Viewing Doctor’s Notes

Should patients be allowed to see doctor’s notes? Legally they can, but that doesn’t necessarily mean it’s a good idea. Patients would like to, but physicians are not so sure. People make strong arguments, but I think it’s really nuanced.

Physicians often write down the differential diagnoses. Say you’ve lost a little weight without trying. It could be a lot of things such as stress, cancer, an overactive thyroid, an ulcer, HIV AIDS, tuberculosis or a thousand other things. After asking a number of questions and doing an exam, I may decide that it’s unlikely that there’s any serious medical problem going on and prescribe a medication for depression. When I see you back in a month I’ll order additional tests if you have not responded as expected, and particularly if you’re still losing weight. But in my first note, I would have likely at least mentioned some of the diagnostic possibilities, and probably using medical terminology such as malignancy. I write these for a number of reasons. Mostly it makes for good care. Just in case it turns out to not be depression, when I look back at my prior note it will remind me of some of the concerns I had. It also provides a road map of what I was thinking if the patient has to see another physician, whether it’s because I’m on vacation, they have to go to the emergency room or see another physician. The note is also necessary due to malpractice concerns. Doctors are usually not expected to know the future, but the legal assumption is that if you didn’t write it down, it didn’t happen. If you don’t show that you considered the possibility of a serious condition, the presumption is it didn’t cross your mind.

Psychiatrists are allowed to protect their notes. Is that because their patients are too unstable to see their notes? Is it because the psychiatrist needs to record things that a patient may misinterpret? During the course of treatment they might have some insight about a patient’s problems, but not know whether their guess is right. By recording their thoughts they can later go back and review them, improve their diagnosis and treatment, and better help the patient. Well the majority of psychiatric care in the United States is actually provided by primary care physicians. There are not enough psychiatrists to treat all the cases of depression and anxiety. But primary care physicians notes are not similarly protected.

One measure of the benefit of a treatment is the number needed to treat. For example, one may need to treat 20 patients with a cholesterol medication for a year for every heart attack prevented. Conversely is the number needed to harm. Depending on age, it’s estimated that for about every 1500 abdominal CT scans, one person will get cancer as a result of the radiation. A good clinician will be correct the majority of time. How many patients will be harmed by reading chart notes (needless worry, additional tests that have their own risks and costs ordered because of that fear, physicians not recording important information for fear of it being read by a patient) for every patient that benefits?

I’m not embarrassed by what I write in a patient’s chart, but patients might be if they read it. Imagine a man asks a family member to review his medical records to see if they think he has been getting good care, given his recent heart attack. He probably forgot that a few years ago he spoke with me about sexual problems he was having.

The system I suggest would be a juried one. Patients could request their records, and in most cases the physicians would grant access to most or all of the record. If there was parts they did not want to show, they could explain why to the patient. If the patient did not accept the answer, they could appeal to a third party health advocate who would then decide whether it should be released or not. This would only apply to patients who are not bringing legal action. I think this approach would make physicians a little more comfortable, and lead to better patient care.

Obamacare and the Supreme Court

This week the Supreme Court agreed to hear a legal challenge to the healthcare reform law, colloquially known as ‘Obamacare”. They have scheduled 5 1/2 hours for oral arguments, dividing the law into four parts, that they will hold over two days. According to a number of articles, this is pretty much unprecedented in modern history. Since 1970 the typical case is allotted one hour for oral arguments, with 30 minutes for each side.

I’m not a lawyer, but I was astounded by these numbers. I realize that the Supreme Court justices spend a lot of time reading written briefs, and probably have internal discussions, but only spending an hour listening to arguments for an issue that has hit the highest court of the nation does not sound like much time to me. If I have a complicated patient in my office, it’s not so unusual that I end up spending an hour on them, and unless they are going on Hospice, they always get a follow-up visit. The Supreme Court gets about 10,000 petitions a year, and only rules on a small fraction of them. Before it gets to that level, many lawyers and judges have already debated the issues, and if the answer was obvious, it would probably have been settled. It seems stingy to me to only giving one hour for oral arguments for cases at that level.

Even 5 1/2 hours doesn’t sound like much. The 12 members of the debt reduction super committee couldn’t come to an agreement on debt reduction after working on the issue for more than 3 months. That’s far more time than the Supreme Court will spend working on the health care law, and I’m not sure that it’s that much less complex than dealing with debt reduction. Of course the justices have the great advantage of not having to worry about getting re-elected.

