Just a warning - I have been informed by the editors at Pulse (an online medical humanities site/organization that puts out emails at the end of every week that I really enjoy) that they are going to "publish" my ""poem"" (yes, that needs 2 sets of quotes) in the next few weeks, probably on 8/15 or 9/5. So, if you don't want to see it, unsubscribe now if you already subscribe to Pulse. If you don't subscribe (it's free), I would heartily recommend doing so after 9/5, when it should be safe. You may want to warn your unsuspecting friends and colleagues, too.
The Doc Saver Blog - Health, Humor, and Whatever
Blogs - Impact of a vanity press, at a fraction of the cost!
Rants, raves, "humor," and other spontaneous eruptions about medicine, health information technology, and anything else that pops into my head and I can't get a journal or newspaper to print. No, there is nothing here about how to save documents, sorry.
Sunday, August 10, 2014
Monday, May 26, 2014
Bathing Beauties
No, not what you're probably thinking. This is just a ***health care free*** posting of some pictures I've taken lately in the back yard of birds bathing in a tiny, unculverted run of an intermittent stream in our back yard (for some reason, about 15' are unculverted before running into the next culvert). Seeing the yellow-rumped warbler (see the previous post for its picture) there made me start coming back and I discovered, after being here over 7 years, that is is a great spot to see birds - and particularly in the act of bathing. Some of the pictures below really should be viewed side-by-side in sequence as diptychs or triptychs to really get a sense of the action and what is going on in the photo with motion and/or water blur. I think they're kind of cool, but that's just me. But since I don't know how to get blogger to put pictures side-by-side, they will just be sequential.
In no particular order:
1) in the catbird bath (albeit not the seat)
Tufted Titmouse bathing and then looking at me quizzically.
Chick-a-dese out! (sorry about that...)
Cleansing itself of a cardinal sin?
A bathing Carolina Wren. I really like the second picture where it is completely submerged, but you need the preceding one to have a clue what it is. And I like the high-speed tail-wagging with blurry lines, too.
I am really annoyed that these goldfinch pictures aren't better. The male's glorious colors are washed out (which I could probably fix with some editing), but when he hopped over and I saw the female bathing there, too, it was awesome. Except: 1) depth of field was too shallow, so the male is out of focus with the female in focus; and 2) there is some green leaf blurred in the foreground I didn't even notice when rapidly shooting but that really messes up the "couple" shots.
And a chipping sparrow. I didn't manage to get any action shots.
That's it - this one's just for the birds.
In no particular order:
1) in the catbird bath (albeit not the seat)
Tufted Titmouse bathing and then looking at me quizzically.
Chick-a-dese out! (sorry about that...)
Cleansing itself of a cardinal sin?
A bathing Carolina Wren. I really like the second picture where it is completely submerged, but you need the preceding one to have a clue what it is. And I like the high-speed tail-wagging with blurry lines, too.
I am really annoyed that these goldfinch pictures aren't better. The male's glorious colors are washed out (which I could probably fix with some editing), but when he hopped over and I saw the female bathing there, too, it was awesome. Except: 1) depth of field was too shallow, so the male is out of focus with the female in focus; and 2) there is some green leaf blurred in the foreground I didn't even notice when rapidly shooting but that really messes up the "couple" shots.
And a chipping sparrow. I didn't manage to get any action shots.
That's it - this one's just for the birds.
Tuesday, May 13, 2014
Just Say Nohydro
Alas, neither the Globe nor the T&G would take this, so on the blog it goes:
A black and white warbler:
And one of our common chipping sparrows doing some personal hygiene:
“Sinaloa
cartel sues US government for ban on heroin” is not a newspaper story we are
likely to see. However, “Zohydro maker
sues to block Massachusetts ban” has recently appeared in news reports across
the country. Why does the former seem
ridiculous and the latter like a legitimate business seeking to defend its
legal product?
Governor
Patrick’s banning of Zohydro is one action to address the public health
emergency he declared over opioid addiction.
Vermont Governor Peter Shumlin devoted his entire State of the State
address this year to Vermont’s opioid addiction problem. Nationally, over 80% of abused opioids are
estimated to be prescription opioids, not heroin. So if we want to address the addiction crisis, we have no choice
but to address prescription opioids.
But why single out Zohydro?
