Temperance and the Addict

From reading the popular press nowadays one gets the impression that our culture is awash in addictive drugs. In an urban hospital emergency department such as the one where I work, there is abundant evidence that substance abuse is a significant social problem.


Spend some time in such an ED, and you will quickly learn that our society has decided this social problem is a medical problem.

Day after day (and even more, night after night), police and EMS bring us people who have used substantial quantities of mood-altering substances. Ethanol, fermented from myriad carbohydrates, remains the most popular. Various derivatives of the opium poppy are close behind. The extract of the coca leaf is favored in some circles. From time to time we see folks who prefer hallucinogens, psychedelics and dissociative agents.


It would appear that life, for some people, is too boring, depressing, or stressful to be lived without the effects of chemicals that alter the connection between the brain and the external world. This has been true for many centuries.




A decade ago I read an illuminating little book titled Forces of Habit: Drugs and the Making of the Modern World, a fascinating examination of the use of mood-altering substances. Attitudes toward such use, I learned, have been tremendously variable across cultures and time.

In our present society we accept, more or less, indulgence in alcohol, although we impose some restrictions on its use. Drunkenness while operating a motor vehicle will get you in trouble with law enforcement authorities, as will drinking to the point of becoming very badly behaved in public.



If this T-shirt slogan applies to you, it's time to cut back.

Nicotine is allowed but restricted, inasmuch as there are so many places where tobacco smoking is no longer permitted, although that is because the smoke itself (rather than its effect on behavior) is considered offensive.



Caffeine seems the least disapproved of the commonly used addictive substances, at least so far.

Thus the Ethiopian coffee farmers can subsist - or do better than that if they are lucky enough to deal with "fair trade" merchants rather than the price-controlling international cartel.




The opium farmers in Afghanistan and the growers and distributors of the coca leaf in Latin America meet with much less favor among Western authorities. Are their products more powerfully addictive or more dangerous than the others? This is an intriguing question.

From my professional observations, it seems cessation of use is every bit as challenging for those addicted to nicotine as for cocaine or heroin.

Doctors, and this is true for those in my specialty at least as much as any other, find substance abuse and dependence troubling and often tragic. Alcohol, tobacco, cocaine, and heroin ruin health and destroy lives, affecting not only users but their friends and families. One of the most vexing aspects of all this involves the derivatives of the opium poppy (known as "opioids"). Because these substances have a legitimate medicinal purpose, physicians are expected to play a large role in assuring that their use is safe and effective - and limited to the management of painful injuries and illnesses.

With so many people determined to obtain and use opioids for recreational purposes, this is quite a challenge. Medical science brought these substances to the modern Western world, and now we are heavily burdened with attempts to control their use.


A German chemist isolated morphine from the opium poppy in the early 19th century, and the German company Merck made it commercially available in 1827. In 1874 an English chemist modified the morphine molecule by adding two acetyl groups, yielding the substance that became known as heroin. Then a German chemist continued work in this area, resulting in its commercial introduction as a cough suppressant and pain reliever by Bayer in 1888. Twenty-five years later Bayer pulled it from the market because of problems with addiction.



That was 60 years before the Drug Enforcement Administration was established (1973). Now we have the DEA, as well as state medical boards and pharmacy boards, to make rules and decide what doctors can and cannot prescribe for patients, and under what circumstances.



It seems every time I pick up a medical journal or trade publication or peruse the popular press via my favorite news outlets, there is something new doctors are supposed to be doing (or not doing) to address this problem. A year ago the Centers for Disease Control and Prevention asked my specialty organization, the American College of Emergency Physicians, to develop guidelines on the prescribing of opioid analgesics in emergency departments, and earlier this month the ACEP Board of Directors approved such guidelines after lengthy and spirited discussion.



