What if We Hypothesized Instead of Diagnosed?

The 19th century Romantic poet John Keats was also trained as a physician.  And it's his definition of a "man of achievement" that gives Arabella Simpkin and Richard Schwartzstein their jumping off point in a fascinating essay in the New England Journal of Medicine.  Wrote Keats regarding the necessary quality of such a person: "...when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason."

How many physicians do you know who would agree with that sentiment?

Simpkin and Schwartzstein go on to make a noble and necessary argument for the place of uncertainty in modern medical practice.  While the proposal is made for the entirety of the profession and the full span of specialties, I was struck by the applicability of the argument to chronic pain management, specifically.

Too often, we focus on transforming a patient’s gray-scale narrative into a black-and-white diagnosis that can be neatly categorized and labeled. The unintended consequence — an obsession with finding the right answer, at the risk of oversimplifying the richly iterative and evolutionary nature of clinical reasoning — is the very antithesis of humanistic, individualized patient-centered care.

This is how non-specific low back pain turns into a 15 year old work comp claim.

The authors make several recommendations, each of which targets the very heart of medical education and clinical practice culture.  We need to cease viewing uncertainty as a threat, but rather embrace it as part of the iterative nature of care.  We need to move away from multiple choice tests in medical education that require definitive answers and instead focus on evaluating medical students' tolerance for uncertainty and ability to posit based on incomplete information.

Perhaps the most daunting recommendation they make, though, is the idea of moving away from concept of diagnosis and instead focusing doctor-patient conversations on the concept of hypothesis.

We can speak about “hypotheses” rather than “diagnoses,” thereby changing the expectations of both patients and physicians and facilitating a shift in culture. This shift may entail discussing uncertainty directly with patients, intentionally reflecting on its origins — subjectivity in the illness narrative, diagnostic sensitivity and specificity, unpredictability of treatment outcomes, and our own hidden assumptions and unconscious biases, to name a few. We can then teach physicians specifically how to communicate scientific uncertainty, which is essential if patients are to truly share in decision making, and we can reduce everyone’s discomfort by reframing uncertainty as a surmountable challenge rather than as a threat.

This requires treating the whole patient.  This requires recognizing the psychological and social contributors to pain perception and tolerance.  This requires seeing through the psychotropic effects of opioids and other addictive medications to get to the root cause issues of chronic pain.  This requires not just patient advocacy, but truly shared decision making.

Of course, this would also require us to move away from the dilapidated and counter-productive world of fee-for-service billing.  This would also require payers and employers to pay for quality, a genuine willingness to pay more dollars for less care (in the traditional sense) and more shared decision making (which will inevitably lead to better outcomes).

So there's a little slice of utopia for you, this Monday morning... with a heaping side helping of reality.

Michael
On Twitter @PRIUM1

The Patient Should Not Be Punished for the Sins of the Prescriber

Dr. Mitchell Katz of the Los Angeles County Health Department wrote an editorial that was published in last week's issue of the Journal of the American Medical Association (JAMA has made this set of editorials on opioid prescribing available free of charge).  The title caught my eye - Opioid Prescribing for Chronic Pain, Not for the Faint of Heart.  Indeed.

His intent is to offer a realistic appraisal of the new CDC opioid guidelines.  The tone of the editorial is best described as "great guidelines... but here's how the world really works."  While the pharmaceutical industry appears to have sheathed their swords for lack of argument, the physician community now has to figure out what to do with these new guidelines (if anything at all). Dr. Katz is supportive of the guidelines, but offers his view of their application through a lens of honest practicality.

A few key excerpts (emphasis added):

Even when seeing a patient who has not already begun taking opioids, we physicians have few alternatives for patients who have already tried nonsteroidal anti-inflammatory medications and acetaminophen without relief. Of the pharmacologic and nonpharmacologic options, none is likely to provide rapid pain relief, and none is very effective. Moreover, many of us work in resource-poor systems where arranging for someone to receive physical therapy or cognitive behavioral therapy—two useful therapies—is more difficult than weaning someone from long-term opioid use. To all patients, I give my well-rehearsed speech on why I believe opioids cause more harm than good for chronic pain, but ultimately I will prescribe them for a patient in pain for whom I see no other realistic option.

Embedded in this paragraph are two brutal facts that we must confront: 1) access to non-pharmacological modalities is not easy and cannot be assumed; 2) sometimes, even good doctors are faced with a choice between the lesser of two evils.  I would add that work comp payers should focus on alleviating issue #1 (by approving alternative modalities, going the extra mile to find practitioners, placing alternative non-pharm modalities in-network, etc.) in an attempt to relieve prescribers of burden #2.

Another cogent point from Dr. Katz:

One thing I am certain of: we need to engage patients in an honest and open way rather than quickly writing or refusing to write opioid prescriptions. Given that many patients may be defensive about using opioids, I always speak of my fears. I do not say “You are going through the pills too quickly.” Rather, I say “I am worried that at the doses of medication you are taking, the medicine will harm you.”

