New Year, New You!

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So, I have conversations about diet, exercise and weight loss every day in my practice. But it seems that sometime around Jan 1, those conversations are more often started by my patients.  We are moving from the indulgent end of the year holiday season, to the fresh start of a new year.  So it seems natural to try to start fresh- live healthier, better, richer…

Well, maybe not richer. But there are a lot of people getting richer of our desires to look and feel healthier. So there are a lot of theories about how we got her, and promises to do this one thing, cut out this, take this pill, and turn your life around. Face it, a quick fix seems pretty damn appealing to all of us.  And I am in the pill pushing business. A big part of my job is to prescribe medicines.  So with all of these conversations about losing weight, medicine is a frequent question.

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So today, I’m going to build on a recent morning report lecture on obesity to focus on medical treatments for obesity.  We’ll talk about old, new, tried and true and up and coming.  I’ll try to highlight the evidence base for these so that you can discuss in an informed way with your patients.

I also want to start with a disclosure.. I almost never prescribe medicine for weight loss. My bias (and I’ll argue, the evidence) is that these are generally not that helpful, and almost always patients gain back weight, plus more, once they stop taking them.  The studies that got these medicines approved were always coupled with a solid diet and exercise plan, and I think that most of the weight loss comes from that activity, NOT from the medicine.

peptobismol3Orlistat

Orlistat inhibits pancreatic lipases, so less fat is absorbed in digestion. In studies, patients on orlistat lost 5-10kg (compared to 3-6kg with diet/exercise alone). It also has been shown to lower blood pressure, and LDL levels more than would be expected by the weight loss alone.  It is safe, as most of it remains un-absorbed. However, the main side effects are GI related: bloating, nausea, and diarrhea. These are generally pretty limiting, and I haven’t found many patients willing to even try orlistat after hearing these effects. However, if patients can stick to a low-fat diet, the effects can be minimized.

 

Phentermine

Phentermine is a stimulant that suppresses appetite. It is the oldest of the approved medicines for weight loss, and also one of the cheapest. It is approved for 12 weeks of therapy, so most studies are of short duration only.  Studies show around 7kg of weight loss. Side effects include hypertension, tachycardia, anxiety, insomnia- in my experience these are pretty limiting.

There is a new medicine that combines phentermine with topiramate, Qsymia. The phentermine dose is lower than if prescribed separately, and it is approved for longer term use.  The initial trial for this Rx showed patients lost 8-10 kg in the first year, and could maintain weight loss if they continued for another year. Only about 60% of patients took the Rx for the whole first year.

Topiramate

So what about just Topiramate itself? Currently topiramate is approved for treatment of epilepsy and migraine. Using it for weight loss is off label- so beware. However, it has been studied, and patients lost about 4kg over 6 months in the various trials.

Lorcaserin

Lorcaserin (Belviq) is a serotonin receptor agonist, and thus serves as an appetite suppressant. A few other serotonin agonists have been tried over the years- fenfluramine- and lead to cardiac valve disease. Lorcaserin is more specific to the 2C receptor, which should minimize cardiovascular effect. In trials, more patients on lorcaserin lost at least 5% of their body weight (mean 5kg). There were also decreases in BP, HR, LDL, CRP, and glucose. All of the trials had dropout rates close to 50%.  Side effects include headache, nausea, URI sx, and back pain.

 

Diabetes Drugs: 

Liraglutide (Victoza, Saxenda- same Rx, two brand names) is the one drug in this group with an indication for weight loss. In patients without diabetes, trials showed around 7kg of weight loss, and in one trial, patients who lost weight pre medicine were more likely to maintain the weight loss if on liraglutide. Side effects include diabetesnausea/vomiting/diarrhea and rarely, pancreatitis.

Metformin Old drug, lots of data on weight loss, but still no indication for obesity treatment. Why? Patients don’t tend to lose a lot of weight with metformin- about 2kg.  But what different with metformin, is that there is long-term data that showed that patients could maintain that weight loss as long as they stayed on the Rx.  And it decreases incidence of diabetes in these people as well. Certainly something to consider in obese patients with pre-diabetes or otherwise at high risk.

Bupropion

Another off label use here, but post marking data did show a tendency toward weight loss in patients on bupropion. Remember, this drug increases norepinephrine effect, so likely has some sympathomimetic benefits. In one short (6 month) trial, patients on bupropion lost 7-10% of their body weight (compared to 5% lost on placebo).

There is a brand new combo drug that uses Naltrexone and Bupropion (Contrave). Patients got about 5% weight loss over a longer study (56 weeks), but only about half of the patients were able to complete the study. Nausea, headache, and constipation were common side effects. There is also a cardiovascular concern that is being actively monitored in the post-marketing period.