Sometimes I feel like Don Quixote tilting at windmills when we in the emergency department are trying to solve social problems. After more than a quarter century dealing with this one, I can tell you emergency physicians are, by and large, very conservative in their prescribing of opioids and diligent in their efforts to ferret out those who are seeking prescriptions for recreational use or diversion (selling the pills for profit). Nothing we do will solve the problem of pill mills, described in all their astonishing brazenness in an article in Bloomberg's Business Week earlier this month.


At the root of all this, I believe, is an inexplicable, desperate human need for an altered reality, resulting in striking immoderation in the use of substances that seem, just a bit and for just a bit of time, to provide that alteration. In my more philosophically reflective moments I wonder why it is my job to try to separate those who want relief from physical pain from those who seek relief from psychological pain in a way that does not meet with societal approval.




But I like my work, even if I don't care for that part of it, and I will soldier on.

Keep the Customer Satisfied

Every so often I find this song playing in the back of my mind as I go about my work in the emergency department. Written by Paul Simon, it was recorded by Simon & Garfunkel and appears on the 1970 album Bridge Over Troubled Water. I was in junior high school when that album was released, so it didn't resonate with me the way it does now. In fact, it would be quite a few years before that phrase took on the meaning it now has for so many of us.

When I was in medical school and residency training there was, as far as I knew, no such thing as this notion of customer satisfaction in the practice of medicine. We were taught to be skilled and thorough in gathering data - medical history and physical examination - and to select the right diagnostic tests as we sought to discern the cause of a patient's symptoms. The goal was to arrive at the correct diagnosis and prescribe treatment that was safe and effective. Ideally, it should also be cost-effective. If, in addition, a doctor happened to have a good "bedside manner," that was icing on the cake.

Doctors didn't think too much about whether their patients found them likable. We all have different personality styles. A patient who doesn't care for one physician's personality style will choose a different doctor - and promptly be replaced by someone who does like the first doctor. It all evens out. Some patients really don't care whether a physician even has much in the way of bedside manner, as long as he or she is diligent, thorough, and competent. Frankly, that's the way I look at it when I'm a patient: if my doctor has the requisite knowledge and skill to figure out what's wrong with me and what to do about it, I don't care if he has the personality of a cigar store Indian.


Times have changed. Everyone is keenly focused on whether patients are satisfied as customers in the business of health care, and everyone wants to measure their satisfaction with the "patient experience." In many health care enterprises, doctors are financially rewarded for getting high scores on patient satisfaction surveys. And there's nothing like money to influence behavior.



This isn't really a new phenomenon, though. In 1990 I wrote an article for the trade publication Medical Economics entitled "Some Days I Feel Like I Work at K-Mart: How Consumerism Has Affected the Doctor-Patient Relationship." Recently I re-read it and was a little surprised that I had already begun to perceive these same challenges more than two decades ago.

Take a look at the photo to the left. Doctor and patient, right? The doctor is smiling and engaged in the interaction. It looks promising for patient satisfaction. Actually, this photo comes from the website of a financial services firm, the doctor is the customer, and the business wants to provide the capital she needs to run her practice. But this notion of customer satisfaction is now pervasive in medical practice, and if you want your doctor to be focused on the medicine and not worrying about getting her patients to think she is kind and caring, forget it. That's the old paradigm. (Forgive me for using that word, but send me a scolding e-mail if I ever - and I do mean ever - use the phrase "paradigm shift." That would be unforgivable.)

There can't be anything wrong with doctors being nice and patients liking them, can there? Of course not. So you can stop reading right now. Except for one thing. I think you've heard of it. It's called the Law of Unintended Consequences. Because of this law, good intentions sometimes fail to produce good results.


When you start trying to measure customer satisfaction and give doctors a financial incentive for getting high marks from their patients, you'd better pay attention to what you're measuring and what the doctors think they have to do to improve their scores.


I believe the biggest problem facing us in this realm is that in many other spheres of their lives doctors are customers, and so they have a sense of customer satisfaction from that side of the transaction. What does it take to create a satisfied customer? It's quite simple. Figure out what the customer wants and give it to him.