A little
history is helpful to understand why Zohydro, a slow-release formulation of
hydrocodone, is particularly deserving of attention. Our current crisis in opioid addiction has its roots in Zohydro’s
older sibling, Oxycontin, a slow release form of oxycodone. The manufacturer of Oxycontin, Purdue
Pharma, initially marketed it in a form that had no measures to prevent
grinding it up for an immediate high instead of the slow release it was
designed to have when swallowed. They
also poured millions of dollars into campaigns pushing the idea that we are
undertreating chronic pain and opioids were safe and effective for chronic pain
not caused by cancer or other terminal diseases. Prescriptions and abuse soared and it was dubbed “hillbilly
heroin” due to the massive addiction problem it created in Appalachia. After many years – somehow, just shortly
before the original patent expired – a new version of Oxycontin was introduced
that actually was more difficult to abuse and, not incidentally, extended the
manufacturer’s monopoly. Street prices
of Oxycontin dropped as, while it could keep someone out of withdrawal, it was
harder to use for a high.
So, why
wouldn’t the makers of Zohydro bring out a tamper-resistant version like the
current Oxycontin, rather than one with no safeguards at all, like the original
Oxycontin? It is technically feasible –
in fact, Zogenix, the company marketing Zohydro, says it plans to do so in
about 3 years. Why not now? They offer no answer.
Perhaps
they are addressing the urgent need for more options for treating chronic
pain. As a family doctor, I can
certainly testify that we need new and better pain treatments. But is there a pressing need for another
long-acting opioid? I don’t think
so. We have sustained release
oxycodone, sustained release morphine, methadone, fentanyl patches, and
buprenorphine. The FDA’s advisory panel
voted overwhelmingly against approving Zohydro, raising the as yet
unanswered question of why the FDA chose to overrule them and approve it at
all. However, marketed without any
protections against abuse, there will be immediate demand for Zohydro and it
will gain substantial market share and generate huge profits far exceeding what
a tamper-resistant version could bring in – the lessons of Oxycontin have
clearly not been lost on Zogenix and Alkermes, the actual manufacturer of the
drug.
The courts
have ruled that the FDA approval of Zohydro trumps the state’s decision to ban
it. But Zohydro is a drug whose time
should never have come. It will do far
more harm than good. The massive
increase in US opioid consumption has not solved the chronic pain problem, but
it has killed thousands, harmed millions, and generated huge profits for the
pharmaceutical industry. The question
should not be whether a state like Massachusetts can ban Zohydro, but what went
on at the FDA that they approved this harmful, unnecessary pill. I have yet to find a single colleague in
primary care who thinks there is any need for Zohydro.
As Nancy
Reagan might say, “Just Say Nohydro.”
And for those of you who only come here for the nature photos, we had a couple of migratory visitors.
A yellow-rumped warbler bathing in the back yard:
A black and white warbler:
And one of our common chipping sparrows doing some personal hygiene:
Sunday, January 26, 2014
Addressing the Twin Problems of Chronic Pain and Opioid Addiction
America is experiencing a remarkable resurgence in opioid addiction. New England, despite its reputation for Yankee toughness, currently seems to be the epicenter, and Vermont Governor Peter Shumlin devoted his recent State of the State message to Vermont's heroin problem. How we got here is, alas, relatively simple, and starts with Purdue Pharma, the creators of OxyContin and the huge P.R. campaign claiming we are massively undertreating chronic, nonmalignant pain and that opioids are a safe and effective treatment for it. Perhaps my views are slightly skewed by practicing in a community health center, but I have become steadily less convinced that: a) chronic opioids are an appropriate treatment for many, if any, patients who are not suffering from painful, terminal conditions and b) the benefits to the few who are genuinely helped to be more functional and less miserable are far outweighed by the massive harm to society as a whole. At this point, personally, I have perhaps 3 patients whom I think may be genuinely benefiting and a few others who I think are unwilling to go through the discomfort of getting off opioids but probably aren't otherwise being harmed or harming anyone else. And I have probably terminated controlled substance contracts with over 90% of the patients I have had who have had them, many inherited from other providers but some started by me with the best of intentions or unintentionally as what I expected to be pain that should resolve in a month or two never did. I am now a buprenorphine provider (required of all faculty in my clinic to precept residents) and, while I think buprenorphine is really important as a way to make opioid addiction treatment available to far more patients than limited facilities and funding allow for methadone, I am particularly bothered that so many of our buprenorphine patients have been created by our own actions. And, while far safer than most other opioids, it is certainly contributing to supply of opioids on the street that are leading to ever more addiction.
