Ronald J Crossno MD

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Posts by Ronald J Crossno MD

President Crossno’s Letter to American Medical News

Letter to American Medical News

January 6, 2012

Re: Handful of States Promise Physicians Online Access to Advance Directives, posted January 3, 2012 on amednews.com http://bit.ly/vFKMvx

When very sick patients are unable to express their wishes toward the end of life, nothing is more heartbreaking for doctors and loved ones than not knowing what those wishes are. It’s up to grieving and frightened family members to try to recall a past conversation, or remember whether there’s an advance directive, and if so, how to put their hands on it. Online registry programs for advance directives that give doctors access to this information would help ensure that we meet our patients’ wishes and that we don’t leave family members always questioning the decisions they were forced to make.

Patients need to hear from their doctors the importance of advance directives. They need to know that an advance directive can be changed, and that it can direct doctors to stop aggressive life-saving treatments, or continue them. Most important, an advance directive needs to be readily accessible when you need it. The American Academy of Hospice and Palliative Medicine has information on advance directives at www.aahpm.org and www.PalliativeDoctors.org

Ronald J. Crossno, MD CMD FAAFP FAAHPM

President, American Academy of Hospice and Palliative Medicine

Patients or Healthcare Consumers? A tipping point in Hospice & Palliative Medicine

by AAHPM President Ronald J. Crossno, MD

Do we take care of patients or do we partner with educated consumers who are knowledgeable about healthcare economics? The answer is clearly some of both, depending on the individual in front of us, but a new report from the Deloitte Center for Health Solutions suggests the prospect of the engaged consumer is increasing. Two findings of this study may also indicate that US consumer attitudes may be changing in a way that may allow for systematic healthcare cost savings.

Deloitte surveyed almost 16,000 healthcare consumers in 12 countries, all with variously developed healthcare systems that often garner similar consumer responses despite their differences. One of those differences is how much of the country’s GDP is spent on healthcare, ranging from a low of 4.7% in China, to an average of 10-11% for most, to a high of 17.6% for the US. Per-capita spending in the US stands out at over $8,000, with no other country surpassing $5,000. However, in many other areas, there was considerable uniformity in answers. Most consumers believe themselves to be in “excellent” or “very good” health, despite roughly half of consumers saying they have been diagnosed with one or more chronic conditions. Data indicates that consumers are increasingly attuned to and knowledgeable about healthcare, in general.

Nevertheless, consumers in all countries rated their understanding of their country’s healthcare system as low and satisfaction with their current system also generally ranked low. Many indicated wasted spending as a major issue, with the most common cause of waste being identified as “redundant paperwork in the system.”

However, it is at this point that the US has another standout point. A common cause of waste identified by 35% of US consumers was: “At the end of life, extreme measures taken to extend life for a short period of time instead of making the person comfortable with things such as pain relief and palliative care.”

So the US spends considerably more than any other nation on healthcare, but consumers identify extreme measures at end-of-life as wasteful. Note that these are consumers – not policy-makers or healthcare professionals. Are these two items really related? Perhaps, though this study isn’t designed to answer that question.

To me, these findings suggest that there is a large group of Americans who innately understand the type of message that Hospice & Palliative Medicine provides – that individualized goal-setting to meet the specific wishes of individuals and their families at the time of life-threatening and serious illness provides the treatments wanted while resulting in overall cost savings. Either we’ve been successful in getting our message out or consumers figured this out on their own.

Both represent success, since all major movements require significant grassroots support in order to garner widespread institutional and/or governmental support for funding and full implementation. It appears that we may be crossing the tipping point for such support. Despite the economy (or perhaps because of it), HPM’s message is being heard. Let’s keep getting it out there!

“What the heck is CMSS and why should I care?”

You may be asking yourself, “What the heck is CMSS and why should I care?” While I knew that this stands for Council of Medical Specialty Societies, I attended their recent annual meeting with less than a full appreciation of what this is and why it matters to us doing Hospice and Palliative Medicine. Afterwards, I have a much better understanding. Sitting through various presentations that included slides predicting not just political ‘fireworks’ in the coming year, but political ‘nuclear explosions.’

So what is CMSS? It is a place where the specialty societies that have ABMS primary Boards and an increasing number of subspecialty societies, like AAHPM, can come together and interface with each other, and with a number of other associated entities, like the Federation of State Medical Boards, the Association of American Medical Colleges, the National Board of Medical Examiners, the Accreditation Council for Continuing Medical Education, and others. The entities just named all provided speakers who educated the attendees on what is happening within their bailiwicks, as it relates to what we, the practicing physicians do.

Besides the aforementioned mention of how the November elections have obliterated many predictions of what to expect legislatively over the coming year, in depth discussion of the following was provided. CMSS, itself, has sponsored and promulgated the CMSS Code for Interactions with Companies, (what is known as ‘the Code’), providing guidance for how member societies can craft their members’ and leaders’ relations with industry, especially in light on the likelihood of passage of the “Sunshine Act,” which will require reporting of industry payments to physicians. AAHPM has already signed onto the Code, which is available online at http://cmss.org/codeforinteractions.aspx.