Language matters.  This is a subtle but critical point in the fight against opioid misuse and abuse: patient engagement isn't as complicated as we sometimes make it out to be.  Clinicians that are willing to have difficult conversations and who are willing to be honest and transparent with their patients will have more success treating pain than clinicians who find themselves, in Dr. Katz's words, "quickly writing or refusing to write opioid prescriptions."  

Finally, in the context of the complicated matter of opioids and benzodiazepines (you'll have to read his editorial for his full view on the matter), Dr. Katz offers this piece of advice: The patient should not be punished for the sins of the prescriber.  

That should serve as a guiding principle to all of us engaged in this fight.  Above all else, we need to focus on the health, safety, and functionality of injured workers.

Michael
On Twitter @PRIUM1

Primary Care Physicians Aren't Prepared for Substance Abuse Issues

In the course of consuming news, studies, and other information related to prescription drug misuse and abuse, I sometimes come across seemingly unrelated data sets that paint a picture of broad, systemic issues.  Often, connecting these dots can illuminate a potential path forward, focus our efforts, and create progress toward solutions.  This week's example: 

Data Set #1

First, the CDC's latest data on drug poisoning deaths is disheartening.  After leveling off and even slightly declining in 2010-2013, the opioid death rate jumped considerably in 2014.  Meanwhile, heroin overdose deaths have continued a depressingly steady climb that goes back nearly two decades, but has clearly accelerated within the last 5 years.  Certainly, we have seen better days.  

Data Set #2

Health Affairs published an interesting piece in its December 2015 issue comparing primary care systems across 10 countries.  Primary care doctors were surveyed regarding general capabilities and attitudes.  While the survey was wide ranging, one of the categories stood out to me: the % of primary care doctors who report their practice is well prepared to manage the care of patients with complex needs.  Two key data points:

1. Patients with substance-use related issues:
• US primary care docs: 16% are well prepared.  This ranked near the bottom of the 10 country survey.  The UK was at the top of the list with 41% of primary care physicians reporting that they're well prepared to deal with substance-use related issues. 
2. Patients with severe mental health problems:
• US primary care docs: 16% are well prepared.  This ranked second to last (just behind Sweden at 14%) among the ten countries.  The UK also topped this category with 43% of primary care docs reporting they feel well prepared to deal with severe mental illness.  

To sum up... 

We have an escalating death rate from opioid and heroin overdose deaths in this country, driven in large part by substance-use related issues and mental illness.  And we have a primary care system not equipped to deal with the complexity of these patients.  

Help may be on the way in form of increased and mandated reimbursement for substance abuse and mental/behavioral health treatment via the Affordable Care Act.  But I'm struck by the fact that the vast majority of opioid prescribing occurs at the primary care level, not in the specialist's office.  If we're to make any progress, we need to focus education, resources, and tools within the primary care community so that a-heck-of-a-lot more than 16% of primary care physicians feel they're well prepared to help this complex group of patients.  

Michael 

On Twitter @PRIUM1

Physicians and Painkillers: A Tale of Two Statistics

See if you can reconcile the following two sets of data points from a survey published by the Journal of the American Medical Association last week regarding physician perceptions of prescription drug abuse:

1) 90% of doctors report prescription drug abuse is a moderate to large problem in their communities and 85% think prescription drugs are overused in clinical practice.

2) 88% of those same doctors are confident in their skills related to prescribing painkillers and almost half of them are comfortable using the drugs for chronic, non-cancer pain.

And there's the rub.  Call this the old "there's a problem, but I'm not contributing to it" phenomenon.  Doctors who profess confidence and comfort prescribing prescription painkillers for chronic, non-cancer pain may be contributing the problem of misuse and abuse, albeit unwittingly.  The study doesn't offer any insights into dosage levels or medication classes or individual drugs, so one cannot draw conclusions.  And I'm certainly not suggesting that painkillers can't be used appropriately for time limited, function-focused management of chronic, non-cancer pain.  But the contrast between the data points struck me.  85% think the drugs are overused... 50% are confident using them with a group of patients for which there's little to no evidence of long term efficacy.  

And this is a commonly observed phenomenon.  Rewind the clock five, six, seven years and a material number of work comp payers (from carriers to TPAs to self-insured employers) were saying the same thing.  "There's a problem, but I'm not contributing to it." I personally heard it at least a dozen times in my first year here at PRIUM (which was five years ago... time flies).  I don't hear it much these days.  As an industry, we're beginning to make concerted, strategic effort to combat prescription drug misuse and abuse and we largely recognize that all payers have a role to play.  While there's still A LOT of work to be done, we've passed through the first step on the road to recovery: payers are not only admitting they have a problem, they're recognizing their past contributions to that problem.

The physician community appears to have the first half down - they're clear we have a problem.  I wonder if they recognize their past and current contributions to the problem.  I know many physicians do.  I hope more come to recognize the need to change patterns of practice in light of the largest man made epidemic in history.

Michael

On Twitter @PRIUM1