By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Constantly talking isn’t necessarily communicating.”

-Charlie Kaufman, playwright/screenwriter

A Spanish-speaking patient calls her primary care health center, and talks with a triage nurse who speaks Spanish. She says her 5 year old son was seen in an emergency room in Southern California and told that her son has Monkeypox. She was given an appointment, the patient was roomed and the medical assistant recorded the chief complaint of Monkeypox.

It turns out, that the patient had infectious mononucleosis (this was what was diagnosed at the emergency room). How did this get misinterpreted?

The answer: Medical Spanglish!

The medical translation of Monkeypox is viruela del simio, but a more colloquial translation is viruela del mono. Viruela is the Spanish translation for Smallpox, so viruela del simio means Smallpox of the simians, and viruela del mono means “Smallpox of the monkeys.”

In contrast, the medical translation of infectious mononucleosis (or acute Epstein-Barr virus infection) is mononucleosis infecciosa or infeccion por el virus de Epstein-Barr. If the emergency physician had used one of these terms, there would not have been the confusion that ensued.

However, the emergency room physician spoke a little Spanish, and so mixed that Spanish with an English language shortened term for infectious mononucleosis: mono.

“Su hijo tiene el virus de mono”  which means to the parent: “Your child has the monkey virus,” which is pretty close to Monkeypox.

Early monkeypox presents with fever, fatigue, headache, and muscle aches, which is also the prodrome for COVID, infectious mononucleosis, influenza, and a hundred other illnesses so the lack of the characteristic rash is not sufficient to make a definitive diagnosis in the early stages.

Decades ago, Chevrolet had great difficulty selling a particular car model in Mexico and South America: the Nova. Nova in English is reminiscent of the French word for new, “nova” as in Nova Scotia. However in Spanish, “No va” means “no go” as in “the car that will not function.”

Providers with a little Spanish language capacity often have such miscommunications when they attempt to talk to their patients without a translator. They mix in English words, speaking Medical Spanglish.

Just as clinicians need to be precise and careful in their diagnostic process, this diagnostic information must be communicated to the patient in a way that they can fully understand, or the diagnostic process has failed. Communicating clearly with non-English speakers is a critical part of our professional responsibility as health care professionals.

For information on PHC provided video and telephonic interpreter services, see our website.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The search for a scapegoat is the easiest of all hunting expeditions.”
-Dwight D. Eisenhower

Part V in Series on Diagnostic Accuracy

Case Example: A 45 year old woman sends a secure electronic message to her primary care clinician, asking what she should do for her “heartburn.” Her PCP works a 3 day per week schedule at a chronically understaffed rural health center, and finally gets to the patient’s message at the end of a long day. The PCP does not ask any additional questions, but suggest the patient try OTC famotidine for a few days and call back if the “heartburn” is no better. Two days later, the PCP receives an electronically communicated consultation note from the local hospital, that the patient was admitted to the ICU in cardiogenic shock from a massive myocardial infarction. Glancing through the electronic health record, the clinician notes that the patient’s mother and father both died in their 40s of heart attacks.

This case of diagnostic error is certainly partly due to the PCP not performing an adequate assessment of the patient: not reviewing the electronic health record for background information, not asking additional questions to find out what the patient meant by “heartburn” or asking about red flag symptoms.

However, several system issues also contributed to the diagnostic errors: the overworked clinician, more prone to shortcuts to get through their day; the PCP’s reduced in-office schedule; the promotion of electronic communication to increase access to clinician; the lack of the PCP’s experience with rarer but more serious causes of “heartburn” because an emergency room/hospitalists sees all patients in the hospital.

The Institute of Medicine’s 2015 book “Improving Diagnosis in Health Care,” categorizes such system issues that contribute to diagnostic inaccuracy into five groups:

1. Organizational factors, such as schedules, staffing models, payer mix, and leadership.
2. Physical environment, including clinical ambiance, proximity to co-workers.
3. Tasks, which may compete for the attention of the clinician, like electronic medication refills, or which may not occur when they need to, like following up abnormal lab results.
4. Technologies and tools, such as the configuration of the electronic health record, and the use of electronic modalities for virtual care.
5. Diagnostic team members, including who is included on the team (adding a triage nurse for example), how communication occurs with the team, and the sense of responsibility team members feel to collaborate (in the case above, none of the physicians caring for the patient in the hospital called the PCP about the admission).

