Start spreading the news - Advanced Access is working!

I'm catching up on work after a week off, so here's the lazy man's post - a link to last week's Advanced Access progress report.

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Would you like whine with that?

I pity the poor medical students who do clinical rotations with me. They have to listen to me complaining non-stop.

They're always polite and attentive about my griping. I hope they don't think their rotation assessment could be affected by the quality of their sympathetic nodding.

When a student is in the office with me, my main topic to moan about is inadequate information in the referral letters I receive. I've blogged about this before. Anyway, a senior medical student just spent a few days with me in the office, and yesterday, I was in mid-kvetch when I thought "I gotta stop whining about this and actually do something about it."

We've had success with sending out a checklist to referring doctors regarding a specific condition (microscopic hematuria). We ask for certain information and test results to be sent along to us, before we see the patient. You can see the letter on our office website.

I'm thinking of a different approach for information on a person's past medical history, medications and allergies. I'll try sending out a questionnaire directly to the patient. After all, it's the same questions they'll answer when they come to see me anyway.

This isn't earth-shattering, I know. It's already done in many offices, whether ahead of time, or as something to be completed when the patient arrives at the office. I'm sure there will be lots of forms and templates I can steal (I mean, collaborate non-consensually). I'm thinking I'll send out 10 trial forms with the patient's appointment letter and ask them to either mail the form back or fax it to me. I'll keep track of who had the forms sent to them and how many are returned.

I'll let you know how it goes.

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Advanced Access updates

I missed linking to the last few "Adventures in Advanced Access" posts. Here they are:

Not So Happy Holidays

Darwin's Cystoscope

Blog's Breakfast

Alberta Bound

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What's wrong with this picture? - X (Med school, Old school)

This lab coat, belonging to a senior medical student, was hanging in the lounge last week. The pockets were stuffed to bursting. In addition to 6 (!!!) reference books (Surgery on call, Internal Medicine on call, etc.), there was a set of critical care flashcards. Geez, buddy, are you part pack mule?

How about trading your collapsed vertebrae in for a PDA? Get some electronic references installed and whip it out when you see your next patient with Dengue fever.

Better yet, convince the College of Medicine to provide access to a standard set of digital reference books (reviewed and approved by faculty) to all medical students. You could use them through any internet connection (ideally wireless via PDA) and they would be updated more regularly than print references.

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No-show no-no

I received this transcript from a CBC Radio Saskatchewan program:

CBC-RADIO, SASK. FEBRUARY 4, 2008. 6:30 HRS.

There could be warning signs at the doctor's office that say you have to pay a charge for missed appointments

PAT HUME [ANNOUNCER]
Don't be surprised if you see warning signs posted on the wall at your next appointment with a medical specialist. Those signs advise patients that if they miss or cancel appointments they could be billed. For skipped appointments the average is between $30 and $50 dollars. For missed procedures the cost is much higher.

Dr. Joe Pfeifer is President of the Saskatchewan Medical Association and a surgeon in Saskatoon. He says in his practice approximately one out of every ten patients misses or cancels appointments each day. Pfeifer says people also skip MRIs, CAT Scan and colonoscopies, procedures with huge waiting lists.

DR. JOE PFEIFER [President - Sask Medical Association]
Patients who do not show for appointments or procedures just create more of a burden on the system. It's a little disappointing that sometimes people have an attitude that is not the most responsible when it comes to health care because it is needy and there is such a shortage of resources and physicians. It's just sad to see them used badly.

PAT HUME [ANNOUNCER]
Under the Saskatchewan Medical Association's guide to uninsured services patients can be billed up to 50% of the cost of the missed appointment or procedure. Pfeifer says his office has seen fewer no-shows since a warning has appeared at the bottom of appointment cards.

Since we started our Advanced Access project last year, I've paid more attention to missed appointments or "no-shows". We've been tracking them regularly. In our practice, there's a 10-15% no-show rate. No-shows are different than cancelled appointments in that we at least get some warning about cancellations. Not so no-shows. They're completely wasted capacity. We don't know about them until after the appointment time has passed.

That's very frustrating for busy physicians who are trying to deal with long wait times. However, I'm disturbed by the tone of the CBC interview. It makes it sound like an adversarial process. Us vs. them. Only bad people miss appointments.

And they should pay a price!

What we have here is a treatment prescribed before a diagnosis is made.

Before laying blame, physicians need to look at the reasons for no-shows. Perhaps the letter announcing the appointment went astray. When that has happened at my office, the patient (or the referring physician) will call after a few weeks to ask when their appointment will be made. My staff will tell them that their appointment date has already passed, and we'll make a new appointment. Sometimes, under those circumstances, the patient will apologize for not attending the first appointment, even though it was our error in not notifying him!

Perhaps the problem is lack of transportation (Saskatchewan is a big place!), a sick child, or another unpredictable event. (Hard as it is to imagine, a doctor's appointment isn't always the most important event in a person's day!)

