Dear Providers,

“Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die,” is the dramatic start to a New Yorker article by Dr. Atul Gawande. The article describes the challenges clinicians face having honest discussions about prognosis, and the probability of treatment success.  “There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.”  Click here to read more.
 
San Francisco Health Plan aims to support providers to have these brave discussions, and to help patients realize that the issue rarely is as simple as “do we or don’t we resuscitate.”  Many providers shy from these discussions due to lack of time, but studies show that end of life discussions add an average of 8 minutes onto a visit.  These tips emerged from a recent End-of-Life Summit held in San Mateo.

Key points about end-of-life talks (courtesy of Health Plan of San Mateo)

They are not about giving up or death. It is best to avoid using this phrase and wording. They are talks about what gives meaning to a person’s life, what they love about life and what they want to have happen when they can’t enjoy those things anymore.
Studies show that an end-of-life discussion adds about eight minutes to a typical office visit. Having this discussion does add time, but it does not significantly extend a usual physician visit.
Expect to have this talk over two or three visits or more. The patient will need time to think about choices, discuss them with family members, etc.
Aim to have a talk like this with one patient every day. Having this talk with only one patient is not so demanding and relatively manageable on most days.
Use the POLST document as a guide.  The POLST form helps you frame the discussion. Many local clinical groups are working to disseminate this important document through San Francisco County:

• POLST allows patients to clearly state what level of intervention they would choose for various types of resuscitation (breathing, feeding, IV, etc)
• State law requires that first responders, ER physicians, nursing homes and hospitals respect a patient’s POLST document
• POLST is expected to go with patients when they change healthcare settings

The POLST form, in addition to other advance directives in many languages, are available for viewing on our website.
 
Oxycontin is a growing problem in the US in terms of abuse, addiction, diversion, overdose, and cost (since it no longer has a generic, it is seven times the cost of long-acting morphine).  Please see ”Pitfalls of Oxycontin” for why SFHP encourages providers to use alternatives when needed for chronic pain.
 
PPI prescription can cause rebound dyspepsia in healthy populations.  SFHP has seen a steady increase in PPI prescriptions across the network. We are concerned, as it can seem easy to treat stress-induced dyspepsia with empiric PPIs, but the practice could create dependence. Two recent studies showed withdrawal symptoms when asymptomatic volunteers were prescribed PPIs (JW Gen Med Aug 1 2—9, p 118, and Gastroenterology 2009; 137;80).  44% vs 9% (placebo) suffered dyspeptic symptoms for two weeks following treatment. SFHP urges providers to limit PPI treatment to patients at high risk for PUD, those who test positive for H Pylori, and those who have tried and failed H2 blockers.
 
Vision benefits reinstated for Medi-Cal .  We saw a drop in our diabetic eye exam rate this year, despite advertising to members that diabetics could continue to get eye exams, even though Medi-Cal cut optional benefits in July 2009. Fortunately, vision benefits were restored by State Medi-Cal, so now all adult Medi-Cal members have access to optometry exams (unfortunately, Medi-Cal will still not cover adult spectacles). Opthalmology exams were never restricted.  Please let your patients know – especially diabetics – that they will continue to have access to routine screening and treatment.

Chlamydia screening – we have seen a decline in screening rates in San Francisco among our members, despite the US Preventive Services Task Force giving Chlamydia screening the highest possible recommendation (Grade A) for women under 26 years old. Cultural issues are frequently a barrier, as teens in some of our populations are seen as low risk, and cultural barriers make it harder for providers to have an open discussion about sexually transmitted disease.  However, the stakes are high, as undetected Chlamydia can lead to pelvic inflammatory disease and infertility. The Sexually Transmitted Diseases section of SF DPH has been concerned about declining screening rates in SF over the last few years. SFHP urges providers to train your staff to collect “dirty catch” urine on all women under 26 – it offers the opportunity of a noninvasive screen, and if institutionalized as part of office flow, it makes it easier to universally screen.
 
Statewide effort to vaccinate all adults with Tdap.  We are all aware of the recent pertussis outbreak and the infant deaths due to loss of herd immunity.  The California Department of Public Health has recommended that all adults get booster shots. Please see our Featured Provider article to learn how one of our providers is immunizing our community.
 
Time to gear up for flu season. Fortunately this year the flu vaccine will also cover H1N1, and the CDC is recommending universal vaccination for all people over 6 months.  
 
Yours in Health,

Kelly Pfeifer, MD