These same five factors contribute to clinician burnout and to health care inequities, so we as clinician leaders have a triple responsibility to spend our discretionary time working to steadily optimize this work system, the external environment that our clinicians work within. This is true for all clinician leaders, whether we work in primary care, specialty care, institutional settings like hospitals or skilled nursing facilities, at a health plan, or a government regulator.

At the same time, individual clinicians must continually strive to improve their own diagnostic processes, being aware of their own cognitive biases and short cuts, and reinforcing a sense of professional responsibility to achieve diagnostic excellence even with the shortcomings of the system we work in.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Listen with your eyes as well as your ears.”
-Graham Speechley

In the days before virtual visits and patients wearing masks, I would enter the exam room by greeting the patient, smiling and looking at them. So much information is communicated in this way. With our demeanor, we can convey caring, respect, and dignity. The patient, in turn, communicates mood, level of confidence, social/language/economic status, and (importantly) understanding.

My visits with patients are now either virtual (video or phone) or in-person with both provider and patient wearing a mask to prevent potential COVID transmission. This is affecting my ability to assess the patient’s mood and understanding, and makes it harder to quickly gain the trust of new patients.

Neuro-psychology experiments show that many human interactions (including social learning, empathy, and transfer of emotions) depend on the Mirror Neuron System of the brain. This system works best when a person experiences more complex sensory input. For example, a 2-dimensional view of a face on a video screen is less effective at influencing the Mirror Neuron System than an in-person interaction, where body posture, body motion, and context add meaning. The greater activation of the Mirror Neuron System when we are in the presence of others helps explain the excitement we now feel with interacting in-person with friends and colleagues, compared to previous video interactions.

The Mirror Neuron System also rapidly and unconsciously allows us to interpret the emotional state of others based on facial expressions. The eyes and the mouth are most expressive, so covering the mouth with a mask to prevent disease transmission decreases the information available to our Mirror Neuron System.

In many health care settings, routine mask wearing is still required. How can we make up for the loss of ability to see the facial expressions of the mouth? Interviews of women in countries where face coverings are common for religious reasons suggest three compensatory mechanisms that we can learn.

Eyes: First, learn to communicate emotion more effectively with our eyes. This takes a bit of practice. It requires us to spend a little more effort making eye contact and intentionality in connecting eye expression with emotional status.

Non-facial body language: Gait, character of a handshake, posture, and use of hand expressions can convey much emotional context. Clothing and grooming contain additional clues. These are difficult to see over video visits, but can be very helpful for in-person visits where the patient is masked.

Voice: Verbal expressiveness can convey information lost when visual cues are not present. This can be more subtle, depending on language concordance, personalities and habits of the clinician and their patient. I have seen a few clinicians who have remarkable natural capacity to strongly connect with patients, even on phone visits. Most of us can learn to master our greeting of patients on phone or video visits to build a sense of trust and empathy. As the clinician starts thinking about the differential diagnosis, options for testing, how many patients are waiting, and any personal stressors, our verbal expressiveness may lose some of its empathic quality.

For an excellent and very readable review of the many ways we communicate non-verbally, see The Power of Body Language, by Tonya Reiman.

For leaders and managers engaging with co-workers and community partners, these same compensatory mechanisms can be used for virtual interactions, but at a price. The level of engagement from virtual conferences and meetings is often significantly compromised, resulting in less interactive dialogue, less productive debate, and less synergistic learning. In particular, partners and policymakers are not cooperating and solving problems as effectively. To overcome this, we must strive to leverage in-person interactions. If infection safety is a concern, we can meet outdoors (particularly good for meetings with a meal) or in a well ventilated indoor setting with sufficient distance to minimize risk of airborne infection but close enough to see each other’s expressions and body language. Judicious use of rapid COVID antigen tests also has a role.

