This article was originally posted on The Turek Clinic Blog on March 18, 2013. Dr. Paul Turek is a SFMS member and an internationally known thought leader in men’s reproductive and sexual health care and research.
By Paul Turek, MD, FACS, FRSM
What makes you feel like a good citizen? Is it giving blood? Coaching your kid’s team? Volunteering at a school or shelter? Church work? Voting? Recycling? What is it that makes you feel part and parcel of the wide, wide world around us?
I asked this question of myself recently. As a doctor, quite naturally I thought of helping people. I am a big fan of the “smallest things make the biggest difference:” opening doors for others and helping the elderly cross the street. But what struck the most resonant chord with me was my commitment to the little free clinic that could right here in San Francisco.
The full story behind my devotion to Clinic by the Bay is published in this month's San Francisco Medicine journal. It’s funny how such large commitments begin so innocently.
It was during a busy cystoscopy clinic at the Veterans Affairs Hospital. Vets in half buttoned medical gowns were meandering all around. And there was Janet Reilly, oblivious yet focused: “Hi, Paul… I really need you to help me get medical professionals, especially retired ones, to volunteer in a free clinic.”
The wall went up. How could I possibly add any more to my schedule? My days at UCSF were chock full of teaching, research, grants, clinics, committees and travel. And then there was the young family. As an academic surgeon, I was spinning at tortuously high rpm, barely holding things together and here was yet another demand on my time.
But her dream was clear. She wanted to start a volunteer-powered, free clinic for the working uninsured in San Francisco, a population of about 63,000 at the time. I emailed her back later that same day and said “Count me in.”
I have always been interested in medical volunteerism, but this was not exactly how I pictured myself getting involved as a professional. During training, I had volunteered in fantastically needy and faraway places like Dakar, Senegal and always imagined going back to the Third World again, when I could offer more expertise and wisdom. But this proposal was different: it awakened me to the opportunities to help in my own backyard. And that’s why her offer was so compelling to me. I didn’t have to fly 16 hours to another continent and leave my family for weeks at a time to help others.
Volunteering is really quite possible in smaller, less disruptive, doses and nearer to home, where I live. It’s really the same giving feeling, just spread evenly over everyday life.
Since I became involved during the Clinic’s planning stages 7 years ago, I have never looked back. As a Founding Board member and Chair of the Medical Advisory Board, my involvement has only deepened with time. Why did I become, and why do I remain, involved with Clinic by the Bay? Honestly, because it feels good to give back in an understated, everyday way. And every single one of the following matters deeply to me:
I know I keep repeating the words attributed to that dotty-old-cigar-smoking-Brit Winston Churchill, but they still ring true for me: “You make a living by what you get; you make a life by what you give.”
So, I offer you, right here and now, an opportunity to share in this historical experience, one that is unfolding as you read this. Our history is being made every day; help us shape it.
Physicians--retired or currently in practice--can make a difference at Clinic by the Bay with minimal time commitment.
Click here for detailed information on physician volunteer opportunities or email David Goldschmid, MD, Medical Director of Clinic By the Bay.
Click here to view the March 2013 issue of San Francisco Medicine and other physicians' perspectives on medical philanthropy.
This article was originally published in the January/February 2013 issue of San Francisco Medicine.
By Catherine Lucey, MD, FACP
A few years ago, I received that phone call that every parent dreads: While riding his bike to school, my teenage son had been hit by a car. Arriving on the scene, I found my son being loaded into an ambulance, strapped onto a backboard, awake, moving all extremities, and apologizing profusely for having been hit. Off to the side was the mangled bike, with the expensive helmet strapped carefully to the handlebars (so much for years of nagging). At the emergency room, a trusted physician colleague carefully listened to the story, asked key questions (no loss of consciousness, no neurologic symptoms), examined my son, and told me that everything looked good. “But you’ll get a CT scan just in case, right?” I asked. He replied no, that the guidelines on scanning in young people recommended against scans in cases like this. To which I responded, “But this is my son! I couldn’t bear it if something was wrong and we missed it.”
When I first heard about the idea for the Choosing Wisely campaign, this experience came to mind. Encounters like this happen every day in doctor’s offices and emergency departments across the country. Worried patients bring their concerns to their trusted physicians and ask them to use all that medical science has to offer to reassure them. Those physicians also worry about the patient, often turning to tests and therapeutic trials to be certain that the most dreaded cause of the symptom in front of them is not present. The genesis of this instinct to test early and often and embrace the (deceptively) benign therapeutic trial of an antibiotic, a prescription pain reliever, or a course of corticosteroids or other drugs has roots within our collective support of the professionalism values of prudence (do no harm), excellence, and altruism. This instinct is often reinforced by grateful patients who believe that more care is better care and by powerful anecdotes about physicians who do less and suffer the consequences in courts of law.