What should we do? Well, below I am including one approach that I think should be considered. Alas, I am clearly in a minority as it is showing up here because I can't get any journal to take it. You can judge for yourself if it is just poorly-written, utterly stupid, or unpublishable for some other, obvious reason beyond being politically unpopular as it would require an acknowledgment of how bad current policies are and the devotion of new resources ("taxes") to carry out. Are there other possible solutions? Certainly. But is continuing on our current course, nibbling at the edges (Massachusetts has just enacted dose limitations, analogous to Washington State) going to make a dent in the problem, or do anything to help us figure out how we might actually do a better job helping all the people with chronic, nonmalignant pain for which we currently have no good answers?
Addressing the Twin Problems of Chronic Pain and Opioid Addiction
The United
States health care system is simultaneously providing opioids to more and more
people for chronic, nonmalignant pain, experiencing a growing crisis in rising
rates of addiction to prescription opioids, and failing to make major advances
in pain treatment. A recent report from
the Institute of Medicine (IOM) highlights the high costs of chronic pain and
shortcomings in its assessment and treatment.
It cites estimates of at least 116 million Americans affected and annual
economic costs of $560-635 billion and contains a “Blueprint for Transforming
Pain Prevention, Care, Education, and Research.” The blueprint starts with a call for a comprehensive,
population-level strategy for chronic pain prevention, treatment, management,
and research, and supporting collaboration between primary care clinicians and
pain specialists.1
The
difficulties in managing chronic, nonmalignant pain arise from several sources,
including problems with measurement, efficacy of treatments, and use of
opioids. Pain is an inherently
subjective phenomenon. Pain assessment
has become the Joint Commission-mandated “fifth vital sign,” but this
measurement has not led to advances in treatment of chronic pain. Furthermore, we have no magic bullets for
treating chronic pain. Many widely-used
interventions have been found to be little or no better than placebo.2-7 Medications are typically mainstays of
treatment for pain, but the evidence base here is also lacking. A systematic review of medications used to
treat sciatica judged the evidence to be limited and of low quality.8 Overuse of NSAIDs is discouraged due to
risks including GI bleeding, perforated ulcers, kidney damage, and now
cardiovascular events. We are cautioned
to limit use of acetaminophen, since it is the largest cause of acute liver
failure in the United States, with about half of cases resulting from
unintentional overuse.9
In the last
two decades, there has been a large increase in the use opioids for the
treatment of chronic, nonmalignant pain, substantially due to new products and
heavy promotion from the pharmaceutical industry.10 Treatment of chronic, nonmalignant pain has
become intimately linked with issues of opioid dependence, misuse and
addiction. The CDC has reported a
number of frightening and depressing statistics about opioid use in America – a
near-doubling of emergency department visits for misuse or abuse of
pharmaceuticals, mostly opioids, between 2004 and 2009, and a quadrupling of
both opioid sales between 1999 and 2010 and opioid overdose deaths between 1999
and 2008. Overdose deaths from
prescription opioids now outnumber deaths from heroin and cocaine combined.11 The incidence and costs of neonatal
abstinence syndrome have also jumped dramatically.12
One might
hope this national adventure in prescription opioid use was based on strong
evidence for their efficacy in the management of chronic, nonmalignant pain, as
opposed to pharmaceutical industry marketing.
However, the proliferation of short- and long-acting opioid formulations
has failed to yield a commensurate reduction in chronic pain. The extant, limited evidence suggests modest
benefits, at best, with some side-effects and unclear effects on quality of
life, employment status, and other outcomes.13 It has been suggested that successful
long-term opioid treatment may not even be treating pain, per se.14 Withdrawal symptoms make it difficult to
wean patients off these medications and to know whether discomfort with
reducing or stopping really reflects efficacy for pain or physiologic
dependence. The proportion of patients
treated with opioids who become addicted may be substantially higher than
generally believed.15 The
CDC report makes clear the societal consequences of the massive increase in the
supply of prescription opioids. Even if
trends were to reverse now, the consequences our current practices will linger
for many years, as highlighted by a recent RCT of treatment for prescription
opioid abuse that found extremely high relapse rates after the cessation of
buprenorphine-naloxone therapy.16
A number of
efforts have been implemented or proposed to reduce misuse and diversion of
opioids. Many states have prescription
drug monitoring programs (PDMPs) but access may be cumbersome and not all even
allow provider access. In
Massachusetts, we are not allowed to delegate access to a nurse or other clinic
personnel, yet the state legislature has passed a law requiring checking the
registry prior to seeing every new patient. PDMPs may reduce abuse but have not so far been shown to reduce
mortality.17 The state-based
nature of PDMPs leads to issues that decrease any potential benefits, as
demonstrated by this email I received from a colleague:
Does anyone have access to
the Connecticut prescription monitoring program? I need to look up a patient.