I'm interested in how no-show's relate to the length of wait between referral date and consultation date. When we started to work on reducing wait times in our office, patients were waiting up to 4 months for appointments. I have trouble remembering appointments 2 weeks from now (ask my wife), let alone 4 months!

Certainly, if you have a medical problem that's painful or debilitating, you'll remember that appointment with the doctor. But some "problems" (such as abnormal lab tests like high PSA levels, or traces of blood in the urine) don't cause symptoms. Pretty easy to forget when you're trying to get a crop off the field.

I wonder what charging for no-shows accomplishes. Perhaps it does reduce no-show rates, but what does it do for physicians' relationships with their patients? Given the relative lack of specialists in Saskatchewan, will some patients feel pressure to pay the fee, even if they had a valid reason for missing the appointment. And, if exceptions are allowed, who's going to judge their validity? I know I already have enough work to do without adding administrative work. I doubt that my office staff would be happy in this role, either.



Although it's certainly inadvertent, the message I get from the CBC piece is that the system is built to suit providers, not patients. Rather than blaming patients for missing appointments, let's try this: Ask what we could do differently to serve them better.

Could we:

Let patients choose their own appointment time?


Phone patients with a reminder 48 hours in advance?


Reduce our wait times?

By the way, doc, if you work on reducing your no-show rate, you'll also increase your revenues. (In a more satisfying way than by nickel-and-diming your patients with punitive fees.)

Physician, heal thyself.

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False positive

My daughter wanted to know about false-positive tests this week. She's a fan of the TV medical drama, House, so I caught a bit of it while I was doing the dishes (you'll have to take my word for it).

An oncologist had to break some disturbing news to a patient. Of course, there was a twist.

The man had been diagnosed with terminal lung cancer, but it turned out that the test was incorrect, i.e false-positive. He didn't have cancer at all. The oncologist expected that the man would be thrilled to hear the news. He wasn't.

The oncologist couldn't understand why the man was upset. Surely he should be overjoyed at having his life sentence lifted!

The problem was that the man had already acted on the false report. He had told his friends the bad news. He had sold his house and spent the money on a trip to Europe. While he was happy that he didn't have cancer, he was not pleased with the profound effect this false alarm had on his life.

A similar situation comes up very commonly in urology practice. Men are often tested for prostate cancer using prostate-specific antigen (PSA). Well, at least they think they're being tested for prostate cancer. The PSA blood test doesn't actually give a yes-or-no answer to this question. It just tells us how suspicious we should be and whether further testing is warranted. The higher the PSA level, the greater the likelihood that prostate cancer is present.

But there's a twist here, too.

Benign prostate enlargement - very common in men over age 50 - also causes the PSA level to rise. In fact, when the PSA is mildly elevated (for example, between 4 and 10), it's more likely that the elevation is due to benign disease rather than cancer, in a 2:1 ratio. That's a lot of false-positives.

The abnormal PSA level leads to further testing, usually a prostate biopsy. This involves inserting a probe into the rectum and using a needle to take samples of the prostate. It's uncomfortable and carries some risk of complications. Also, men with abnormal PSA levels suffer anxiety about the possible cancer diagnosis.

When there is no cancer present (i.e. the PSA level was up because of benign prostate enlargement), the man goes through a needless biopsy and worry. Yet, when I call men about their negative biopsy results, they universally say "Whew, that's good news."

I sometimes wonder why they don't react like the patient on House: "You mean I went through all that worry and that biopsy done for nothing? I never had a problem in the first place. If I hadn't had that PSA test done, I could have been spared all of this. That test was a false alarm!"

When a false-positive test comes back, it means we've taken a healthy person (well, at least, they don't have that particular disease) and put them through stress and further testing that is of no value to them. Many people rationalize this with the old "Better safe than sorry" argument.

Of course, it's up to each man to decide whether he wants to take the chance of having a false-positive result. That means he should be informed of the risks and benefits of PSA screening before being tested. My experience is that most men haven't been informed before testing. Many of them aren't even aware the test was done (usually as part of "routine blood work") until they're called with the abnormal result.

"Better safe than sorry" only holds true if the patient has had the chance to consider how much "sorry" they're willing to accept to be "safe".

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Outside the RateMDs box

A member of my spy network reported overhearing some first-year medical students talking about their clinical shadowing.

Medical students are required to spend time with clinicians in order to get a broad exposure to the various medical disciplines. These students were planning to surf RateMDs to check out potential mentors for shadowing!

Brilliant. (Really.)

Most of the comments on RateMDs pertain to the physician's affability and communication skills. When patients are unhappy with a physician, it almost always means that communication has been poor.

As such, if physicians are rated highly on RateMDs, they're likely to be pleasant to spend time with under other circumstances, i.e. clinical shadowing.

Plus, they'll be good role-models. That counts for something, too.

Hey, you kids! How about a mash-up that combines the list of College of Medicine-approved clinicians with their RateMDs profiles? It'd save you time and probably make for some entertaining reading. Let me know when you've whipped it up.

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