Although the risk and cost of “probably nothing wrong but to be sure” (PNW) tests seems minimal at first blush, this is often not the case. All of us have had the experience of ordering a test “just to be sure” and getting a false positive result that then generates many more diagnostic studies. The tests that follow are often more invasive and more risky. And some of those benign therapeutic trials result in drug side effects that can range from annoying diarrhea to life-threatening anaphylaxis or other serious adverse consequences. What's more, the financial impact to the patient of PNW tests is difficult to ascertain. The easy-to-order MRI scan for chronic headaches may lead to substantial out-of-pocket costs for the patient with less than comprehensive health insurance. On a larger scale, these tests and treatments contribute to the rapidly expanding costs of health care nationally. As much as a 30 percent of the nation’s 2.7 trillion dollar expenditures on health care may be due to waste, with waste due to overuse of tests and treatment equaling the waste related to administrative complexity.1
The Choosing Wisely Campaign has its origins in Howard Brody’s 2010 New England Journal of Medicine article, in which he called upon each medical specialty society to appoint a blue-ribbon panel to identify the five most frequently used medical tests or treatments that current evidence suggests do not provide benefit for most patients for whom they are ordered.2 Subsequently, the National Physicians Alliance (NPA), supported by a grant from the ABIM Foundation, launched the Good Stewardship Working Group and created “top 5” lists in internal medicine, family medicine, and pediatrics. Research published in Archives of Internal Medicine estimated that cutting back on the tests in the top five lists in primary care alone would lead to savings on the order of $5 billion per year.3
In 2011, building on the work of NPA, the ABIM Foundation recruited nine additional physician organizations to create lists of tests and treatments that are at times overused by physicians in their specialties. The campaign was carefully constructed to reinforce the trusted role of physicians in society. Physicians (not administrators or payors), embracing the professionalism values of excellence and prudence, used scientific evidence to develop lists of tests and treatments that are often given to patients unlikely to benefit from them. Using these lists, the ABIM Foundation launched the Choosing Wisely campaign in April 2012. The campaign reinforces the shared decision making that underpins successful doctor-patient relationships. It encourages physicians to discuss the limitations and risks of the tests and treatments on the list with their patients and help them understand the problems of overtesting and overtreatment. Careful focus on the importance of conversations has helped differentiate the Choosing Wisely campaign, which encourages physicians and patients to talk about tests that do not help and can sometimes cause harm, from rationing, where needed care is restricted to save costs. The campaign also recognizes that changing the culture of U.S. health care—from one in which “more” care is better to one in which “right” care is better—requires addressing public expectations.
The work on Choosing Wisely is not done yet, however. Developing and disseminating the lists is a starting point. The important work must be done by physicians in the exam room, in the emergency room, and on hospital wards. Campbell and colleagues remind us how difficult it is to say no to a patient who requests a test that is of no or marginal benefit. In a 2011 study of physicians across the country, they documented that more than one-third of physicians would accommodate a patient who asked for a test even if that test was not indicated.4 The frequently used argument that patient autonomy demands that physicians acquiesce is a misuse of the concept of autonomy and ignores our commitment to excellence and prudence.5 Next steps in this work include formulating strategies to help physicians in practice and physicians in training master the skills necessary to communicate the risk of unnecessary tests and treatment and to offer other forms of reassurance to worried patients. Medical students and residents need to learn when to watch and wait rather than prescribe unnecessary tests and treatments. It is also critically important to support physician decision making that uses the tests and treatments on the lists when they are indicated. More outreach to community organizations, patient advocacy groups, and educators responsible for health education in our schools will lead to patients who are willing to engage with us in meaningful conversations that focus on getting the right care at the right time.
And what about my son? The physician took me aside, explained that new studies have documented the risks of radiation on growing brains, and showed me the practice guidelines that outlined when CT scans were indicated following accidents. He then reassured me that I could call him personally if new symptoms emerged. All in all, it took more time, empathy, and skill than simply ordering the CT scan – and considering I was a physician myself, it also took a certain amount of courage. But our conversation gave me confidence that the decision not to test was based on our doctor’s willingness to put my son’s best interests at the forefront of his decision-making process – the true definition of professionalism. All is well.
Click here to access the January/February 2013 issue of San Francisco Medicine focusing on the Choosing Wisely campaign and perspectives from physicians of different specialties about reducing waste in medicine.
Answer to the December 2012 San Francisco Medicine crossword puzzle, Cranial Nerves.
Back by popular demand! The SFMS has updated and published a short guide on domestic violence screening and intervention for physicians and other clinicians in consultation with some of the most experienced clinicians in this arena.
Published in the December issue of San Francisco Medicine as an insert and also available on the SFMS website, this guide represents a concise and clinically based approach to this complex issue, distilling knowledge from existing, longer documents. Covered topics include:
The original guide has been widely distributed and well received by clinicians citywide and beyond, and it was cited in the Journal of the American Medical Association as one of the best such resources. This new version has been updated with current contact information and new information.
