Archive for October, 2014

Ebola and Quarantine

Wednesday, October 29, 2014 // Uncategorized

Here is the editorial from today’s  New England Journal of Medicine.  I agree with the premise that quarantines should be based on medical evidence.  The problem is that the media has fanned the flames of hysteria about this disease to the point where decisions are not solely based on fact.  Health care workers may need to be quarantined to protect them from those in the general population who feel threatened.  There is precedent for quarantine for public health all the way back to Typhoid Mary.  Certainly, it should be reserved for those circumstances where it makes sense medically.

Editorial

Ebola and Quarantine

Jeffrey M. Drazen, M.D., Rupa Kanapathipillai, M.B., B.S., M.P.H., D.T.M.&H., Edward W. Campion, M.D., Eric J. Rubin, M.D., Ph.D., Scott M. Hammer, M.D., Stephen Morrissey, Ph.D., and Lindsey R. Baden, M.D.

October 27, 2014DOI: 10.1056/NEJMe1413139

The governors of a number of states, including New York and New Jersey, recently imposed 21-day quarantines on health care workers returning to the United States from regions of the world where they may have cared for patients with Ebola virus disease. We understand their motivation for this policy — to protect the citizens of their states from contracting this often-fatal illness. This approach, however, is not scientifically based, is unfair and unwise, and will impede essential efforts to stop these awful outbreaks of Ebola disease at their source, which is the only satisfactory goal. The governors’ action is like driving a carpet tack with a sledgehammer: it gets the job done but overall is more destructive than beneficial.

Health care professionals treating patients with this illness have learned that transmission arises from contact with bodily fluids of a person who is symptomatic — that is, has a fever, vomiting, diarrhea, and malaise. We have very strong reason to believe that transmission occurs when the viral load in bodily fluids is high, on the order of millions of virions per microliter. This recognition has led to the dictum that an asymptomatic person is not contagious; field experience in West Africa has shown that conclusion to be valid. Therefore, an asymptomatic health care worker returning from treating patients with Ebola, even if he or she were infected, would not be contagious. Furthermore, we now know that fever precedes the contagious stage, allowing workers who are unknowingly infected to identify themselves before they become a threat to their community. This understanding is based on more than clinical observation: the sensitive blood polymerase-chain-reaction (PCR) test for Ebola is often negative on the day when fever or other symptoms begin and only becomes reliably positive 2 to 3 days after symptom onset. This point is supported by the fact that of the nurses caring for Thomas Eric Duncan, the man who died from Ebola virus disease in Texas in October, only those who cared for him at the end of his life, when the number of virions he was shedding was likely to be very high, became infected. Notably, Duncan’s family members who were living in the same household for days as he was at the start of his illness did not become infected.

A cynic would say that all these “facts” are derived from observation and that it pays to be 100% safe and to isolate anyone with a remote chance of carrying the virus. What harm can that approach do besides inconveniencing a few health care workers? We strongly disagree. Hundreds of years of experience show that to stop an epidemic of this type requires controlling it at its source. Médecins sans Frontières, the World Health Organization, the U.S. Agency for International Development (USAID), and many other organizations say we need tens of thousands of additional volunteers to control the epidemic. We are far short of that goal, so the need for workers on the ground is great. These responsible, skilled health care workers who are risking their lives to help others are also helping by stemming the epidemic at its source. If we add barriers making it harder for volunteers to return to their community, we are hurting ourselves.

In the end, the calculus is simple, and we think the governors have it wrong. The health care workers returning from West Africa have been helping others and helping to end the epidemic that has killed thousands of people and scared millions. At this point the public does need assurances that returning workers will have their temperatures and health status monitored according to a set, documented protocol. In the unlikely event that they become febrile, they can follow the example of Craig Spencer, the physician from New York who alerted public health officials of his fever. As we continue to learn more about this virus, its transmission, and associated illness, we must continue to revisit our approach to its control and treatment. We should be guided by the science and not the tremendous fear that this virus evokes.

We should be honoring, not quarantining, health care workers who put their lives at risk not only to save people suffering from Ebola virus disease in West Africa but also to help achieve source control, bringing the world closer to stopping the spread of this killer epidemic.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article was published on October 27, 2014, at NEJM.org.

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Who Determines Physician Effectiveness?

Monday, October 13, 2014 // Uncategorized

Physicians are being graded constantly.  The government and health insurers are constantly collecting patient  information on which they rate physicians. ” Pay for performance” is their mantra.  The only problem is, most of these numbers are not under the control of the physician. Whether they have any bearing on the quality of care delivered is another topic.