I contacted them and they said that I should have a CT license in order
to get access.
Washington
State has instituted a guideline limiting maximum opioid dosing for non-cancer
pain18 and New York City has issued guidelines to limit
prescriptions of opioids by emergency departments.19 Mandatory continuing medical education
requirements in pain management, including both state-based programs and the
proposed opioid risk evaluation and mitigation strategies (REMS) from the FDA,
are hypothesized to help, without much supporting evidence. Becker and Fiellin discussed shortcomings of
the current REMS proposal and made some suggestions for improvement, while
discussing that these were still likely insufficient.20
Opioid
prescription registries and mandatory provider education will not solve the
interconnected issues of chronic pain and opioids, nor will guidelines. I can see three possible options for the
future:
1)
continue as we have been doing, nibbling at the edges without
addressing the central issues;
2)
ban most or all prescribing of opioids outside of the settings
of postoperative, trauma, and terminal disease care; or
3)
try a new, more controlled approach that might actually help
patients with chronic, nonmalignant pain access safer, more effective treatment
and provide better evidence about the benefits and harms of long-term opioid
and other therapies.
Option 1 is
self-explanatory. I had thought option
2 was both self-explanatory and unlikely, but Blue Cross Blue Shield of
Massachusetts (BCBSMA) instituted a new policy for opioid prescriptions on July
1, 2012, demonstrating that insurers can and will create policies moving in
that direction without any state or federal action. It allows prescribing an initial 15 day supply of short-acting
opioids and one additional 15 day supply within 60 days of the initial supply;
any other short-acting prescriptions will require prior authorization. Prior authorization is required for all new
long-acting opioid prescriptions and for all buprenorphine prescriptions.21 This will almost certainly decrease opioids
prescribed to BCBSMA patients, increase administrative burdens on providers,
decrease BCBSMA costs for opioids, and shift some costs of opioids onto
patients. However, it is unlikely to
lead to increased knowledge about the treatment of chronic, nonmalignant pain
and the role of opioids therein.
For option
3, I propose an approach with three key components: 1) development of regional,
regulated, multidisciplinary pain treatment centers, whose providers could
access a wide range of therapies and prescribe long-term opioids for chronic
pain if deemed appropriate; 2) development of training programs and
certification for primary care specialties in both chronic pain management and
addiction medicine; and 3) strict annual limitations in how long an outpatient
could be prescribed opioid medications by other providers outside of the
setting of terminal disease – perhaps 2 months cumulatively by all
providers. Due to the nature of opiate
addiction, there is a strong argument for time limitation. Dose limitation, such as that enacted by
Washington State, likely also has a role, particularly given the evidence
suggesting its efficacy in reducing overdose deaths.18 Patients reaching their annual limits (with
exceptions for clearly-identifiable situations like undergoing multiple
surgical procedures) who felt they needed more opioids would be referred to one
of the pain treatment centers, where they would receive a thorough assessment,
state-of-the-art pain treatment (which might or might not include opioids), and
the opportunity to participate in clinical trials of new approaches to pain
management.
This would
accomplish several important goals simultaneously. We will not cure everyone’s pain, but we will not be
undertreating it. I believe the vast
majority of providers would gladly trade the right to prescribe unlimited
opioids to their patients for a system that would let them treat acute pain and
provide a resource for helping them manage patients whose chronic pain was not
adequately controlled, irrespective of whether opioids were an issue. Instead of saying to a patient, “No, I am
not giving you any more opioids for your pain,” they could convey the much more
positive message, “I cannot prescribe you any more opioids, but since your pain
is still causing you such distress, I am referring you to a center that can
provide you the best available care for your pain, which may or may not include
opioids.” These centers would be
ideally positioned to enroll patients in high quality studies and advance the
science of treatment for chronic pain, much as cancer centers of excellence do
today.