Click here to see the SFMS Domestic Violence Guidelines.
By Jeffrey Newman, MD, MPH, and Steve Heilig, MPH
“When it came time for my family to discuss end-of-life care issues for my father, the POLST framework was invaluable. It greatly facilitated early and useful dialogue and allowed us to come to a very comfortable consensus despite a longstanding history of disagreement over his earlier long-term care issues.” —Keith Loring, MD, FACEP, emergency physician and SFMS board member
There is an ever-increasing focus on health care provided toward of the end of life, for multiple reasons. For one thing, there is growing awareness that end-of-life care has often fallen short of what is desirable and possible, and thus the growth of palliative care, new models of long-term care, and so on. A generation of baby boomers is bringing their high expectations for self-determination into their later years. New policies will force attention to cost issues as reimbursement becomes more tied to quality and use standards.
The modern medical ethics movement can be seen at least in part as a “patient empowerment” trend, and one way this has been codified into practice is through the use of various advance directives used to document patient preferences for care. The documents have been available for decades, but still only a minority of patients completes them. And it must be admitted that more forms are not a panacea—but they can help immensely when patients might no longer be able to tell clinicians what they desire.
The SFMS and some key partners have been working with grants from the Metta Fund and the California HealthCare Foundation to support a number of activities increasing conversations among patients with advanced illness, their physicians, and other health care professionals. Advanced directives and POLST documents are more widely used in nursing homes, hospitals, and ambulatory care. Again, however, most patients in the “last chapter” (operationally defined as life expectancy of less than a year) still do not take advantage of these opportunities. A recent survey of EOL attitudes and practices among California adults reveals that while 82 percent believe that it is important to have wishes in writing, only 23 percent have done this; 47 percent would like to have “the conversation” with their physician (61 percent of those over 65); and 70 percent would like to die at home, but this occurred in only 32 percent of deaths in 2009.1
Another recent study of POLST implementation among nursing homes in California indicates that POLST use has become common, especially in areas served by a POLST Coalition, as in San Francisco. We and other Coalitions have assessed the POLST process in nursing homes and offered suggestions for quality improvement.2
Steven Pantilat, MD, a leading figure in palliative medicine at UCSF, has offered the following practical suggestions to increase availability and access to palliative care: Establish organized programs at all hospitals, open access to hospice without giving up advanced illness management, expand the supply of physician and nurse specialists, educate all clinicians in basic palliative care, and educate the public through a marketing campaign.3 Widespread programs to reduce hospital readmissions should also focus on advanced illness and EOL issues that underlie many of these cases. The San Francisco Department of Aging and Adult Services (DAAS) has been awarded a Medicare Community-Based Care Transitions Program (CCTP) contract to provide services through a hospital-to-home transitional care model focused on lowering hospital readmissions. This collaborative model includes DAAS, nine additional community-based organizations, and eight hospitals in San Francisco County. Services include coaching, care coordination, and a support services package of meals, homecare, and transportation. We are exploring opportunities to incorporate assessment of needs for palliative and EOL services and referral.
Among the many ways San Francisco physicians can support this and other hospital readmission efforts is to provide early follow-up appointments for patients after hospitalization—and, when appropriate, initiate referrals to palliative care, advanced illness management, and hospice. And whenever appropriate, consider using a POLST form with your patients—for the third time in this journal, the actual form is included here for your convenience. Your patients, their families, and some of your colleagues will be grateful.
For more information, see POLST California's website. For a copy of the POLST form, click here.
Dr. Jeff Newman is director of the Sutter Health Institute for Research and Education, adjunct professor at UCSF, and a former SFMS board member. Steve Heilig is on the staff of the San Francisco Medical Society and is coeditor of the Cambridge Quarterly of Healthcare Ethics.
1. Lake Research Partners and the Coalition for Compassionate Care of California. Final Chapter: Californians’ Attitudes and Experiences with Death and Dying. http://www.chcf.org/publications/2012/02/final-chapter-death-dying#ixzz28ve6oIpt.
2. Wenger NS, Citgo J, OMalley K. Implementation of physician orders for life-sustaining treatment in nursing homes in California. J Gen Intern Med. August 2012. http://link.springer.com/article/10.1007%2Fs11606-012-2178-2.
3. Pantilat SZ. When it’s the right care, more is better. Arch Intern Med. 2012; 172(15):1172-3.
At last month’s annual CMA meeting, the following new statewide policy was adopted:
INCREASING UTILIZATION OF POLST ORDERS
Authors: Jeffrey Newman, MD; Leslie Lopato MD, Adam Schickedanz, MD
That to increase and improve use of Physicians Orders for Life- Sustaining Treatment (POLST), CMA encourage physicians to become educated about all aspects of the POLST form and to integrate discussions about, and utilize, POLST in all appropriate instances where medical services are provided to patients at the end-of-life.