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Big Picture

Diet and exercise are the key- slow and steady wins the race. There may be some small incremental gains with the medicines above, but I think that the evidence is thin, there are clear side effects, and the risks are not always understood. Given the millions of Americans that could end up on these medicines, I’d prefer to hang back and wait for the fallout before becoming an early prescriber of any of these.

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Crowdsourced tips for clinic success- 2016

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More Clinic tips!

Welcome to those who moseyed over after lecture today. As promised, more and more tips on success in clinic. Enjoy and have fun in clinic this year!

Prep Before Clinic  Very common advice from your fellow residents.  Spending 30 minutes the day before is huge to keep your clinic session moving.   

Karla Williams: Review your clinic schedule including the patient’s history, last clinic note and the reason for their visit before the start of clinic.

Prep your clinic notes. This gives you the opportunity to make tentative plans of care for chronic and health maintenance issues in advance. It also helps me to create my goals for the visit and not miss key issues/interventions. You can always in error the note if the patient is a no show.

Lauren Shea: I start by going through the most recent note and any d/c summaries to construct a past medical history. I type this up by hand when I write my notes, so I can use if for next time (rather than the pre-populated list).

I review the reminders beforehand to make sure there is nothing I’m missing.

Last, I make three lists: “Labs”, “Discuss” (smoking, pain, etc). and “Orders” (immunizations, eye clinic, etc) for every visit beforehand. With all this, I tend to miss less!

Rachel Labovitz: Before going into the room I search the chart and know the things I must get answered in that visit (is it a wellness/ACRF and know what goes along with those, any screening tests that need to be ordered etc)

Jake Lancaster: I’d say that preparing beforehand is key. I usually spend 30 minutes to an hour before clinic clearing out my reminders and reviewing each patient as well as taking notes about what their main issues are and what screening items they need. I then can spend the time in clinic addressing their primary concerns as well as the main things I feel we need to cover. Most of the time they have new issues that tend to distract us from the main issues that I want to address. I usually try to refocus the conversation and bring them back soon to further address their other issues.

Katie Chitwood: pre-round on your clinic patients- I print off the plan from the last note and also make notes about labs/imaging/subspeciality clinic visits since they were last seen in clinic so that I can focus on these highlights and address specific points during the visit without staring at the computer and scrolling through results while talking to patients. It also helps to highlight health maintenance that may be due soon so that you aren’t scrambling at the end of the visit to discuss this.

 

Preventative Health  Automate as much of this as you can. Checklists/templates or the EMR generated Heath Maintenance tools are all recommended.

Ginnie Prater: I made my own template in CPRS in which I list indications for specific screening (ex: screen 40-70 year-olds who are overweight for diabetes). When previewing clinics I jot down what is missing so I can devote more time to listening to the patient and quickly make preventive care recommendations at the end of the visit.

Susan Karam: Spend some time making checklists for health maintenance, immunizations, DM etc. It is a little work up front but will save you time in the end

Andrew Land: It is a time investment upfront but the Health Maintenance section in the chart actually is really useful and is customizable

Chitwood: Have a health maintenance list that you can insert at the bottom of your note that you can refer to in order to see what is due for the patient. The impact populated HM list is less user friendly and some things can get lost in translation. (Ed. We can’t always agree…  My take, the IMPACT HM tab is helpful, but requires several visits and attention to get right. Residents don’t always have that luxury, it is harder to see the benefit)

Shea: For health maintenance, I use the “Worksheet” in CPRS to review HIV, HCV, Hgb A1c and lipids, and calculate their 10-year ASCVD risk in advance if appropriate. I use “Health Summary” under the “Reports” tab to review Immunizations and make sure all these are up to date. Then I just scan the “Onc-Watch” note for the last colonoscopy and recommended follow-up.

 

Negotiating the Agenda  You just can’t do it all, and patients generally understand this. Bring them back! 

 Land: For patients with too many concerns, the earlier in the visit you set up the understanding you aren’t going to be able to discuss everything the better they accept i

Louis Cummings: If chest pain is mentioned as problem #9, when your hand is on the doorknob to escape, it is probably not unstable angina

It is ok to tell pt ‘that is enough new problems for today, I’d suggest a followup appt for you other concerns, so we will have time to address everything thoroughly’

Karam: Bring people back frequently. You don’t have to address every condition at each visit. Better to focus on a few and be thorough than to try to do too much and not do any of it well. Explain this to patients at beginning of visit and let them give input on what issues are important to them to include in the visit.

Erin Contratto: The biggest tip I have for residents starting out in clinic is that not every problem has to be addressed at each visit.  Except emergent ones (new chest pain, sob, abd pain).