There are a
number of reputable pain clinics in existence, but nowhere near enough to meet
the demand, and most primarily focus on procedural interventions that are
well-remunerated. A key question is
whether there are sufficient providers qualified and willing to work in the
centers I am proposing. Three
specialties currently have subspecialty certification in Pain Medicine –
Anesthesiology, Physical Medicine and Rehabilitation, and Psychiatry and
Neurology. This needs to be expanded to
primary care specialties. Training
would need to include the range of options available for treating pain,
including pharmacologic, behavioral, interventional, and physical approaches
and a solid grounding in behavioral and addiction medicine. I recognize that this approach could not be
implemented nationwide with existing personnel, but there is no reason that one
state, region, or even an integrated delivery system could not undertake a
pilot program.
While these
centers would likely have close oversight of opioid prescribing, pain
specialists and other clinicians who prescribe opioids currently have no
protection from what might seem like capricious enforcement actions by the Drug
Enforcement Administration. Treatment
protocols and internal oversight in these centers should lead to both safer
prescribing and lower risk for enforcement actions. Although the barriers to creating effective health care teams
should not be underestimated,22 the opportunity to work in
state-of-the-art, multidisciplinary pain centers at the forefront of clinical
research should attract more providers into the field and facilitate formation
of effective teams. Such a system could
increase fragmentation of care, so it would need to be carefully designed to
include patients’ primary care providers as key members of the team, as called
for by the IOM.1
Who would
oversee such centers and how this would occur would require creative thinking
and novel collaborations, since different aspects would likely fall under the
purviews of the Drug Enforcement Administration, state medical licensing
boards, and the Substance Abuse and Mental Health Services Administration – but
the model of office-based buprenorphine treatment for opioid addiction suggests
this is not an insurmountable barrier.
At least initially, centers would likely need set-aside research funding
pools, but over time they almost certainly would become highly competitive for
more traditional grant funding. We will
need to accept a new social contract in which indefinite access to opioids for
pain is not viewed as a “right” and the centers will need Institutional Review
Boards willing to deal with the complex issues raised by the studies that will
be proposed. However, patients do not
have an inherent right to receive unproven therapies and long-term opioid
therapy for nonmalignant pain is clearly a risky, unproven therapy.
The
reorganization I am proposing would place us well on the way to addressing the
IOM’s charge to transform the treatment of chronic pain.1 The failures and harms of our current
approach are obvious. Tinkering will
fix neither treatment of chronic pain nor the epidemic of prescription opioid
abuse. Given the high costs to society
of both, can we afford not to try a new model such as this?
References
1. Institute of
Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention,
Care, Education, and Research. Washington, DC: National Academies Press; 2011.
2. Kirkley A,
Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery
for osteoarthritis of the knee. N Engl J Med 2008;359(11):1097-107.
3. Laupattarakasem
W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for
knee osteoarthritis. Cochrane Database Syst Rev 2008(1):CD005118.
4. Eccleston C,
Williams AC, Morley S. Psychological therapies for the management of chronic
pain (excluding headache) in adults. Cochrane Database Syst Rev
2009(2):CD007407.
5. Rubinstein SM,
van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative
therapy for chronic low-back pain. Cochrane Database Syst Rev 2011(2):CD008112.
6. Gross A,
Miller J, D'Sylva J, et al. Manipulation or mobilisation for neck pain.
Cochrane Database Syst Rev 2010(1):CD004249.
7. Chou R, Atlas
SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back
pain: a review of the evidence for an American Pain Society clinical practice
guideline. Spine (Phila Pa 1976) 2009;34(10):1078-93.
8. Pinto RZ,
Maher CG, Ferreira ML, et al. Drugs for relief of pain in patients with
sciatica: systematic review and meta-analysis. BMJ 2012;344:e497.
9. Bower WA,
Johns M, Margolis HS, Williams IT, Bell BP. Population-based surveillance for
acute liver failure. Am J Gastroenterol 2007;102(11):2459-63.
10. Ornstein C,
Weber T. Patient advocacy group funded by success of painkiller drugs, probe
finds. Washington Post 2011 December 23, 2011.
11. Vital signs:
overdoses of prescription opioid pain relievers---United States, 1999--2008.