So the patient has cold symptoms or a sore throat. The doctor thinks the patient must want an antibiotic. Why else would he be consulting a physician? To be told it's a cold and advised to go to the drugstore and buy an off-the-shelf medicine to treat the symptoms? The patient could have just watched TV commercials or asked the druggist at his local pharmacy if he wanted that. No, he must want something by prescription. So he gets an antibiotic for his head cold, sore throat, or chest cold, some illness caused by a virus. Antibiotics don't work against viruses, only bacteria. So there is no potential for benefit - only harm. But the illness gets better on its own, because that's how these things go, and the patient, who did not go on to have eternal bronchitis, figures the antibiotic must have helped. So what will he do every time he gets a viral respiratory infection henceforth and forever? Right. And all those unnecessary antibiotic prescriptions will help promote the development of resistant bacteria.


The doctor who wants to practice good medicine and still get high patient satisfaction scores can just take some extra time and explain to the patient why antibiotics are not indicated, how they are more likely to harm than help, and how they contribute to the problem of resistant bacteria. And then he can hope that his scores will be just as high as those of his colleague in the next office who just writes the antibiotic prescriptions, taking a fraction of the time and mental effort. Good luck with that.

And then there is the challenge of diagnostic testing. Patients like tests. They believe in tests. They have no idea that a smart doctor can often figure out what's wrong with them by eliciting a detailed account of their symptoms and performing a focused physical examination, without ordering any tests at all. Most of the time, test results serve primarily to confirm the diagnosis that was already established in the physician's mind.

For a recent study, investigators queried patients visiting an emergency department with abdominal pain about their confidence in the doctor's diagnosis and their overall satisfaction with the "patient experience." Confidence and satisfaction were low (shockingly low, I thought) when the doctor took a history and examined the patient but ordered no tests, which surely reflects the physician's belief that the diagnosis was simple and straightforward. Both confidence and satisfaction rose steadily as the number of tests increased, with the highest levels reached when the evaluation included a CAT scan.



What this study demonstrated, however, was something emergency physicians already knew intuitively. Abdominal pain is the single most common reason for visits to the emergency department. Many CAT scans are performed. How many of them are really necessary? How many are performed in the pursuit of diagnostic certainty? (And how useful is it to raise diagnostic certainty from 93% to 97%?) How many are ordered because the doctor is afraid of being sued if she misses something? How many are ordered because it will improve customer satisfaction? How would we know? What we do know, however, is that CAT scans are expensive and expose patients to radiation and sometimes to intravenous contrast agents that occasionally cause harmful reactions.

I don't know about you, but I want my doctor to order a CAT scan only if it is really necessary, and certainly not because he thinks I will have more confidence in his diagnosis and a higher level of satisfaction with the "patient experience" if he orders more tests.

Doctors now live and work in a world in which health care managers worship at the altar of customer satisfaction. There are serious problems with how patients' satisfaction is measured and how the results are interpreted. We are just beginning to understand these problems.

And yet, at a time when we should still be very concerned about our ability to define and measure patient satisfaction, to figure out what to do with the results when we do measure it, and to prevent unintended consequences, the federal government is already implementing a system that will financially punish hospitals that don't get high scores.

None of us should be surprised that public policy is being formulated and implemented without good science to support it. But we should be worried.

Don't Drink That!

Michael Bloomberg, the mayor of New York City, is proposing a ban on the sale of "sugary soft drinks" in containers larger than 16 ounces in restaurants, movie theaters, stadiums, and arenas. This is just the latest move in his campaign to get people to make more healthful dietary choices.

Given that people can simply go back for seconds, it would seem that the effect of this restriction might be educational, in that it would force New Yorkers to think about the fact that they are consuming large amounts of sugar in their beverages. The city's health department already runs ads in the subways telling consumers this is not good for them.