Rachel Labovitz: They might do a ROS and complain of 50 things, if that is the case I ask, what of these things are new? I’ll try to tackle some of the new things that are bothering them, but not all.

In residency I feel so often that you have to address every item at every visit because 1) you think they all might be connected and will give you some amazing diagnosis 2) you think every problem needs to be addressed at every visit BUT these people walked in here today and for the most part they are going to walk/wheelchair right back out and come back the next visit to further discuss these issues. I would say that I could reasonably tackle 5 problems/diagnoses a session if there are some uncontrolled issues. Sometimes less than that depending on the issue. Now that I have return visits for people that I know and have stabilized it is obviously more than 5, but starting out I think 5 might be a maximum to try to tackle

 

Efficiency  How the heck will I see 5 patients (or 10-20) in a session?  Read on…

Williams: I tend to type key details of the HPI while in the room, a tentative plan of care while awaiting checkout, and place all orders (Rx, labs, and consults) either while awaiting checkout or after.

Land: May be worthwhile to arrange for someone to cover your pager while in clinic, nothing disrupts the flow like having to go deal with an inpatient issue for 20 minutes while still seeing patients

Putting orders in while in the room with the patient will help save time and helps to avoid forgetting to order things later on

Oubre: Gaining home access is the biggest game changer (although that’s a huge issue at the VA right now). It allows you to look up your patients prior to clinic and have all the data at hand and a plan in mind. Additionally, it allows you to look up results, write letters, clear reminders etc at home or when you get a second of free time at the hospital.

Read the Clinic portion of the VA survival guide prior to clinic. THEN 3-4 months into clinic read it again.

Shea: Telederm and E-consults are wonderful resources at the VA.

One thing I have had to start doing is calling in person about every CT or MRI I need ordered. Otherwise, several months can go by and my patient is never scheduled for his or her test. This is easiest to do when the patient is with you in the office, but sometimes I have to do it after clinic due to time constraints

Labovitz: “Hi, how are you today (fine, fine), anything “new” going on since our last visit?” If that doesn’t get much response I ask “ Is there anything you are concerned about today?”

Then, for those who the answers might be yes I always ask “ Any chest pain, palpitations, dyspnea, cough, nausea, vomiting, diarrhea, fevers, chills, or sweats?” [It is funny because it basically all comes out of my mouth at once now that I have asked it so many times, but these are the things I do not want to miss on a patient and the things that can REALLY slow me down if it is an “oh by the way” comment at the end of a visit.

Jake Lancaster: I also used to write very elaborate subjective/HPI components of the note which I came to realize were not so helpful. Most of the time when I review patients or other providers notes I do not read this section at all. It allows me to spend less time documenting “fluff” and record a more accurate plan.

Most of all, I try to do everything the same day during the same clinic slot. That way I don’t have to come back on a different day to complete it. Doing so made it feel like my life was consumed by clinic and finishing the same day gives me a sense of completion.

Cummings: For work in patients it is important for the patient’s expectations to be  lowered consistently from initial contact: the Dr. is seeing you for this problem only, you have been worked into a busy schedule, so please stick to the complaint and do not try to get routine refills and other problems addressed ‘while you are here’. And it is OK for the Dr to remind the pt of the deal when he or she strays “ I’m happy to see you if you are sick, but you cannot expect me to do a lot of routine stuff while scheduled pts are waiting.”

Chitwood: Don’t be afraid to send impact messages to sub specialists regarding mutual patients. It is a lot easier to get a question directly answered and most are very happy to communicate with you. It is also a lot quicker and more convenient than waiting for the patient to see them or trying to reach them through the phone sometimes

 

On Follow up AFTER clinic   So you had a great session, things went smoothly and your patients and attending seem to like you.  Great work. But time marches on and all those orders will lead to results, suggestions, and new possibilities. How to keep up with all of that?  These guys have some ideas..

Prater: View alerts: I took some of the non-mandatory ones off. I organize them by last name and by priority and process the HIGH priority ones first, in between patients if possible. I take some time after my last clinic of the week to go back and process alerts, make phone calls and write results notification letters.

What I wish I knew as an intern:  1) How consults work at the VA…I would take some time to read the material available and understand it.

Prater: 2) The value of the RN care managers… They are there to help make sure things don’t fall through the cracks with your patients.

Williams: I usually finish my notes after clinic. Labs are usually back around this time and available for review. I have found it very important to review labs the same day or at least within 24hours. I have called patient’s the day of their office visit due unexpected labs and needed them either to report urgently for further evaluation or following instructions for an intervention before having repeat labs. I usually send a letter (via the IM IV nursing pool) to the patient explaining their testing results that same day that I view the labs.

