The One Thing Primary Care Needs
(Answer: “Reverse Engineered” Physician/Patient Centric Support)
Why won’t CME alone be enough to fix painkiller problems in the clinic? Because administrators and support staff didn’t take that CME.
If you have 10 doctors, and a problem with patients abusing painkillers in your clinic, CME won’t solve your problem alone…why? Because patients abusing painkillers abuse the system, including the doctors, and the doctors don’t design the system. There are several employees for every clinician, so lots of opportunity for chaos that CME doesn’t solve. (See my recent Medscape post on 3/25 if you are a medscape member. http://www.medscape.com/viewarticle/841346) Unless management is involved in reverse engineering resources for the providers, then the docs will continue to be put into the “hot-seat”.
When patients “split” office staff and clinicians for prescriptions – CME will never be enough to fix the hole in the dyke. Clinic administrators and managers need to design support for providers, otherwise left in the hot seat all day. The support staffs’ perceived “job” is to take messages, and transfer work back to those who have sufficient authority to act. This is like an army where every bullet gets routed to the General for further action. Now wonder the clinicians are burned out. Perhaps we can teach those on the front lines how they can function, on our behalf, in various circumstances. This takes a director or a manager, not an arbitrary CME.
However we got ourselves into this mess, we need to lead the way out of it.
Painkiller abuse and dependence exploded on the turf of primary care. State laws and draconian opinions won’t make it go away. It blows up in our faces in the form of a high risk patient, where the tools to say no seem to have been misplaced in our minds. Or the inefficiency of “someone else’s patient”, that all of a sudden becomes our care decision. Or the EMT’s call and tell you your patient is dead. Whether you manage a lot of patients or a few, you deserve to have support built around you so you are well positioned to do the right thing.
Regulations are not exactly the floor for what is beneficial for the patient… they are more like the basement.
In other words, if the standard is “everything goes, until it is illegal” then we have some sloppy management going on in the grey zone. Patients often will invoke this. “I can’t afford the gas to get all the way here and the DEA allows you to give me 90-days supply”. I don’t care as much about what the DEA thinks, or the licensing board, because all of my standards exceed theirs. So I remind patients as they try to bully me into submission, that my professional standards are higher than simply avoiding unlawful acts, and my professional opinion about how long in between appointments or how large a supply to give them is not entirely dictated by third parties. By the way, this is where internal office polices can come in handy.
It is important to create unbiased training in primary care.
I like writing and speaking, and so I have produced radio shows, podcasts. I have been featured several times on satellite radio. I even had my own live program on CBS. These days I do blogging, and I produce CME and informational webinars. I have also done a lot of live speaking in front of audiences, and writing custom commissioned reports. Which do I like the best? I like when I get to create by own material without interference from third parties. This is why I don’t do any training that isn’t paid for by the end user. Primary care doctors are so highly influenced by pharma, they can hardly see it. We might see when our patients are, but our concern for their “satisfaction” influences us as well. My communications and training is often focused on helping clinicians see through all that, and do the right thing. In order to effectively do that, I can’t be a hired gun from a drug company, or designing a CME based on funds from a national association funded by pharma. It has to be original, and free from bias. This kind of learning is not easy to find.
Too much of what we are exposed to, even via American College of XYZ is industry influenced.
In 2012, somewhat reluctantly, I was on the panel to deliver “REMS” education related to long acting opiods. This was a program mandated by the FDA, and paid for by pharma, to provide some additional training for MD’s who prescribe long acting opioids. One of the attendees (ACP state leader) stood up and said “this sounds like a promotional drug talk”, even though it wasn’t. I couldn’t disagree with her, and I really appreciated she was brave enough to speak up about the elephant in the room. The slides were all FDA approved, but that process was also the result of years of back and forth and lawyers and executives from pharma companies. In the end the whitewashing felt more like we were hypnotizing the audience, like a patient who tunes out the package insert because it is so jargon rich it is barely meaningful.
It’s refreshing to have physician and patient-centric objectives- void of third party influences.
Remember when Barak Obama said he wasn’t going to take “special interest money” and that made him special? Of course he did a 180 degree turn, and anyone who felt he had “extra integrity” had to reset those expectations. It’s easier for me to say I won’t go to work for pharma, etc; because I don’t need to, and it would wreck the my claim that I am less biased (than if I were working for them). I’m not perfect, but I have more time to consider what doctors and patients REALLY NEED the less I dilute myself towards someone else’s agenda.
Patient agreements don’t help without a reasonable plan for what happens if it is violated.
The phone staff getting a report a med is lost or destroyed, often simply relay these messages.
This is like sending all bullets to the General for further action.
This keeps the army safe but the general is dead before the day starts. If instead you design some clinic wide standards for what happens in various circumstances, then you can develop support for the provider. For example, suppose a lost Rx automatically means the phone staff tells the MA, and the MA generates a prescription monitoring report BEFORE alerting the doc. If this is an MA task, the doc is not left in the hot-seat to access the report. It begs the question, how many of your MA’s, who earn 1/20th of the salary of your clinicians, have access to that system, to support the MDs? If it is less that 20%, it’s likely not because the docs want it that way, it’s because leadership has failed to make it so.
If your staff spend five minutes executing a patient agreement for 100 patients, that’s greater than 8 hours in one year .
If your clinic leadership produced a video to provide meaningful and universal execution of the agreement, you would save time. Moreover, it works great as a staff training tool, now the front desk understands what the agreement says, and the patient can no longer “negotiate” what “they were told”. You need to get your providers on the same page (enough, for some reasonably basic requirements), but isn’t that what a medical director is for? For the clinicians who subvert the process, you have to ask yourself: Why you are bothering with them? There is a primary care shortage. Somebody else needs them.
One minute spent executing a patient agreement, how many spent deliberating a variant of “what they were told”?
How many times have you heard that, and how many times does it undermine your authority in the face of aberrant behavior. How many times do you wish you had gotten your MBA, or opened a pizza place. With a video companion to your patient agreement, you can have your medical assistant showing them their initials from the date they viewed the video, while you eat your pizza.
Do you insist on patients following dosing instructions, for medications with an achievable threshold for toxicity?
This is important. Patients are often given enough meds to hurt themselves, and the “sig” is presumed safe, but if they make up their own dose, do we want patients navigating enough and too much, beyond what you have already indicated as the dosing limit? Prescription opioids result in 16,000 unintended deaths per year.
Clinic leaders need to be able to access expert guidance in order to design the right support for providers
Have you ever had an experience that you could easily have missed, but you didn’t and in transformed everything? In primary care, when we build new support systems we produce high impact. Building a system of support around clinicians to reduce chaos and drama created by patients related to prescribed narcotics. The support systems you build keep paying dividends the more organized you get.
No matter how you go about it, process improvement efforts should always produce high value and high ROI.
For training resources visit www.aleadersguide.com/primarycare.