Let's Ring in the New to Get Back to the Old

While reading a blog post by Dr. Kent Bottles I was struck by a quote from Lewis Mumford: 

“For most Americans, progress means accepting what is new because it is new, and discarding what is old because it is old. This may be good for a rapid turnover in business, but it is bad for continuity and stability in life. Progress, in an organic sense, should be cumulative, and though a certain amount of rubbish-clearing is always necessary, we lose part of the gain offered by a new invention if we automatically discard all the still valuable inventions that preceded it.”

Although Mr. Mumford has been gone awhile (22 years), part of his foresight, as I understand it, is that technology should serve humankind and not vice versa. The more things change the more things stay the same. Technology is infinitely more complex which makes it incumbent on IT and medical professionals that it serve to improve patient care and not worsen it. While I am jumping on the EMR (Electronic Medical Records) and Medical Social Media bandwagon, I am anxious to see that it is done in a manner that serves the patient more than me, the IT guy or the hospital where care is given. So many of the EMRs that I have sorted through as a provider makes patient care HARDER, not easier. Perhaps this will improve when, and IF, our different systems can talk to each other but now it is difficult to find labwork, tests, and pertinent history when wading through thirty pages of printed material that has nothing to do with the patient's problem. The important stuff gets lost in the minutia.

http://thecourse.webicina.com/

The EMR train has left the station and we will ultimately all be on board (how many transportation idioms am I going to use in this blog...). I see Social Media as a means to better care for patients, specifically as a way to return to patient-centered care and much more importantly, to get on the bus of participatory care. In The Social Media Course a well-known advocate for patient participation in their own medical care, e-patient Dave, addressed the fact that patients are the most under-utilized resource in healthcare. The best clinical teachers I had in medical school taught me that if I listened to my patients, they would tell me what was wrong with them. After many years of medical practice I know with certainty that no truer words were spoken. With the wealth of information on the web physicians and patients can work together as partners, a manner of practicing medicine that has very little down side.

To get back to Mr. Mumford, my vision for the future of medicine includes accepting what is new because it brings us back to what is old--taking care of the individual patient (the old) by utilizing the new (Electronic records and social media) and in the process creating partnerships with patients as well as other physicians and healthcare providers. This doesn't mean that my "partnered" patient will get the inappropriate antibiotic she insists is necessary. But it does mean that patients may once again see me as something other than a prescription supplier and test taker. Dialog is so much more satisfying than one-way conversation.

I've got some bad news and some good news

That's the old joke, right? "I've got good news and bad news-the bad news is that you have Alzheimer's. That good news is that you're going to meet lots of new people." Unfortunately telling people bad news is no joke and I mused on the experience today as I read an oncologist letter to me regarding one of my patients with a terminal cancer. How do you do that day in and day out? This morning I had to tell a patient, a former smoker, that his chest xray was abnormal and he needs further tests. I've known this patient for years and am worried about him. Maybe it will turn out OK...maybe not.

The fact that it bothers me is a good thing. It reassures me that patients' concerns remain foremost in my practice of medicine. I notice when it's time for a vacation or at least a few days break from my office, that one of the first things I lose is empathy. When a patient comes in with a problem that seems simple and unnecessary for a doctor's visit, if my first reaction is "this guy's wasting my time" I have to stop and think "why do I feel that way?" Usually it has nothing to do with the patient and everything to do with me--worried about my daughter who is working in a third world country, worried about my mom's forgetfulness and is it something more insidious, etc.

It is curious to see how individuals react to a life-threatening illness. Most of them have such dignity. Often it is the family members whose behaviors become difficult, which in turn makes the emotional turmoil to a patient worse. I remember memorizing Kubler-Ross's Stages of Grief in medical school. I have been amazed at how much that optional course has enabled me to help patients and their families by better understanding what they are going through. Although things are improving immensely, with programs like Baptist East's Cancer Resource Center and Friend4Life as well as specific coordinated care centers for certain cancers, the system is still difficult to navigate.  

Often, once a patient begins the work of honing down the diagnosis and determining the treatment of their life-threatening illness, the primary-care physician loses contact with him/her. If my patient is constantly in other doctor's offices, undergoing uncomfortable procedures and treatment, it is hard for me to add the burden of another doctor's visit. This is where I see social media as an exciting place for improving care and remaining in contact with my patients. It would be easy to check-in with patients privately on a business Facebook page (which I don't have yet) or send  private tweets on how they are doing (once all the HIPAA compliant rules are in place). Even now they can send me a secure email private message. These channels would help me to identify when I might need to step in, give advice or just more support. The future is here and I'd like to embrace it. Family physicians have been giving patients bad news for a couple of hundred years. But only in the recent past have we stopped walking their journey with them. I don't think that's good medicine, for the patient or for me.