It's possible there are many people who don't already know this, but I'm skeptical. One need not conduct a laborious search to find information about this sort of thing. Drinking Coca-Cola®? An eight-ounce serving has about 100 calories from sugar, the same amount you'd get by adding four well-rounded teaspoons of sugar to a cup of coffee. The effect of this is not a mystery, either. Just one such 8-ounce beverage per day will add ten pounds of fat to your body in a year. Put another way, the substitution of a non-caloric beverage, such as water or a diet soft drink, would translate into a ten-pound weight loss in a year. If you're the sort of person who goes through a two-liter bottle of regular soda pop each day, getting rid of those calories would help you drop 80 pounds in a year, assuming you didn't just replace the calories by eating chocolate chip cookies. We all have to make choices, of course, so if I'm keeping my calories constant, I'll definitely take the diet cola and eat the chocolate chip cookies, thank you very much.

The problem is not a lack of information. Everything is online nowadays, and a few keystrokes on a computer, tablet, or smartphone will summon the caloric content of just about anything. If you don't know, it's because you don't want to know. And if you don't want to know, Mayor Bloomberg is not going to change that by keeping you from buying more than 16 ounces in a single container at a time. He could send you off to a reeducation camp in the countryside, like they did in China during the Cultural Revolution, but I think the libertarians and others opposed to the "nanny state" approach to public health would find this more objectionable than the soft drink limit.

Mayor Bloomberg is correct when he opines that obesity is a major public health problem in the United States. When people register as patients in the emergency department where I work, a nurse enters height and weight in the computer system, and body mass index (BMI) is automatically calculated. This is one of many bits of information I can see at a glance for every patient. So many patients are overweight that I am pleasantly surprised when I see a BMI less than 25.

Public education is a good thing. I readily concede that it may help if people are frequently reminded of things they already know. And educating our children about healthful dietary choices is certainly a sensible approach. So Michelle Obama's focus on childhood obesity may make a difference in the lives of some Americans. Perhaps as a result of her interest in this problem, some of us will grow up choosing our food and beverages more wisely and getting more, and more regular, exercise. The Bush Administration's efforts to improve public education, labeled "No Child Left Behind," have no shortage of critics, but I'm hoping Mrs. Obama's programmatic vision, which I have whimsically dubbed "No Child with a Fat Behind" will be better received and more effective.

Government's efforts to protect us from ourselves have produced mixed results, mostly because we stubbornly resist. We have seatbelt laws, and yet people drive without wearing their seatbelts, with predictable and tragic results when they are involved in crashes. We have motorcycle helmet laws, and riders generally comply where such laws are in effect - mainly because police can see so easily when riders are violating the law. But everywhere that there are helmet laws, freedom-loving bikers incessantly lobby for their repeal. It is difficult for me to believe that the families of unhelmeted motorcyclists who die or suffer severe, permanent disability from head injuries are thankful for the legislative efforts of the libertarian bikers. Yet those efforts continue unabated (pun intended).

This time of year I begin seeing many young people who somehow find it appealing to ride all-terrain vehicles in the dark, in the woods, drunk, with no helmets or protective clothing. The results of such behavior are predictable, even if you are not too bright and have never set foot into the trauma bay of a hospital emergency department.

So what, exactly, does Mayor Bloomberg think will be the effect of figuratively shaking the nanny state's finger at such stubborn folk when they want to buy a soft drink in a Big Gulp size? Bloomberg likes limits. He thinks if laws limit citizens to purchasing one handgun per month, we will have less violent crime committed with guns.

Maybe that's true. And maybe if you can't buy a 20-ounce soft drink at Yankee Stadium, that will help you get thinner.

But Americans don't like limits. And New Yorkers don't like Bloomberg's policies, at least judging by a 44% approval rating in one recent poll. We do like information. (Consider Wikipedia's estimated 3 billion page views per month in the U.S., if you have any doubts about that.) It's just that we like to decide for ourselves what to do with that information.