Here is an opinion online from today’s online Journal of the American Medical Association.

Viewpoint | October 13, 2014

Who Determines Physician Effectiveness? FREE ONLINE FIRST

Paul J. Hershberger, PhD1; Dean A. Bricker, MD2
1Department of Family Medicine, Wright State University Boonshoft School of Medicine, Dayton, Ohio
2Department of Medicine, Wright State University Boonshoft School of Medicine, Dayton, Ohio

 

JAMA. Published online October 13, 2014. doi:10.1001/jama.2014.13304

 

 

It is a paradox. Although physicians do not control patient behavior, physician effectiveness is increasingly determined by patient behavior. There is a trend toward physician ratings being based on specific metrics related to the management of chronic illness. Such markers include glycosylated hemoglobin levels, blood pressure, body mass index, and smoking rates, along with other factors known to affect risk of morbidity and mortality. However, the physician contribution to changing the actual outcomes is limited.

 

Population analyses of health outcomes suggest that medical care accounts for only 10% of the variance in outcomes, whereas approximately 50% can be attributed to behavioral and social factors.1 With respect to the chronic conditions that receive the largest proportion of health care attention, such as cardiovascular disease and diabetes, physicians identify risk factors, diagnose disease, prescribe treatments, and educate patients regarding relevant lifestyle factors. The result of these efforts, however, is ultimately determined by patient adherence to prescribed treatment regimens and recommended health behaviors (eg, diet, exercise, smoking cessation).

 

Extensive physician time and effort is devoted to determining what medications and dosages patients need to take for their chronic conditions, but nonadherence to medication regimens for the treatment of chronic illness has been estimated to be 50%.2 Primary nonadherence (not ever filling or picking up the prescription) is estimated to be approximately 30%.3 Outcomes of surgical interventions (eg, bariatric surgery) also largely depend on patient behavior over the long term (ie, changes in eating patterns must be maintained by patients for sustained weight management).

 

Other variables associated with health outcomes are not directly affected by physicians. Educational attainment affects life expectancy, such that individuals with an advanced degree can expect to live approximately a decade longer than individuals with less than a high school education, although childhood adversity can attenuate the advantage of education.4 There is a similar gradient for other socioeconomic indicators. Positive affectivity, that is, a trait-like tendency to experience positive emotions and to be actively engaged with other people, is associated with a life expectancy of approximately 4 to 10 more years compared with more negative affectivity.5 Although physicians are not held accountable for life expectancy, these traits influence overall health and well-being.

 

Because so many variables beyond physician control affect patient outcomes, relying solely on outcome data (or proxies for outcomes) to determine physician effectiveness may be both inaccurate and unjustified. There is a parallel with public school teachers who are increasingly evaluated using student outcomes, even though student achievement is affected by many variables other than the teacher’s qualifications and skills, such as socioeconomic factors. However, until better measures of overall physician effectiveness are identified, physicians, like teachers, must do their best to affect outcomes in the face of performance measures that are influenced by circumstances outside their control.

 

The prevailing approach to this dilemma is to treat and to teach—the physician-centered intervention models that have been traditionally emphasized in medical education. However, prescribing, recommending, and educating do not necessarily change patient behavior. Much of the management of chronic illness is ultimately the behavioral responsibility of the patient. Overemphasis on patient education often leaves both the patient and physician mutually frustrated. Notably, a leading concern of patients is that physicians are unresponsive to their primary concern,6 whereas physicians recognize that patients often do not follow their recommendations.

 

An alternative approach to patient behavior is for physicians to become more patient-centered and to emphasize asking, listening, and understanding, not just the patient’s symptoms but also the patient’s circumstances, environment, perspectives, barriers, stressors, and goals. Patient behavior is more affected by the pervasive conditions and influences in their lives than by what is learned in the hospital or physician’s office (and patients remember only a small proportion of what is discussed in a given appointment).