MMWR Morb Mortal Wkly Rep 2011;60:1487-92.
12. Patrick SW,
Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal
abstinence syndrome and associated health care expenditures: United States,
2000-2009. JAMA 2012;307(18):1934-40.
13. Noble M,
Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic
noncancer pain. Cochrane Database Syst Rev 2010(1):CD006605.
14. Sullivan MD,
Ballantyne JC. What Are We Treating With Long-term Opioid Therapy? Arch Intern
Med 2012;172(5):433-4.
15. Juurlink DN,
Dhalla IA. Dependence and addiction during chronic opioid therapy. J Med
Toxicol 2012;8(4):393-9.
16. Weiss RD,
Potter JS, Fiellin DA, et al. Adjunctive counseling during brief and extended
buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase
randomized controlled trial. Arch Gen Psychiatry 2011;68(12):1238-46.
17. Gugelmann
HM, Perrone J. Can prescription drug monitoring programs help limit opioid
abuse? JAMA 2011;306(20):2258-9.
18. Franklin GM,
Mai J, Turner J, Sullivan M, Wickizer T, Fulton-Kehoe D. Bending the
prescription opioid dosing and mortality curves: impact of the Washington State
opioid dosing guideline. Am J Ind Med 2012;55(4):325-31.
19. Juurlink DN,
Dhalla IA, Nelson LS. Improving opioid prescribing: the New York City
recommendations. JAMA 2013;309(9):879-80.
20. Becker WC,
Fiellin DA. Federal Plan for Prescriber Education on Opioids Misses
Opportunities. Ann Intern Med 2012.
21. Blue Cross Blue
Shield of Massachusetts. New Quality and Safety Measures in Opioid Management,
Effective July 1, 2012. (Accessed March 30, 2012, at
http://www.bluecrossma.com/bluelinks-for-employers/whats-new/special-announcements/opioid-management.html)
22. Grumbach K,
Bodenheimer T. Can health care teams improve primary care practice? JAMA
2004;291(10):1246-51.
Sunday, January 19, 2014
Hot and Cold under the Collar
Warning - this post has nothing to do with medicine, EHRs, or anything I've written about before. It will mostly be of interest to my geeky friends who haven't already heard all this.
We've been getting letters from the gas company that our consumption is around the 75th %ile of our "peer" houses. I find it hard to believe they are comparing to true peers - we have 2 set-back thermostats that go down at 11 PM and I have made interior storm windows for all the windows that will accommodate them. But our gas bill certainly is unpleasant in the winter.
I was also made aware that the gas company was offering a $100 rebate on the purchase of a wifi-enabled thermostat. So, I figured, let's give it a try, though I wouldn't expect much savings when we already have programmed, set-back thermostats. Our house just has 2 wires going to each thermostat and, according to their websites, all the wifi thermostats except the Nest require more wires than that. So, I swallowed hard and bought a Nest, even though we are an Apple-free family(TM).
The Nest installed easily. Despite my starting it off with some settings, the house was noticeably, unpleasantly cold at first. That has improved. Its "away mode" kicked in a few times when we were home, yet when we went to Hawaii, it took about 3 days for it to decide we were away. Luckily, I could turn it down remotely, anyway.
However, the boiler is right off my office and I started noticing an annoying buzz coming and going at night and eventually realized it was from the controller box. One of the relays was buzzing so I ordered a replacement. I later thought to swap with the relay for the other zone and... it wasn't the relay, it was the circuit. The one with the Nest. Googling quickly revealed that, in a 2-wire system like ours without a "common wire" for power, the Nest frequently pulls a small amount of current to keep its battery charged. Some furnaces are listed on the Nest website, if you know to go hunt, as incompatible because this is enough to make them turn on. Ours doesn't, but the relay buzzes. I could quiet it a bit by suppressing harmonic vibration of the box, but it's still there. I emailed Nest support, who eventually responded that I could return the Nest to the place of purchase. Thanks, guys. I'm still trying to decide about that. Google having just announced that they are purchasing Nest is pushing me more toward removal...
