free up vaulable time for physicians to see other patients in the office.

Better organizing health care systems and support networks, said Lynne Kirk, M.D., MACP,immediate past president of the American College of Physicians (ACP) and the second speaker at the Annual Education Program, is also important in delivering patient-centric medicine. "The Patient-Centered Medical Home (PCMH)," created by the ACP, is a health care model that gathers physicians, patients, and families together to create full-circle treatment plans, said Dr. Kirk. The PCMH coordinates care in partnership with patients and families and incorporates health information technology.

Another way to personalize medical treatment, stressed Alan E. Guttmacher, M.D., deputy director of the National Human Genome Research Institute and the third speaker, is to partake in genomic medicine and testing. By learning about their genetic makeup, said Dr. Guttmacher, patients can work together with physicians to identify risk-associated genes and embark on appropriate preventive medicine -- before the patient even develops a disease. While the test could be costly for some patients -- $1,000 -- Dr. Guttmacher said this type of personalized medicine could be invaluable for effective preventive medicine.

To round out the offerings of the other speakers, Frank Moss, Ph.D., dirctor of the Massachusetts Institute of Technology Media Lab, addressed the audience on the importance of new medical technology -- specifically, inventions that can improve the lives of mentally and physically disabled children and adults. New prosthetic devices are being developed that conform to patients' bodies and movements. Software that allows children with autism and cerebral palsy to compose symphonies simply by moving their heads is being tested. All of these developements, Dr. Moss said, aid in the improved quality of life of patients.

Annual Meeting Blog: Afternoon HOD Session

After a spirited debate on the merits of retail-based medical clinics, delegates decided to have the Board of Trustees study the issue and decide the Society's policy. Debate -- which was inconclusive -- centered on whether it was wiser to oppose the clinics outright, or to develop principles under which such clinics might be a benefit to the health care system.

Among the two dozen resolutions considered during the afternoon session, the delegates also approved a sweeping study of the extent and impact of defensive medicine in Massachusetts.

In his State of the Society remarks earlier today, MMS President Kenneth R. Peelle, MD, said the Society must continue to evolve, as the needs of its changing membership evolve -- even to the extent of rethinking the nature of participation in professional medical societies.

"When I started as a member, it was simple. If you wanted to be involved, you got active in your district or specialty society, or joined a committee," he said.

"Today, young people meet, connect and socialize in many ways. They have faster, easier, more frequent ways to connect. They learn, socialize, and grow with digital tools. They use them every day, and they expect them in their medical society. We must provide them. If we offer only face-to-face dinner meetings, we become irrelevant."

He said, "In a day when most printed mail finds its way into the waste basket unopened, we must keep exploring new ways to communicate our value to physicians. We are experimenting with new technologies, new offers, new messages, and new activities. Through this, we will continue to grow."

Annual Meeting: Morning HOD Session

Delegates debated a range of topics in this morning's House of Delegates session. Some important highlights:

• Physcial Activity for School-Aged Children: This resolution seeks legislation that would mandate a minimum of 30 minutes of physicial activity each day for elementary school students and  a minimum of 45 minutes per day for middle school and high school students. Referred to Board of Trustees for decision.
• Mental Health Patient Surveys By Insurers: This resolution opposes the collection of mental health information from patients by insurance companies and requires the MMS to take future action to prevent insurance companies' use of personal health surveys to determine provider compensation or patient coverage and eligibility. Adopted.
• Tiering of Physicians Who Are New to Practice: Opposes placing physicians who are new to practice in low quality/high cost tiers, therefore requiring patients to pay high copays to see that physician. In addition, this resolution encourages future discussion with tiering groups, such as the Group Insurance Commission, on the impact placing new physician in low tiers will have in contributing to physician shortages in the state and interfering with adequate patient access to medical care. Adopted.
• Financing of EHRs and Electronic Health Networks: Supports a partnership between the MMS and the Massachusetts eHealth Collaborative to study and report on the potential value of EHRs and EHR information exchange in terms of quality, efficiency, and safety. Adopted.
• Patient Prescriptions versus Pharmacy Benefit Alleged "Cost Savings": Opposes third-party policies that interrupt patient treatment regimens based on cost savings and requires that the MMS work with "appropriate regulatory bodies" to ensure that neither pharmacies nor other insurer-pharmacy arrangements withhold or delay patient prescriptions while they attempt to find generic brands or alternative medications. Adopted.

The House of Delegates will resume its session at 2:00 p.m. today.

Annual Meeting Blog: Should Doctors Apologize? Yes, Claims an Expert

The concept of apologizing seems simple enough -- one does something wrong and then admits fault, remose even, to the offended. But if apologizing is so simple, then why is it difficult for us to admit to mistakes, errors, and wrongdoing?

There are plenty of reasons, said Aaron Lazare, M.D., an expert on apology and this year's MMS Orator. Shame, fear of a lawsuit and isolation from colleagues, and anger are all reasons why doctors avoid apologizing to patients in adverse events, he said. In one instance, Dr. Lazare likened the apology experience to becoming "a soldier and going into battle without armor or a gun." Professionally, specifically in the medical field, an apology is often seen as inviting a lawsuit.

