Monthly Archives: November 2012

Denial Ain’t Just a River in Egypt: 5 Stages of Reactions to Quality Report Cards

We received the our monthly physician quality report cards recently.  Software mines our EHR and generates these reports to tells us if we are meeting our quality goals.  These goals are defined by recognized guidelines or insurance companies pay for performance programs.  As usual, a great hue and cry arose from the audience.

I prefer creating and using our own data instead of relying on incomplete and inaccurate claims data from insurance companies.  While I firmly believe that we must measure our performance then use the data to improve our clinic operations,  I have been through this often enough to find our reactions humorously consistent.  Dr. Kubler-Ross could use us as a case study.

  1. Denial – “These patients aren’t mine.  The attribution algorithm is wrong.”
  2. Anger – “I referred him 5 times to get a colonoscopy”
  3. Bargaining – “If they could just correctly identify my patients, then I would know where to start.”
  4. Depression – “This is impossible.  How can I get my patients to exercise?  I’ve told them a thousand times.”
  5. Acceptance – “OK, fine.  Schedule those diabetics to see me with our dietitian so we can talk about healthy eating.”

After a few meeting we work through Stage 5 and get back to work.

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Engage With Grace

From Paul Levy’s Not Running a Hospital blog

@engagewithgrace #blogrally12 Once again, a group of us (including Matthew Holt, Alexandra Drane and our friends) are launching the Engage With Grace blog rally to coincide with Thanksgiving weekend. As in previous years, we’re suggesting that people who want to join the rally simply post the attached “ready made” blog content starting tonight, November 21, and leave it up through the entire weekend (consider it a much-deserved break from blogging for a couple days).

One of our favorite things we ever heard Steve Jobs say is… ‘If you live each day as if it was your last, someday you’ll most certainly be right.’

We love it for three reasons:
1)      It reminds all of us that living with intention is one of the most important things we can do.
2)      It reminds all of us that one day will be our last.
3)      It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.
Most of us do pretty well with the living with intention part – but the dying thing? Not so much.
And maybe that doesn’t bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people….
Then one day it does – happen to someone else.  But it’s someone that we love.  And everything about our perspective on end of life changes.
If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has.  Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values.  And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf.
Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught?
Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter.  Here’s the crazy thing – in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important.
Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony.  So let’s take that off the table right now, this weekend.  Know what you want at the end of your life; know the preferences of your loved ones.    Print out this one slidewith just these five questions on it.
Have the conversation with your family.  Now.  Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW.  Have it this Thanksgiving when you are gathered together as a family, with your loved ones.  Why? Because now is when it matters. This is the conversation to have when you don’t need to have it.  And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating.  We find sharing almost everything else about ourselves fascinating – why not this, too?   And then, one day, when the real stuff happens?  You’ll be ready.
Doing end of life better is important for all of us.  And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die.
One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama.  Others had before. Why was this day different?  Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.
Each of us has a story – it has a beginning, a middle, and an end. We work so hard to design a beautiful life – spend the time to design a beautiful end, too.  Know the answers to just these five questions for yourself, and for your loved ones.  Commit to advocating for each other.  Then pass it on.  Let’s start a revolution.
Engage with Grace.
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If Behavioral Counseling Doesn’t Work, What Then? – Patients Must Decide To Change

I used to feel as though I was beating my head against a wall trying to motivate my patients to quit smoking, eat healthy foods, and lose weight.  While my more experienced partners shrugged their shoulders and said “It’s up to them,” I was certain that I just needed to try harder.  I would comb journal articles for the latest technique and then despair that I had neither the time or the resources to try these ideas.

Most of my patients who changed their behaviors seemed to do so for their own reasons, not mine.  The medical evidence cited by the US Preventative Task Force and Cochrane Collaborative matches my experience.  When I reflect on this, it makes sense.  Each of us must find our own motivation.  I eat healthy food, run, and bike in hopes of dodging my family history of high blood pressure.

I have not stopped trying, but I have shifted my approach.  I am ready to help you, when you are ready to change.  Let’s work together to find what motivates you.

Essential Evidence Plus:

The U.S. Preventive Services Task Force recommends against routine behavioral counseling in primary care settings to promote a healthful diet and physical activity as primary prevention for cardiovascular disease in patients without hypertension, diabetes, or hyperlipidemia (grade C recommendation, moderate certainty of a small net benefit). Though seemingly harmless, counseling that is largely ineffective has an opportunity cost, in that it may prevent other, more helpful services from being provided. As primary care office visits get more crowded with effective preventive care services there is less room for ineffective interventions, no matter how seemingly easy or well-meant. (LOE = 5)


Moyer VA, on behalf of the U.S. Preventive Services Task Force. Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S.Preventive Services Task Force recommendation statement. Ann Intern Med 2012;157:367-372.

Synopsis: This guideline focuses on adults without a known diagnosis of hypertension, diabetes, hyperlipidemia, or cardiovascular disease. Although there is a strong correlation between a healthful diet, physical activity, and the incidence of cardiovascular disease, there is not good evidence that behavioral counseling — even high intensity — results in change in diet or exercise or has any meaningful effect on risk factors such as blood pressure, lipid levels, or glucose tolerance. The guidelines suggest that some patients who are ready to change and have the social support and community resources to support the change may benefit from counseling, at least theoretically. In a related recommendation, the task force recommends screening for obesity and treating patients with intensive behavioral interventions (Ann Intern Med 2012;157:373-378).

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

The Cochrane Collaborative reached the same conclusion

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A Teaspoon of Honey, Not a Teaspoon of Sugar, Makes Your Child’s Cough Better

Now that the FDA tells us to avoid most over the counter (OTC) cough and cold medicines in children under age 4,  what are we to do?

While I did not agree with these recommendations at first, I now like encouraging supportive care and milder treatments like nasal suction and nasal saline drops.  Since most OTC cough and cold medicines had little  evidence to support their benefit in young children, I am now happy to use them less often.

These Israeli investigators studied several types of honey in the treatment for nocturnal cough in children ages 1-5 years.  Whether the benefit is due to real reduction in the cough drive, or to simply giving the parents something to do, I will consider this for the next child I see.

Maybe we have always used OTC cough and cold medicines in young children because they gave us and the parents something to do, not because they actually worked.

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