 

Physicians can address patient behavior in a manner that both supports patients’ autonomy and responsibility for their behavior and that increases the likelihood that patients will make healthier choices. An example of such an approach is motivational interviewing, a form of interaction with patients that highlights the ambivalence patients have about health behavior. Motivational interviewing requires setting aside the tendency to educate patients and rather emphasizes eliciting from patients what they know and what most concerns them. This is done through the use of reflective listening and open-ended questions. For example, instead of discussing with the nonadherent patient with diabetes who has a glycosylated hemoglobin level of 9.2% that she needs to take her medications regularly, lose weight, and again receive diabetes education, the patient might be asked what concerns her most about not having her diabetes under control. The physician may learn about the patient’s ambivalence; although she is worried about possibly needing dialysis in the future, she presently tends to make adherence to her medication regimen a low priority because she is “just trying to get through the day with a stressful job and family problems.” Given such circumstances, the patient might then be asked how she wants to proceed regarding her health. This is to acknowledge reality, which is that she is the decision-maker about what she will or will not do, regardless of what the physician prescribes or recommends. Such a collaborative approach gives necessary consideration to factors that ultimately drive patient decision making. Systematic reviews and meta-analyses of randomized controlled trials of motivational interviewing indicate some efficacy of this approach with medical populations.7 If the patient’s HbA1c level is not in the acceptable range, it is important to explore what health behavior change the patient is willing to pursue.

 

Physicians are also evaluated using patient satisfaction scores. Patients who take greater responsibility for their health tend to report more positive experiences with their physicians.8 A patient-centered approach such as motivational interviewing fosters greater patient ownership for health-related behaviors and choices. The notion that patients will not make healthy choices if physicians do not discuss with them what they need to do ignores that fact that simply telling patients what to do has limited influence.

 

In addition to the potential benefit of improved patient outcomes, a patient-centered approach also may be beneficial for the physician. A cause of physician frustration and burnout is patient nonadherence to treatment or recommended lifestyle change. Goals established collaboratively with the patient are more likely to be realistic and attainable, potentially leading to reduced physician frustration. Furthermore, better-quality physician-patient relationships are known to reduce the likelihood of malpractice suits.

 

Certainly there are some real and perceived barriers to implementing patient-centered approaches such as motivational interviewing. Time pressures, insufficient skills, and physicians’ perceptions about their role are among these. Yet it behooves physicians to recognize that their direct effect on patient outcomes is usually limited and adjust their interactions with patients accordingly. The more effective approach is to adopt a patient-centered and collaborative style that can meaningfully help patients determine how they can best manage the myriad influences on their health.

 

Although the physician’s direct effect on patient health may be decreasing, patient health outcomes are increasingly used to evaluate physicians. Physicians cannot control what patients do, but to ignore or ineffectively address influences on patient behavior is to disregard what ultimately will determine patient outcomes and, accordingly, ratings of physician effectiveness.

ARTICLE INFORMATION

 

Corresponding Author: Paul J. Hershberger, PhD, Department of Family Medicine, Wright State University Boonshoft School of Medicine, 2345 Philadelphia Dr, Dayton, OH 45406 ([email protected]).

Published Online: October 13, 2014. doi:10.1001/jama.2014.13304.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

REFERENCES

 

1 +
Kaplan  RM.  Behavior change and reducing health disparities [published online April 26, 2014]. Prev Med. doi:10.1016/j.ypmed.2014.04.014.
2 +
Brown  MT, Bussell  JK.  Medication adherence: WHO cares? Mayo Clin Proc. 2011;86(4):304-314.
PubMed   |  Link to Article
3 +
Tamblyn  R, Eguale  T, Huang  A, Winslade  N, Doran  P.  The incidence and determinants of primary nonadherence with prescribed medication in primary care: a cohort study. Ann Intern Med. 2014;160(7):441-450.
PubMed   |  Link to Article
4 +
Montez  JK, Hayward  MD.  Cumulative childhood adversity, educational attainment, and active life expectancy among U.S. adults. Demography. 2014;51(2):413-435.
PubMed   |  Link to Article
5 +
Diener  E, Chan  MY.  Happy people live longer: subjective well-being contributes to health and longevity. Appl Psychol Health Well Being. 2011;3(1):1-43.
Link to Article
6 +
Jagosh  J, Donald Boudreau  J, Steinert  Y, Macdonald  ME, Ingram  L.  The importance of physician listening from the patients’ perspective: enhancing diagnosis, healing, and the doctor-patient relationship. Patient Educ Couns. 2011;85(3):369-374.
PubMed   |  Link to Article
7 +
VanBuskirk  KA, Wetherell  JL.  Motivational interviewing with primary care populations: a systematic review and meta-analysis [published online August 11, 2013]. J Behav Med. doi:10.1007/s10865-013-9527-4.
8 +
Greene  J, Hibbard  JH, Sacks  R, Overton  V.  When seeing the same physician, highly activated patients have better care experiences than less activated patients. Health Aff (Millwood). 2013;32(7):1299-1305.
PubMed   |  Link to Article
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