This is our new normal. We owe it to our patients, our organizations and ourselves to put our Mirror Neuron Systems back to work.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The pessimist complains about the wind. The optimist expects it to change. The leader adjusts the sail.”

-John Maxwell

The COVID pandemic was a storm that caused not only loss of life and disability, but tremendous lasting stress to the health care delivery and public health systems. Since March, the storm is settling down, and we seem to be beginning a prolonged recovery phase. Staffing shortages, financial stresses, and anxiety about COVID, the economy and world events are major headwinds to this recovery. These headwinds are diverting leadership energy away from collaboration, innovation, and quality improvement activities.

It is possible to move forward against headwinds. Sailboats do this by trimming their sails, and carefully navigating their boat to a heading as close as possible to directly into the wind, and then changing tack periodically so that the net movement can be directly into the wind. The skipper (leader) needs to pay close attention to the wind, communicating quickly with a crew that knows they need to work together to achieve their goal.

Mastering the headwinds

As clinical leaders, I hope you are in a phase in this pandemic recovery in which you can trim the sails, and refocus your teams on moving forward with performance improvement and collaboration activities. Our teams at Partnership HealthPlan of California (PHC) are here to support you in this effort.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

People almost invariably arrive at their beliefs not on the basis of proof but on the basis of what they find attractive.”

-Blaise Pascal

Clinicians strive to base our diagnostic and treatment practices on appropriate interpretation of scientific studies. The Evidence Based Medicine (EBM) movement has grown in the past 50 years to help create frameworks for evaluation and application of such studies. The worthy goals of EBM are to avoid unnecessary interventions that can potentially harm patients, and improving the health care that we do provide.

The term “evidence based” is sometimes misused.

I recall a resident physician from UCSF, commenting on a particular intervention: “there is no good evidence that this intervention works.” In this case, however, there was no strong evidence for any other intervention, including the one used at UCSF. The resident earlier had pointed to previous studies that showed both a lack of statistical improvement with an intervention, and a “trend towards benefit.”

On the other hand, a study can be done that shows that an intervention has no benefit. These two situations are not equivalent. “Lack of evidence of benefit” is not the same as “evidence that an intervention does not work.”

In the first case, a clinician can very defensibly try out the intervention if there is not established superior treatment. In the second case, when studies definitively show no benefit, a clinician would arguably be practicing substandard medicine to use the particular intervention.

Evidence based medicine was also misused several times in the Covid-19 pandemic. Transmission of earlier Coronaviruses causing SARS-1 and MERS was found to be impeded by use of masks. Early in the Covid-19 pandemic, before studies could have been conducted proving that use of masks also reduced transmission, the Center for Disease Control and Prevention (CDC) stated that mask wearing by the public was not recommended, because of the absence of evidence that masks helped. It incorrectly implied that absence of evidence of benefit meant that there was no benefit, even though the prior probability based on related viruses suggested that a benefit was likely. When the evidence became available and the message flipped to recommend masks and later highly effective masks to prevent transmission, this fundamental change in recommendation contributed to lack of trust in the CDC.

In behavioral health and social science research, the “evidence-based practice” is a standard requirement for programs to be funded. For example, an academic study of a new behavioral counseling technique might show that it reduces depression symptoms by 5%, from an average PHQ9 score of 20 to 19. Technically, this is evidence based—a published study showing a benefit of this intervention. Many government grants would allow this intervention to be implemented more widely.

Implementing this “evidence-based” intervention would be a mistake, for two reasons:

First, the setting that this academic study was done almost certainly differs from any real-world setting. “Implementation science” studies such questions. In general, four different replications of a behavioral intervention in different settings all with a similar benefit are needed to have a 95% or greater confidence than another implementation of this intervention will also have the same benefit.

Second, although the 5% reduction may be statistically significant, is it not clinically meaningful. Sadly, one often has to read scientific studies carefully to see if a difference is clinically meaningful.

The term “evidence based” has also been used to disparage a person’s educational level. For example, a community health worker (CHW) with at 10^th grade education may be intuitively skilled at connecting with clients and getting them to change behavior yet lose a job to a more educated and articulate applicant if the hiring manager, instead of recognizing that the CHW has not been trained on “evidence-based approaches,” says that the CHW does not use such approaches. This statement is arguably a reflection of implicit bias against someone with less formal education.

