Big Data, chronic disease and the future of medicine.

Every day, I make important decisions with my patients.
They are calculated decisions from integrating a lot of information.
Some of that information is subjective, but in modern medicine, a lot of it is objective. The history, the physical exam, blood work, radiology; I integrate all the data to make good sensible decisions. This task becomes more challenging when patients have multiple chronic diseases. Each disease generates countless points of data that need to be considered. Putting all of this together in a 20 minute office visit is very difficult. One way I try to overcome this problem is by scheduling multiple visits and try to peck away at select problems on each visit.

“Team-based” care is also a popular buzz word in medicine. In team based care, multiple people from different disciplines get involved to create comprehensive care plans for each patient. Each team member  collects  more data that is pooled for the team members to make better calculated decisions.
It’s a lot of data collection, but is it enough?
For the chronic disease patient, it isn’t.
Chronic disease persists 24 hours a day, 7 day a week. From genes, to cells to psyche, the damage never stops in the chronic disease state. It’s impossible to catch and fix every bit of damage being done to the mind and body
But instead, we see patients at an arbitrary interval (e.g. 1 or 3 months) and try to identify some basic root causes and address the damage after the fact. It is an exercise in futility. 
But technology will help bridge this gap between the perpetual chronic disease state and physician intervention through the generation of medical “Big Data.” 
An example of this is self-monitoring or self-tracking. We cannot monitor patients 24/7, so patients will utilize technology to watch themselves. Self-monitoring is in its infancy. Blood sugar, blood pressure, heart rate are just the beginning. Technology will evolve to create monitoring mechanisms that cheaply and efficiently collect a tremendous wealth of information from the patient’s home. The data will be better than static information (e.g. a series of blood sugars readings) but dynamic; static data that is automatically trended, analyzed, cross referenced against other monitored variables. In the end, the physician will not receive a series of blood sugar readings. Instead it will be a comprehensive report that tells us what’s happening in the patient from gene to psyche and everything in between. Initially it will be a tremendous volume of information, hence the term “Big Data.” But it will evolve to eventually become concise patient centered “Smart Data.”  
The whole idea of a wired chronic disease patient and 24/7 monitoring may seem like science fiction right now. But I have faith in the world’s innovators out there; to share my vision and one day give me the tools to provide the kind of care and intervention my chronic disease patients deserve.

Changing the way we present our chronic disease patients.

Old habits are hard to change.

We teach our medical students to recite the following preamble, when presenting a patient.

Mrs. Jones is an  __  year old female with a “Past Medical History” of x,y and z.

This was drilled into my head in medical school and residency.

If I didn’t preface my patient presentation with this statement and information, venerable attending physicians would give me scornful looks and senior residents would take me aside after rounds to correct my mistakes.

I realize why this information is important. Knowledge about the patient’s medical conditions can help frame the visit and symptoms. It guides our thought process.

But the actual term “Past Medical History” serves no meaningful function and we need to stop teaching our medical students and residents to present their patients with this vestigial term.

We practice in the era of chronic disease where conditions like obesity, diabetes, kidney disease, coronary disease, copd (just to name a few) are the greatest public health threat. It’s time we change the language of medicine to properly reflect the gravity of the situation.

Advocacy for this immense public health problem requires that we talk about it as much as possible. It requires that it remain in our consciousness at all times.

When our medical students and residents present Mrs. Jones, they should stop using the term “Past medical history,” Her story needs to begin as a “Chronic disease patient.” Such a description sets the tone for her entire care team that is is a complex patient, that will require broad patient centered clinical acumen. It let’s everyone know that this patient IS modern medicine and the ability to manage her is a challenging and gratifying process that defines what it is to be a physician.

Do you have guns in your home?

I did my internal medicine residency training in Philadelphia from 2005-2008. The city of brotherly love is no stranger to gun violence. It’s one of the reasons I was taught to always ask patients if there are guns in the home. If they did have guns, I was instructed to provide some counseling and literature on gun safety. But after 3 years, hundreds of patients of all sexes, ages and races, in a city notorious for crime, not once did a patient tell me they owned a gun. Nevertheless, the issue of gun safety seemed like an important patient education endeavor that I left Philadelphia with.
After residency, I decided to travel by doing some Locum Tenens (contract) work.  Having grown up in New York City, then training in Philadelphia, my view of the world and medicine felt skewed. I decided to practice medicine a little off the beaten path.
One of my many stops was rural Maine, near the Canadian border. Far from the lights of Rittenhouse Square, a small yet busy town of 15,000 lovely warm people showed me medicine was the same no matter where you are.  I was dealing with the same spectrum of chronic illnesses . I stayed true to my training and discussed wellness in all its forms. Obesity, diet, exercise, mental health, smoking cessation, addiction, prevention, I did it all. I also asked about guns. It’s this question that showed me, I wasn’t in “Kansas” (or in my case Philadelphia!) anymore.
Many of  the patients had guns in their homes. I remember the first patient who admitted to owning a gun. I was rapidly going through a series of screening questions with little expectation of hearing “yes.” When he said yes to owning guns, I stuttered, and asked again. My heart rate accelerated since I honestly didn’t know what else to ask or how to counsel him appropriately. I only asked whether it was stored safely. He proudly mentioned a make and model and reassured me no one else could get their hands on it. I also sensed consternation and an immediate change in his demeanor when he asked me how that was relevant in an annual physical.

