The Quiet Epidemic

To sin by silence when they should protest makes cowards of men. —Abraham Lincoln

Last year a resident sent an e-mail harangue about how much time it was taking her to do the things her preceptor had asked her to do for patients. It had eaten into her “free time” to take care of these patients. Although she may have been tired at the time she wrote the e-mail, this resident is a very conscientious physician. She wanted to say that being a physician is a “job,” that she should not be spending so much of her time “following up from clinic,” and that her preceptor “has to stop doing so much for the patients,” because this was part of that clinic. She listed examples: she had answered a question from neurology about the necessity of referring a patient to neurosurgery for his debilitating back pain; she had answered a question from pharmacy about a patient's hyalgan injection (a last-ditch effort to avoid either an electric scooter or a knee-replacement surgery); she had talked to a patient who was unclear about his medication after leaving the clinic (she was the resident who saw him); she had had to clarify whether an MRI was necessary in a patient and then whether or not to use contrast; she had to call a patient at home after arranging a 23-hour observation to begin rituxan infusions to give him the date of admission. Incredulous and saddened, we felt it highlighted a generational change in what it means to be a physician and the expectations of some of its younger members.¹

This has been the best and worst of times for our profession. New diseases and their pathophysiology have been elucidated, but the existence of some, such as chronic Lyme disease, are contested, and some physicians treat with therapies that have proven to be useless. We have powerful new therapies in some diseases, but they are extremely expensive and difficult for some patients to access. For instance, the anti-TNF agents have transformed the lives of persons with rheumatoid arthritis, spondyloarthropathies, and psoriatic arthritis, but the agents are expensive, and many working patients cannot afford their co-payments. The genomic revolution is under way, and some therapies, particularly in oncology, can be individualized with genetic characterization to maximize outcomes. House staff are better rested, but their attending physicians are more anxious, as the fundamentals have taken a back seat and the histories of complicated patients seem to be left in the dust. The components of what we used to call comprehensive, multidisciplinary team care seem to have been replaced by only those services that are allowed or reimbursed.

The world, at times, seems to have gone mad with senseless (at least from a clinical point of view) administrative rules. We have new powerful agents for gout and hyperuricemia, but colchicine, a highly efficacious drug used for gout since 1500 BC, is no longer readily available in Veterans Affairs hospitals (VAHs) because the cost has gone from 50 cents to more than 3 dollars a tablet. COX-2 inhibitors cannot be prescribed for Illinois Medicaid patients receiving nonsteroidal anti-inflammatory drugs no matter what the circumstances, unless they’ve had a GI bleed. The billing and documentation process and procedures to ensure compliance have created a major income transfer program for the infrastructure to police this bureaucracy, which means less money is spent on health care itself. Patients are discharged with complicated medication regimens and no starter medications to save money, which leaves barely recovered patients searching for a way to obtain essential drugs on their own.

While these administrative decisions are mind-boggling and infuriating, we have found ways to cope with them, often by working around them (making telephone calls, working with patients to replace services with home options, speaking with pharmacists and colleagues about replacement medications). We continue to alternate between grousing and “sucking it up” when faced with them. It seems the effort to protest and fight the regulations has worn us down, and in one generation, physicians have gone from being advocates for their patients to gatekeepers for health care practices that may be cost saving for the system but may feel heartless and tragic to the individual patient. The sentinel events we face every day should be the raison d’être of a system. Each instance of this craziness is off the radar screen: a silent epidemic.

It is clear that something has to change to facilitate patient care and address physicians' helplessness to perform our jobs to the best of our ability. Complaining has not helped, and individual coping mechanisms are not always productive. We can change our attitude, change the system, or change the assumptions and conceptual framework behind the system. The latter two are daunting and can appear beyond the capability and control of the individual physician. If anything is obvious, it is that every strategy to contain the rising cost of health care has failed or has had only transient benefit. However, as with other problems, if we physicians band together to address it, the solution may be far easier than expected. The solution may lie in “hard data,” the interpretation of which preoccupies bean counters and policy experts.

The goal of accumulating the data is to aggregate these sentinel events so that the signal of administrative interference with the ability to provide good health care is both clear and compelling, providing the information necessary for a change in the system and possibly its conceptual framework. It would allow detection of an epidemic of damaging administrative decisions and, like all epidemiologic surveillance data, illuminate areas for detailed analysis. The surveillance should not further burden time-starved physicians. This database would assemble sentinel events interfering with optimal care. The demographic information associated with the source, once registered, could be keyed in with one's login, and the window could be always active on one's computer. A minimum of data would be needed and include the following:

• Desired action: prescribe colchicine for acute gout

• Reason unable to perform desired action: insurer will not approve

• Alternative action: nothing; advised patient about possibility of increased flares

A user could also elect different formats to contribute, such as writing the event in prose rather than filling out a survey form. Professional societies and patient advocacy groups could host these surveillance systems. Whistle-blower protection would be assured. As events accrue, and the data and reasons became a pattern, an epidemic, of sorts, will become apparent.

Another way to identify and aggregate possible management malpractice would be to mandate publicly accessible databases of administrative appeals, such as a request to Medicaid to provide a COX-2 inhibitor for an elderly patient on multiple medications and NSAIDs who could not safely tolerate a GI bleed, or a request for more physical therapy in an adherent patient with severe knee osteoarthritis who badly needs quadriceps strengthening. Data would be collected regardless of how each appeal is ultimately adjudicated or resolved, corrected for the number of persons covered, and standardized by age and gender. Both these types of surveillance could direct us to potential systems problems in a timely manner but would still require the commitment to use the information to improve outcomes and processes of care. Iatrogenesis is addressed by malpractice systems, continuing education, quality assurance, and risk management, but we have no systems in place to identify, prevent, and correct management malpractice. Given the commitment to put a surveillance system in place, we could have data to effect a change before another generation of physicians is trained.