One thing the "smart thermostat" hasn't helped at all is the fact that our bedroom is the coldest room in the house - a corner room, and I think a smaller amount of radiator for its square footage than the other rooms. That got me thinking - with small computing devices like the Arduino and sensors so cheap, should't I be able to put temperature sensors in each room and turn the hot water supply to the radiator on or off depending on whether the room was above or below a temperature I set? Then, even though the whole upstairs in just 1 zone, each room could be its own mini-zone, with a demand for heat in any room kicking on the boiler. I think an über-geek friend has sensors for climate control in individual rooms in his house. (I am a bit worried that his Arduino network has started addressing him as "Dave.") He was sure I was reinventing an existing valve and, while I'm not sure it's quite the valve he was thinking of, it turns out folks in the UK have had thermostatic radiator valves (TRVs) for years and now can get electronic/programmable/remote controllable ones. But, remember, they have a long tradition of gas meters you have to keep feeding to stay warm and the like, so I suspect even current construction likely has shut-off valves on radiators. Here in the US, we believe that, if we are cold, we should heat up the entire planet. If I wanted to install such things in my house, I'd have to cut into all the radiator piping and sweat in new joints for the TRVs. Not worth it to me.
This strikes me as a good case for the heavy hand of jackbooted government thugs. If building code for hot water heat had required shut-offs for each radiator, I could easily put in a system to keep the bedroom more comfortable at night without heating the rest of the house, keep the boys' rooms cooler when they were away, etc. It would probably increase the cost of a new house by, say, $100, but could save hundreds of dollars a year on energy bills. But there's no incentive for any builder to do it unless they are pushing the house as a "green house" and consumers are aware of the potential value of this. It should be easier and cheaper to do a retrofit on forced air heating systems, where you just need to open or close dampers in ducts (which might be a nice niche business for one of my legions of readers to look into starting).
Sorry, this is just another case (like health care) where a regulated market could deliver greater efficiency than the free market. Remember, the theoretical free market requires complete information on the part of buyers and sellers.
Speaking of which, today's latest NY Times article on the cost of health care, focusing on Dermatology, is well worth reading. Damn - almost made it through without any reference to health care.
Saturday, January 18, 2014
The Ins and Outs of Primary Care
I realized I might as well post this piece here that came out this week my Department's "Thursday Morning Memo," a weekly email containing brief, reflective writings about our roles and experiences in primary care. It's just a reflection from a couple of recent experiences on some of the things we are losing as primary care moves more and more toward complete separation of outpatient and inpatient care.
As this was written for folks in my Department, there are some local references that might not make sense to someone outside the Department reading it.
As this was written for folks in my Department, there are some local references that might not make sense to someone outside the Department reading it.
Like many
primary care physicians, I have mixed feelings about the evolution of my role
in inpatient care. I like taking care
of acutely ill patients and (usually) seeing them get better. I like (well, liked) being there for my
patients, bringing my knowledge of them developed over time as an outpatient to
their inpatient care and, hopefully, avoiding mistakes and duplicated effort
that new providers might make. Of
course, like most of us, I don’t like the extra time demands of going to see
hospitalized patients – and it seems particularly painful if I have no official
role in their inpatient care. Clinical
systems don’t like those time demands, either, if they come out of scheduled
clinic time; more and more, inpatient care is firmly walled off from outpatient
care, connected at best by a discharge summary sent to the PCP and very rarely
with any attempt to communicate when a patient is admitted.
In
different practice locations, I have participated in various inpatient call
schemes, including every 3rd night coverage for the practice, taking
a week at a time, and no inpatient call – but not being on call for all my
patients (nearly) all the time, so I cannot claim to occupy the moral high
ground on continuity. Mark Doescher and I published an
editorial in the early days of the hospitalist movement, pointing out that
there was no good evidence for better outcomes and there were potential
significant downsides from loss of continuity.
But forces other than maximizing patient outcomes have driven the
movement toward hospitalist care as the default in more and more settings,
while the evidence for quality benefits continues to be rather modest.
Recently, I
had 2 seriously ill patients hospitalized at University Hospital. I was not, of course, contacted when they
were hospitalized, though I did receive notification when one was transferred
to the ICU because of a relatively new policy in the ICU to contact PCPs when
their patients are admitted. Since I
have an office in the Benedict Building in addition to seeing patients at the
FHCW, it is relatively easy for me to visit my patients at University Hospital,
unlike Memorial, which requires making a trip just for the purpose.