The momentum of what was an otherwise pleasant, efficient and successful visit came to a grinding halt.

I had more questions for myself than I did for him.

Does he own a  hand gun, hunting rifle or semi automatic weapon? Does it matter?

He seems nice enough, but how much do I really trust him with a weapon?

Was this my liberal bias creeping into my medical care in a conservative population?

Do I really know enough about this person from a 30 minute medical visit to predict if this gun in his home will ever be used for the wrong reasons?

Is it really stored safely?

Do I really trust the randomness of the cosmos enough to ensure me that this gun won’t end up in the wrong hands ever?

Ultimately, these questions didn’t matter. It was his legal right to own this weapon. And so I mentally moved on  just as I imagine, Nancy Lanza’s physician may have had to if he or she were to ask the same question.

Top Ten Reasons Work is awesome today

So today, I come back to work after 2 weeks of paternity leave.

10: Great to work with an incredible group of Internal Medicine residents. Bright minds and even brighter future

9: Get to work with some really fun and energetic office and nursing staff who are not afraid to say whats on their minds

8: Seeing many different patients means seeing different perspectives on the health care system. This means more insight on coming up with innovative ways to improve the patient experience

7: Get to talk about my NY Giants with my buddy from the cleaning staff (Myron). He’s a cowboys fan 🙂

6: I get to talk to patients. I love to talk. Talking is fun. Conversation is basic human necessity and I thrive on it!

5: I get to continue to learn medicine. Even after years of training, I enjoy learning new things.

4: Work drives me to participate in social media. Tweeting, blogging, Healthtap. It’s all so much fun.

3: Our healthcare system is a disaster and Primary Care (my field of expertise) is under fire. I love a good fight!  The opportunity to create change in medicine is a privilege!

2: Truth is stranger than fiction. I love a good story. My day is filled with stories from patients who never cease to amaze me.

1: No better feeling than after a long hard days work, to open my front door and see my two beautiful kids and loving wife. I love coming home to my family.

Celebrating 30 Days

30 day hospital re-admission rates.

It’s a statistic that keeps hospital administrators up at night. Whether you agree or disagree with the use of this statistic as a quality and reimbursement metric, if it creates change, reduces hospital re-admissions and improves patient care, then in theory I support it.

I’m reminded of Mrs G. She is emblematic of today’s chronic disease patient. She was admitted to our hospital for a congestive heart failure exacerbation, complicated by a COPD (related to her smoking) exacerbation. Throw in some poorly controlled diabetes, atrial fibrillation, depression and generalized deconditioning, this lovely 64 year old lady spent 9 days in our hospital receiving absolutely excellent care. She improved to the point where our terrific inpatient team was able to discharge her directly to home on Tuesday March 27th. From there she was in the hands of her 2 caring daughters and her outpatient doctors at my clinic. And that’s when the clock started ticking.

Tuesday April 3rd: Hospital follow-up. We were able to see her 7 days post-discharge. She was doing well, taking all her medications and her family seemed content with the current situation. Despite how well she was doing, we felt this was the type of patient who could easily decline. We scheduled another appointment in 1 week for further monitoring.

Friday April 6th: Some blood work results came back to our office. Her kidney function had steeply declined. We suspected the high doses of diuretics (water pills) she was taking were the reason. We contacted her over the phone, advised to reduce the doses of her medication and keep her next appointment. She expressed some frustration from constant thirst and generalized fatigue.

Wednesday April 11th: She seemed worse compared to the first visit. She was still thirsty and her legs appeared more swollen. She was also more short of breath. Her atrial fibrillation (irregular heart rhythm) was not controlled.   We adjusted one of her 11 medications to try and counter this. One a side note, she insisted she wasn’t smoking anymore. We ordered more follow up blood work.

Monday April 16th: Her kidney function improved. We called her to discuss these results. She said she felt fine but then her daughter grabbed the phone and from a separate room, explained to us how she hasn’t been following any of our dietary recommendations, and continued to smoke daily while on oxygen! Her family asked us to see her again to bring up these issues at the next appointment.

Friday April 20th: She vehemently denied smoking and drinking excessive fluids, despite having worsening leg swelling and smelling of cigarettes. We increased her water pills back to her prior dose, realizing she had re-accumulated fluid. It was only a matter of time before the fluids got into her lung and she became short of breath again. She was headed in the wrong direction. 

For her next appointment, she came to our office looking absolutely terrible. She couldn’t breathe well, lie flat and her legs were even more swollen. She had been to a barbecue over the weekend and ate salt ridden food without much thought. She had declined to the point where it was no longer safe to try to mange her in the clinic. It was time to head back to the hospital. She shook her head out of frustration as her daughter welled up with tears in the corner of the exam room. Mrs. G asked me if I thought she’d miss Mothers day.