Despite these negative side effects, apology can create positive experiences for both the patient and the physcian, he said. Apologizing can help patients that have been victims of medical error or adversity feel empowered through apology, all the while creating open lines of communication and improving the physician-patient relationship. And, contrary to popular belief, said Dr. Lazare, studies have shown that incorporating apology and other risk management tools into standard medical practice can actually lower litigation rates, not increase lawsuits.

While Dr. Lazare stressed that apology is a necessary part of medical practice, he did not understate the complex nature of such an action. How do I apologize? When do I apologize? What do I say, how can I avoid a lawsuit, and can an amicable relationship between myself and the patient be reached? These are all questions that physicians face when apologzing, he said, and none of the answers are the same for all physicians and situations. The one thing that is constant, he claimed, is the apology's profound ability to improve the quality of patient care and experience.

Annual Meeting Blog: Opening Session

House delegates this morning accepted to endorse the MMS officers' slate for 2007-2008. It includes Dale Magee, MD, of Shrewsbury as president; Bruce Auerbach, MD, of Lexington as president-elect; and Mario Motta, MD, of Salem as vice president. Dr. Motta was elected over Claudia Koppelman, MD, of Holyoke, who was nominated from the floor.

Kenneth Peelle, MD, used his annual report to the House to detail the MMS' position on the Group Insurance Commission's tiering program. He said the GIC program "still does meet the fundamental tests of reliability and credibility." He added, "We are not opposed to transparency and public reporting. We just want it done right."

Later today, we'll file a report on the Annual Oration and the Ethics Forum. Both are focusing on the benefits of apology when something goes wrong in medical care.

Worth a read: Understanding Physician-Pharmaceutical Industry Interactions

Much has been written about the relationships between the drug industry and physicians.  Headlines blare: "Doctors reap millions for anemia drugs;" "Pills for Patients, Payday for Docs;" "Posing as pals, drug reps sway doctors' choices." To some, even within our own physician ranks, it appears an insidious relationship exists. Press reports would have you believe most doctors are checking patients with their right hand and looking for a hand-out with their left. Some may; most do not.

Understanding Physician-Pharmaceutical Industry Interactions, a new book for which I had the honor of writing the forward, is long overdue. Written by a young physician, Shaili Jain, M.D., a General Adult Psychiatrist in Milwaukee, Wisconsin, it focuses on a critically important topic for all health professionals who prescribe medicines.

These interactions continue to generate heated debate in academic and public arenas, yet sadly, research shows that physicians and physicians in training remain ignorant of the core issues and poorly trained to face the sophisticated industry promotion which has become ubiquitous in medical environments. This book aims to address this gap in education by providing a single concise resource that explains the essential elements.

Business ethics and medical ethics are different. What Big Pharma, as a business, considers normal, the medical profession considers unethical. But the principles I learned in medical school many years ago -- prescribe as few medicines as possible, but when doing, use medicines that are therapeutically effective, safe, and cost the least -- hold true today. Yet to curtail the rising cost of health care, everyone must become cost conscious, especially for medicines. No other service or product is purchased so blindly.

The achievements in medicine during the 20th century were spectacular. Vaccines have saved millions of lives and prevented countless suffering. More medicines and discoveries are in progress. To continue that advance, the pharmaceutical industry and the medical professional must work in synergy. The relationship must be completely devoid of conflict of self-interest and greed. And the relationship between the prescriber and drug manufacturer must not be self-serving for either. It is - and should be -- all about the patient and the betterment of the health of the world's population. 

Leonard J. Morse, M.D., Commissioner of Public Health, City of Worcester, Past Member and Chair, Council on Ethical and Judicial Affairs, American Medical Association; Past President, Massachusetts Medical Society

Mini-Clinics: Not So Fast!

CVS has announced plans to open 20 to 30 "mini clinics" throughout the state.

At first glance, these “mini-clinics” may seem like a good idea: convenience, extended hours, multiple locations, no long lines in emergency departments, no long waits for appointments with primary care physicians.

Not so fast.

Concern #1: Safety. We’re worried that medical care will be delivered without the knowledge of the patient's primary care physician and without the knowledge or availability of a patient's medical history. This raises the risk of medical error. Elderly persons with multiple chronic conditions, on multiple prescriptions, are even more challenging.

Concern #2: They could kill our fragile primary care system. Our primary care network is already in crisis. Allowing mini-clinics to skim the easy, less complex patients might be the death knell of primary care, and our community health centers, too. Who would pick up the slack if that happens? Our emergency departments, of course, which are already over capacity. In other words, these clinics could replace what already exists -- with something worse.

Concern #3: Conflict of interest. It’s an inherent ethical conflict when a pharmacy is located at the same site as a primary care clinic, owned by the same company. There’s good reason why most doctors can’t dispense drugs in their own offices; the same reasoning applies to mini clinics like these.

We don’t think the Department of Public Health should allow mini-clinics to cut corners on good standards that serve the public well. If such organizations want to establish clinics, they should be subject to the same rules and regulations that govern other, designated sites for medical clinics.

Kenneth Peelle, MD
MMS President