Both
patients primarily spoke languages other than English, which can present a
barrier. The floor admission note when
one patient was transferred out of the ICU noted that she spoke broken English
and her native language and a limited interview was conducted in English as “no
interpreter was available.” To my
relief, when I went to see her, the speakerphone on a pole (product of a past
project in our Department) was right next to her bed, so clearly someone knew
about using that, even if not the admitting resident. Other times I visited her, it took up to 5 minutes to find the
speakerphone so I could contact a telephonic interpreter. I spent my time just asking what questions
she and her family had and doing my best to answer them, in the absence of any
communication from the inpatient team beyond what I could glean from their
notes and her labs. A couple of times,
I hunted up her nurse to see if they could ask to covering inpatient provider
to write some orders to make her more comfortable. My patient asked if I could, please, come see her every day. I said I would come frequently, but probably
it wouldn’t be every day. It certainly
seemed that nobody else was taking the time just to sit and answer questions
with an interpreter.
My second
patient sustained a stroke and initially had complete expressive and dense receptive
aphasia. Her recently-immigrated family
spoke little or no English but, luckily, I speak one of their languages
reasonably well and I had met several of them previously so they knew who I
was. They had many questions – many of
them unanswerable, like why this had happened and what was going to happen to
her. They asked when I could come back
and see her again. The day she was
being transferred to a rehabilitation facility, I came by and found she had
made remarkable progress from my previous visit a few days earlier, with good
comprehension and the ability to express brief sentences with only moderate
dysfluency. The family members
clustered around her immediately asked me to talk with her about her discharge
plans, as she was saying she wanted to go home and did not understand why she
should go somewhere else. After I
reviewed the rationale and potential benefits of intensive rehabilitation prior
to going home, she agreed to the plans for a discharge to rehab.
In these
cases, my visits were purely social.
They were not billable (or at least not billed) and came out of my “free
time.” I am no saint – I did not see
these patients every day, nor do I do this very often for patients hospitalized
at Memorial given the added barrier of needing to make a special trip
there. But having two hospitalized
patients at the same time and seeing how much my visits apparently meant to
them and their families has made me reflect on the perhaps Faustian bargain we
have made to separate outpatient and inpatient care in the name of greater
efficiency (our Department and clinics love the increased clinic sessions and
scheduling predictability, and evidence suggests modest decreases in inpatient
costs and length of stay with hospitalist care). It certainly doesn’t feel patient-centered. Perhaps, as we move to Accountable Care
Organizations, we could reconsider this path, since payment should not depend
simply on visit volume, but I suspect no metrics, even patient satisfaction,
would capture the benefits of maintaining this human connection in a way that
could change the calculus of this choice.
Absent a metric and a push to improve it, are we and our patients losing
an important component of the patient-provider relationship?
Tuesday, December 31, 2013
Happy New Year 2014
Pushed by popular demand (translation - I think the one person who asked me is popular), I have drawn yet another in my series of poorly-drawn cartoons, in honor of the new year. You can tell it's a new year-themed cartoon because it says, "HAPPY NEW YEAR!" right at the bottom. It could have been a Halloween cartoon, I suppose, but I didn't draw it till now. It is completely apolitical, unrelated to medical care, and has no social commentary at all. Well, at least it really doesn't refer to electronic "health" records in any way. Perhaps because, now that Mark is being employed by Epic, I have a conflict of interest. Nah, just didn't happen.
I will try to blog more regularly. There are lots of things I've been meaning to write about, so maybe I'll get off my rear at some point soon.
Anyway, to completely obviate the need for a brag letter that ain't coming, Mark is now working for Epic, proving that Zoology is a viable major, as long as you have a Computer Science minor, Keith is now a junior and it seems switching from Econ to Comp Sci (so he can get a Zoology job after graduation, I'm sure), and Rose had both knees replaced in July and is still not exactly a happy camper.
Best wishes to you (whoever you are, reading this) and yours for the new year!
And now, the alleged cartoon:
I will try to blog more regularly. There are lots of things I've been meaning to write about, so maybe I'll get off my rear at some point soon.
Anyway, to completely obviate the need for a brag letter that ain't coming, Mark is now working for Epic, proving that Zoology is a viable major, as long as you have a Computer Science minor, Keith is now a junior and it seems switching from Econ to Comp Sci (so he can get a Zoology job after graduation, I'm sure), and Rose had both knees replaced in July and is still not exactly a happy camper.
Best wishes to you (whoever you are, reading this) and yours for the new year!
And now, the alleged cartoon:
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