I looked at the calendar and I said probably not. If things went according to plan, I anticipated a short hospital stay. A midst her breathlessness, I sensed some relief in her.

Once I realized what day it was, I too breathed a sigh of relief. It was Monday April 30th.

She was discharged on March 27th. And so I counted 7…14…23…33 days had elapsed. She had eclipsed the 30 day readmission window. My first inclination was to pat myself on the back and hang up a mental banner with the words “Mission Accomplished.” But as I saw Mrs. G getting wheeled away on a stretcher and her distraught daughter trailing behind. I felt very little desire to celebrate having reached this important 30 day benchmark.

Medical Linguistics Failure

    I have a problem with any medical conversation that utilizes the term “Failure” in it.

Acute Renal Failure
Hepatic Failure
Congestive Heart Failure
Failure to thrive ( A personal favorite)
Respiratory Failure
Premature Ovarian Failure
(Name your body part) …Failure.

As an internist where most of my patients have chronic conditions, I deal with many of these “failures” daily. I usually have a pretty good grip on handling the medical aspect of such conditions. It’s the psychological component of such a diagnosis and the counseling necessary, that’s harder.

In my efforts to be an empathetic physician, I’ve likened the experience to as follows.

Let’s say I really like my car, but I don’t know much about how it works. The car starts breaking down for a variety of reasons (partly my fault, which I feel terrible about). Its slower, less fuel efficient, makes all kinds of weird noises, leaks random fluids and generally just doesn’t look as good as it used to. So I take it to my trusted mechanic who after extensive work up tells me I have Name your vital auto part Failure. He offers me this prognosis. Instead of maybe 20 years, the car will last only about another 10 years if I’m lucky. And in those 10 years, I can expect frequent mechanic trips, and I may not have access to that car for weeks at a time. I can expect to try a lot of fixes, some of them quite expensive with questionable efficacy. It’s also our only car, and my family relies on this car for anything and everything.

This would be really upsetting, especially when I connect the dots and come to the conclusion that my car is basically dying.

Patients know what vital organs are, and the term “Failure” implies its demise. Every week, I see patients, anxious and upset about these diagnosis mentioned in passing during hospitalization, by specialists or anyone else with an opinion. So in addition to managing the actual conditions, I have to do psychological damage control by trying to put a positive spin on the situation.

Thank goodness, we are now referring to acute renal failure as acute kidney injury. Besides being a more medically accurate term, it’s so much easier to explain to patients. They are less likely to ask about dialysis now and more likely to ask what injured their kidneys and what they can do to prevent it. 

I move to abolish the term “Failure” from all medical terminology.
It’s medical hyperbole that is unnecessary and frankly makes my job a lot harder! 🙂


Shared decision making with patients

    There’s nothing better than sitting down with a patient, going though an entire visit, and  collaborating on a well thought out plan that meets everyone’s expectations. Shared decision making is a wonderful and necessary concept in modern patient care. Paternalistic attitudes are fading away in the medical community as the next generations of doctors continue to get educated on how to manage patients who are very knowledgeable and yearn to be active participants in their care.

    But as patients become more involved in the decision making process, differences in opinion become more prominent. Although these differences can be overcome through open discussion and trust, it is a challenge that is occurring with regularity. In this era of short pressured visits, it’s hard to have long conversations to help meet the patient in the middle when there is a difference in opinion. Litigation concerns also influences decision making immensely, and when there is a debate about whether “to test,” or “not to test,” we might be inclined to align our opinions more towards what a patient wants.
     When a patient adamantly wants something done, and I rationally disagree, it can be a disheartening experience. I reflect on how I’ve spent years studying, training and practicing. I think about how I’ve spent years, not just memorizing facts, but cultivating clinical acumen that integrates multiple data points to compute probabilities of disease states and figuring out likelihood ratios of different tests or medicines and whether the benefits greatly outweigh potential harms and costs. And I have to do this within seconds to minutes in my head, while factoring in patient preference and medico-legal concerns.  I do this juggling act countless times a day, and when I’m wrong it hurts. It hurts my ego a little bit. But it hurts more because you always want what’s best for the patient.
   I’m sure we all have stories of things we regretted ordering for our patients. I can think of several instances of how I acquiesced to a patient’s request that resulted in poor outcomes. Antibiotics that I didn’t want to give, leading to C-Diff colitis, imaging with incidental findings that lead to unnecessary worry, procedures and complications are just a few examples. I can also think of many instances where patients have come to me with positive test results or better outcomes from things I was reluctant to do.
    Whether you are for or against shared decision making, it is here to stay. Patients want to have to more say in their care and that’s a wonderful thing. Involved patients will always do better than detached ones. The modern physician will need a balanced temperament to handle the ups and downs of this two way relationship. Fortunately my ego is just big enough that I return to work every day smiling, feeling good about all my  decisions.  But I do keep my ego in check, mainly by taking some Tums tablets. I’ve realized my heartburn isn’t caused by the coffee I drink, but all the pride I’m willing to swallow and the large heaping servings of humble pie medicine serves me with regularity.