All of these examples of misuse of “evidence based” are a reflection of cognitive biases of one form or another. In the first case, the resident preferred one approach over another and incorrectly used the term “evidence based” to disparage one approach and prop up another. This is sometimes called the “confirmation bias” or the “my side” bias, a very common and very human bias to which scientists are not immune. In the second case, many Asian countries commented on the bias against public mask wearing in the United States, which likely played a role in the early recommendation to NOT wear masks to limit the spread of Covid-19. In the third case, the confirmation bias is also at play, because the researcher really wants something important to come out of their research, as this more often leads to publication of studies, invitations to give talks, and academic reputation.

When someone smart uses “evidence based” to promote or disparage a particular practice or treatment, our internal bias-detection should move into high gear. Switch to system 2 thinking (slow thinking), and critically review the underlying evidence for statistical significance, clinical meaningfulness, and replicability.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation.”

-Dr. Rudolf Virchow

Paul Farmer, MD PhD, an infectious disease specialist and anthropologist who started a foundation to provide care to impoverished populations in Haiti and around the world, died suddenly of an apparent heart attack this past week, at age 62.

Dr. Farmer studied Haitian culture as a medical anthropologist before becoming a physician and a specialist in infectious diseases. Through his direct patient care activities and by developing a public health infrastructure in a remote area of central Haiti, he cultivated a deep understanding of the links between disease, poverty, and political power. He wrote several books on this topic, using patients’ experiences to drive home his arguments.

Biographer John Tracy Kidder in “Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man who Would Cure the World,” relates this story:

A TB patient from a village hadn’t shown up for his monthly doctor’s appointment. So—this was one of the rules—someone had to go and find him. The annals of international health contain many stories of adequately financed projects that failed because “noncompliant” patients didn’t take all their medications. Farmer said, “The only non-compliant people are physicians. If the patient doesn’t get better (because they don’t take medications as prescribed), it’s your own fault. Fix it.”

Of the many moving and interesting parts of Farmer’s life detailed in the book, this one sticks with me, because it is so at odds with how many of us think about “non-compliant” patients. Attributing failure of an intervention to non-compliance is a way for health care professionals to assign responsibility or blame to our patients for them not getting better, because they don’t follow our scientific advice. The alternative term “non-adherence” was initially used with an intent to look for underlying factors that could be impacted, but it has come to be used in place of “non-compliant” just to sound less judgmental, but with the same implicit intent and outcome. The clinician moves on to their next task, their next patient.

Dr. Farmer believed that an understanding of a patient’s culture is essential to build trust between the physician and the patient allowing a skilled physician to devise a way to form an alliance with the patient that will lead them, long after they feel better, to complete an antibiotic treatment for tuberculosis, to cure them of the infection. This is difficult work in many ways. It requires time spent listening to the patient, as well as mental creativity, and tenacity.

This belief is what drove Dr. Farmer, a handful of Haitian doctors, a larger group of community health workers, and the community health center/hospital he ran in Haiti, to uncompromisingly provide quality health care to an impoverished population about the size of Shasta County. No one in the region served by his health center had died of measles or tuberculosis in many years (unlike other areas of Haiti, where deaths from these diseases were sadly common).

Dr. Farmer said his role model, since his undergraduate years, was Dr. Rudolf Virchow, a 19^th century German physician of many skills and interests. Dr. Virchow was known as both the father of modern pathology (with an understanding of the central role of cells in tissues and diseases), and also the father of the field of social medicine. Like Farmer, Virchow was an anthropologist and a scientist as well as a prolific writer on both scientific and socio-political topics.

The work that you do in your health centers and offices follows the same spirit of service to the most vulnerable members of our community. Let Farmer and Virchow inspire us to not accept mediocrity, bureaucratic barriers, or blame our patients for poor outcomes. We must develop a deep understanding of the cultures of the patients we serve, the system we are working within, and combine this with compassionate medical care to meet the challenge of caring for the individual patients before us.