Physician workforce shortages were addressed by various entities, including AAMC, with discussions centering around deficiencies in how we select physicians, with current selection tools only accurately predicting how well students will do in the first half of medical school, rather than how well the future selectee will meet expected demands as practicing physicians. FSMB and ACCME discussed Maintenance of Licensure and Maintenance of Certification, and what to expect in the coming decade. ACGME duties hour limitations for residents were also discussed.

As the newest member of this august organization, AAHPM’s representatives were welcomed with open arms by the other member representatives, giving further indication that HPM is increasingly recognized as a crucial component of the entire continuum of medical practice. It was my privilege to represent the Academy, following up on the groundwork laid by Gail Cooney, our immediate past president. Other Academy representation included Steve Smith, our CEO, Laura Davis, director of marketing and membership, and Julie Bruno, director of education and training.

Another indication that HPM is becoming more mainstream?

In the category of ‘what goes around comes around,’ a recent event reminded me of the ironies life can bring; but this is a cautionary tale for all. At this time last year, I was immersed in a trial. While there is a general impression that hospice and palliative medicine are relatively immune from issues of tort liability and malpractice, this is proving to be increasingly untrue. In some parts of the country, trial lawyers are exploring new theories of litigation with causes of action against hospice and palliative medicine providers, an untapped and fertile ground for potential malpractice awards. While this clearly isn’t “good news,” ironically it may be another milestone in HPM’s ongoing efforts to integrate into ‘mainstream medicine.’

The case involved a middle-aged man who presented with non-small cell lung cancer. At initial diagnosis, disease seemed to be limited. He underwent surgical resection to remove the mass; however, biopsies showed tumor present in the contralateral lung, as was confirmed by subsequent bronchoscopy. After completing radiation therapy, he had two more bronchoscopies, each confirming ongoing malignancy in both lungs. He was referred to hospice when he declined chemotherapy.

His course was complicated by pain, at least in part related to post-thoracotomy syndrome. This required high dose opioids for pain management, after failure of interventional techniques and other adjuvant therapies. While on hospice over the next couple of years, he underwent further diagnostic and prognostic evaluation, including imaging studies showing ongoing progression of disease.

Then something changed. Coincidentally at the time he moved out of our service area, reevaluation by his new treatment team indicated radiographic regression. His performance status began to improve. Believing his prognosis was extending, he was discharged from hospice and his new internist assumed duties as his primary care physician (PCP), including management of his ongoing pain.

Almost two years after his hospice discharge, a suit was filed. Five years after that, the suit finally went to trial. Discovery proceedings showed that his new PCP told this patient that there was an error, and that his cancer must have been misdiagnosed because if he really had cancer in the first place, he would have died. His PCP weaned the patient off opioids (despite ongoing pain) and told him that by giving him high dose opioids when he didn’t have cancer, the hospice and yours truly as the hospice doctor, (though I was eventually dropped as a named party in the suit) had turned him into an addict, which was malpractice.

This theory that we made him an addict then formed the basis for a suit, supported by one board-certified “expert” (a very part-time, hospice and palliative medicine physician from four states away), as well as a stack of articles indicating that opioids cause harm. These studies involved street heroin users, polydrug abusers, or patients with sleep apnea; not individuals being treated under careful medical supervision for severe pain. The defense included several HPM specialists and a renowned pain specialist, all of whom agreed that care was not only appropriate, but exemplary. In the end, this jury of our peers were evidently swayed by plaintiff attorneys theatrics like: referring to the commercial showing an egg frying in the pan with the statement, “here’s your brain; here’s your brain on drugs,”; or pouring out a 50-lb bag of beans over the floor in front of the jury to indicate (without having to prove up the numbers) how many pills the patient supposedly took during his hospice stay. Defense testimony that this represented a rare case of spontaneous remission was met with derision, the implication being that claiming “a miracle” as our defense is really no defense at all. The judge, clearly trying to champion the underdog, made several rulings favoring the plaintiff, which all later agreed would have been adequate basis for a successful appeal and eventual retrial.

When the jury, in its deliberations, began sending out questions indicating that an award was being contemplated, the suit was settled. Defense attorneys wanted to limit a potential high-dollar award, while plaintiff attorneys wanted to avoid the risk of an appeal sending the case back for re-trial. Post-trial juror debriefing revealed that no one really believed anyone had done anything wrong; but, “no one can have cancer like that just go away,” and “the poor man just deserved some sort of compensation for all he had been through.”

Regarding this being a cautionary tale: all medical practitioners should be aware that at trials, our legal system is much more about theatrics than scientific facts. To plaintiff lawyers, this is a business in which they will push all limits in order to win. To defense attorneys, this is about limiting financial risk. To judges, this is often about protecting the poor and unfortunate, even at the expense of those who did nothing wrong other than not being so unfortunate. Sadly, I used to believe what we’ve all been taught: that this is supposed to be about fairness and justice. During this almost three-week trial, I heard much more talk about winning the lottery than about achieving justice.

Ironically, what served as the trigger for blogging about this (if you can believe it), is that last week we received a referral to our hospice for a now slightly older man with terrible pain due to wide-spread, metastatic non-small cell lung cancer. His statement was that he’d had a “bad experience” with hospice once, but now he believed he needed that kind of care once again. Upon legal advice, it was decided to refer him on to a different agency; one that he had not previously sued. I have to admit feeling sad over that decision, since I still believe we treated him correctly the first time, and could again provide him appropriate relief of suffering, during these, his last days. But then again, life isn’t always fair.