Check your message box daily if possible or at least every other day. You will receive messages from partnering practitioners regarding care of your patients, nursing and patients.

If you have any questions concerning scheduling patients or referrals while you are out of clinic, send the message to the IM IV Nursing pool. They are excellent about responding.

Karam: The first time you see a patient confirm with them that you have a good contact number as the ones in the chart may not be correct. This is especially important if you have important results that need to be communicated.

Learn how to write letters to send to patients with results. They are much quicker than calling and patients appreciate getting their results.

If you put in a referral or order imaging for a patient outside of a clinic visit (either your personal patient or through the pool) send a message to the nursing pool and let them know so they can get things scheduled

Oubre: For follow up I now have a running email to myself which has names and things to follow up for my clinic patients so that they don’t get lost in the mix. I used to rely on the view alerts but those don’t always go come back to me.

Building a relationship  This is the good stuff, but sometimes the details can overwhelm it.  Here are some tips to keep your humanity about you, and to find the good stuff in clinic life.

Tyler Fuqua: One piece of advice that I received that was really helpful was this: “the more visceral reaction you have towards a patient, the sooner you need to bring them back.”  Often times you get new, very complex and challenging patients and the best way to become comfortable with them is to see them back frequently until you know their history, quirks, etc. Hope this helps. 

The pool  IM4 residents, check this section.

Karam: Use your nurses! They are great resources and can answer lots of questions and help facilitate follow-ups, imaging and paperwork. I wasted a lot of time especially as an intern trying to handle paperwork/referrals/etc. that they do every day and could get done very quickly

Keep an eye on the pool. If everyone does a few messages throughout the morning/afternoon when you have a few free minutes it prevents it from building up at the end of clinic

Chitwood: Try to tackle pool messages between patients if you have time. This is easier for interns at the beginning of the year. That way, everyone in clinic is not stuck with the whole pool at the end of the day.

Write notes only when pool messages have been completed. It helps to jot some information down either in the chart or your pre-round sheets, but be mindful that the pool is everyone’s responsibility. I usually have to do my notes at home or outside dedicated clinic time.

Learning outpatient medicine  Medical knowledge?  We’ve got it…

More great stuff from around the internets.

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Love your clinic

Thanks to everyone who came out and participated in noon conference today.  I love clinic and love talking about it- so thanks for indulging me. The full slide deck is on medhub for the locals. But here are the highlights of the discussion.  I would love to hear more from you in the comments.  Chime in!

Communication is the key

As I said, the relationship is the key.  The key to patient satisfaction, physician satisfaction, compliance, negotiating agendas, not getting sued, working in teams, and really just getting out of bed in the morning.  The effort that you put into learning about your patients, listening to their stories, and even hearing about their grandkids will be rewarded many times over.  Plus it’s really interesting. I have a patient who was a civil rights foot soldier. Another one ran away and joined the circus.  Another plays the fluglehorn.  Your patients have these stories too, you just have to find out.

A Fluglehorn, in case you were wondering

Negotiating agendas

You can’t cover it all at every visit, and you will go crazy if you try. Know what you want to cover before you go in, and know what you are willing to give up if your patient surprises you with something. And to minimize the last minute surprises, try to give your patient the chance to speak up right off the bat.  I recommend giving time to the patient to go through their list without a lot of comment or questioning on your part. Just get the list first, then you can negotiate the top few things to cover.

Not the best attitude when negotiating agendas.

Billing in the Clinic

Billing in medicine is all about the note. We are paid for thinking and for taking excellent care of patients, and the only way that anyone knows that we are doing either is to look at the note. There are three parts of the note: History, Physical, and Medical Decision Making (aka Impression and Plan). You always need to document the Medical Decision Making, but for a return patient, you can skip either history or physical. Yep, you just need 2/3 parts.

Challenging patients

As much as I love most people, I don’t get along with everyone. When a patient and I don’t see eye to eye on something, and can’t move past it, it is hard not to let emotions get in the way. If the relationship is going to continue, however, you have to figure out a way past it. Acknowledge (to yourself) the frustration, own it, and then take a deep breath and plunge in. I find that I pay extra attention to my decisions to be sure that I am being objective and fair to the patient. The guiding question is, “What is the right thing for this patient?”  Oftentimes, that is you- since you are such a great primary care MD. Other times, that might be to find someone different to help or to take over care. Just be sure you are making that decision with their, not your, best interests in mind.

A great message, even if it didn’t come from a chief resident.

The big picture here, is think of your clinic as another place to learn medicine, practice communication skills, and meet some interesting folks. You don’t want to miss it.

Clinic is just like this, with better lighting.