Medicaid Documentation Nightmare

Washington State Medicaid has new requirements for ordering imaging tests. I ordered a dobutamine Cardiolite stress test for one of my patients. The coder in my office brought me the Cardiac Imaging Questionnaire – CarePlanner/iEX form. It had 41 questions which she gave to me because she can’t tell from the chart how to fill it out! As it turned out I didn’t have to answer all the questions, but it still took a while to figure out what questions I needed to answer and look up the information in the chart.

Physicians usually lose money when seeing patients on Medicaid since the reimbursement is less than the cost. Add in ridiculous paperwork burdens, and they may find that primary care doctors start referring their patients to specialists rather than do the test themselves. Then the Washington State Department of Social and Health Services (DSHS) can pay for the cardiology consult instead, to be followed by the test I wanted to do in the first place, or a more costly cardiac catheterization. If I think a patient needs a test, it’s pretty rare when the specialist does not agree that the patient needs that, or a more expensive test, done. Making it more cumbersome for primary care physicians will likely ultimately raise costs, not decrease them.

Let the Sunshine In, Let the Sunshine In

A GlaxoSmithKline representative came by to drop off samples in my office and asked if there was anything else they could do for us. GSK makes some inhalers so I asked if they could supply spacers to give to patients, something they used to do. Spacers come in different designs, but basically it’s a plastic tube that fits between an inhaler, such as albuterol, and the mouth. The extra distance causes the medication particles to get smaller, so they deposit deeper in the lungs. The spacers are relatively inexpensive, probably less than the cost of the inhaler for a week, and can last years, but because insurance companies usually don’t cover them, patient’s usually don’t get them. Handing one out in the physician office is a good way to get patients to use one, plus the proper use can be demonstrated in the office.

The representative said that his company was not giving the spacers, and in light of the Physician Payment Sunshine Act, doubted they would. This proposed regulation of the Centers for Medicare and Medicaid Services (CMS), part of Section 6002 of the Affordable Care Act, stipulates that, effective 3/1/12, that pharmaceutical companies report payments to physicians over $10. It makes no difference whether the spacers are for the physician, or their patients.

The purpose of the Physician Payment Sunshine Act is to discourage physicians from making prescription decisions based on financial inducements. Just to be clear, pharmaceutical companies don’t just give physicians cash to prescribe their medications, which would clearly be immoral, if not illegal, but can give other incentives in the form of meals, books, speaking fees, etc. In this case, however, the reporting requirements are not consistent and don’t make sense. They don’t have to report leaving samples of their inhaler, which costs far more than a spacer, but they would have to report the spacer, even though it could be used with inhalers made by other manufacturers. Although in balance I like having samples, they tend to encourage one to prescribe them since we don’t have generic samples. I think insurance companies would save money providing free generic samples, but that’s another story.

The bill was introduced by senators Charles Grassley, R-Iowa, and Herb Kohl, D-Wisconsin. As recently reported by 60 Minutes, congressmen can legally trade on insider information, so this law was hypocritical (in fact I see that only 25% of the Sunshine Act sponsors senators are sponsoring the Stop Trading on Congressional Knowledge Act  S.1871 or S.1903 bills) . But as physicians we are ‘Hippocratical‘ and hold ourselves to a higher standard. That said, I think there are many instances where it’s legitimate for physicians to accept items of value from pharmaceutical companies.

The science of medicine advances at a fast rate, and it’s difficult, if not impossible, to keep up to date. This is true for specialists, and even more so for primary care physicians. The majority of medications I prescribe every day were not available when I was a resident in training. One way I help stay up to date is to listen to pharmaceutical representatives, or physicians they bring in, while I eat a meal they provide. There is no quid pro quo agreement to prescribe their medications, and many a rep can attest that I frequently challenge what they say. But what they do get is some of my time and a chance to present information that ultimately may benefit my patients. True, there are other ways to get the information, but time is the problem. I have to eat, so that’s a good time to talk. Listening to top physicians they’ve flown in, and having the opportunity to ask questions, is very valuable. I also participate in research trials (needed to create new medications), and those fees will show up in the database. The act would not make such payments illegal, but the concern is that the public will not be able to put the numbers in context and it may incorrectly imply impropriety.

Physicians and other providers do need to be careful they are not unduly biased by pharmaceutical companies, and I have a lot of concerns about pricing manipulations of medical drugs, but when it comes to the Physician Payment Sunshine Act, I think it’s pointing a light at the wrong place, or at least with too broad a beam.