Specialist versus Primary Care

This morning a patient calls the office stating that his surgeon, who has been treating him for an abdominal wound that is still not closed, told him at his followup appointment that he needs to see a wound care specialist. The patient was instructed to call his primary care physician (PCP) and tell me to set that referral up for him. WHAT?!?!?!?! A few hours later my 28-year-old new patient tells me the orthopedist she saw this morning told her she had a kneecap problem, take Advil, stop running and get an MRI. When the patient explained that she wants to be an Air Force nurse and will have to go through boot camp, it was reiterated that she needs to stop running and maybe she broke her kneecap, so she should wait for the MRI. She has NOT had an injury and  BOTH knees hurt. She has noticed that after exercise her knees feel better. I spent five minutes explaining what patellofemoral syndrome is and suggested that she delay the MRI and see what routine quadriceps exercises do to improve her pain. I suggested substituting bike riding for the running but if running doesn't seem to bother them, then she might just cut back on that and substitute biking. WHAT?!?!?!?!

This is not an uncommon experience for me. The first episode made my blood boil. AT LEAST once per week, many times more often, specialists tell patients that I will set up appointments, refill medications or interpret the tests that THEY did on a patient. If this occurs following a phone call to me BY THE PHYSICIAN HIMSELF, this is appropriate. But making the patient the intermediary is unfair to the patient, boldly rude to me and in a patient-centered environment, absolutely terrible care.

It is ironic to me that the individual who makes the least amount of money per patient in the doctor hierarchy, is more and more forced into the position of spending more time with patients to make up for, or frequently do, the job of the specialist. I love taking care of patients but I will NOT be used and abused by individuals who, whether they recognize it or not, are treating me like some sort of glorified physician-extender. 

Now I realize that the counter-reaction from the specialists is going to be that we, the first-line doctors, are sending patients to them without adequately working up the problem thus earning the label of "lazy intellect" from the specialist. I truly try not to do that. After all, that is the most interesting part of being a physician, the detective aspect of putting symptoms and tests together to try to make a diagnosis. That is one of the reasons I chose primary care. And most specialists are not egregiously forgetting their own responsibilities. But as it gets harder and harder to navigate the insurance traps and pharmacy coverage nightmares, as specialists accounts receivables fall and they try to increase their patient load to keep up (PCP's gave up on that a long time ago, we just decided to become employed in droves), it gets easier to tell the patient to call me with the expectation that I'll take care of it.

"The good physician treats the disease; the great physician treats the patient who has the disease." William Osler. I would add to that "The good physician sends written communication to colleagues. The great physician picks up the phone to communicate with colleagues."

OH, and while I'm on the subject of phone communication--does ANY specialist out there remember the common courtesy rules of making phone calls? If YOU want to talk to me, then YOU call me. You do not have your nurse call me and leave me sitting on the phone fuming while I await your presence. Why in the world do you think your time is more important than mine? I mean besides the fact that you get paid thousands of dollars more than I do. Your mother would be ashamed!

Social Media and ... mental health.

First of all--this blog has nothing to do with healthcare, other than my own mental health. This afternoon was a small demonstration of what an powerful tool social media can be. My husband was visiting our neighbor down the street for a play date for our airedale, Ensign.  The yard is large and somehow he found a way under the fence into the nature preserve behind. Tim called but Ensign had disappeared. While one friend combed the bushes in gloves and boots, four more of us looked through the neighborhood, knocking on doors and feeling frightened because we live in a VERY urban neighborhood full of heavy cars. Four hours later night fell and we had to give up the search. Nauseated and exhausted I texted a friend regarding our loss.

She suggested that I post the disappearance on Facebook. Not very hopeful, but needing something to do, I wrote a description of the dog, where he was last seen and included a picture. Within twenty-three minutes the following post appeared:

• Whitney I know who has him!
  

  13 hours ago ·
• Kathy Nieder You're kidding?
  

  13 hours ago · 
• Whitney No I'm not!
  

  13 hours ago · 
• Whitney I'm waiting for him to give me his number so I can give it to you but he just posted that there was an Airedale terrier in his back yard and he lives in Clifton....
  

  13 hours ago ·
• Ashley Lynn OMG I HOPE ITS HIM!
  

  13 hours ago ·
• Barry I HOPE SO AS WELL...
  

  13 hours ago · 
• Leigh US TOO!
  

  13 hours ago ·
• Kathy Nieder IT'S HIM!!!!!

Our graphic artist friend Barry, who had been one of the four people combing the neighborhood, made up a poster and was on the way out the door to print several and hang them up when I called him with the news. So here is his post on my timeline:

Ensign had no idea what the fuss was about but my husband and I were ecstatic. As a bonus, I got to sleep last night, soundly and well.

Physician Employment Regrets?

Six years ago I left private practice and never looked back. I traded my autonomy for restful nights, a 401K plan (which I'd never had the money to fund), a regular paycheck (no more doing without at least once in January, February and March, and the disappearance of staffing issues. While I am occasionally frustrated by the "Dilbert" corporate environment, I work for a system that has a strong patient-centered mission and they have been reasonable and kind to me.

How did doctors get to this point? There are so many factors it becomes an interesting mind game to see if I can remember all the headaches that my partner and I wrestled with for the sixteen years we suffered through it. About six years into it we decided our theme song was Chumbawamba's "I get knocked down but I get up again..." It didn't help that we were both mothers with two young children when we started out. Neither of us were willing to sacrifice our time with our children so we refused to work eighty hours a week, thus our salaries looked more like teacher's pay BUT without the retirement benefits and summers off. Then there were the staffing issues. We always kept a key group of loyal individuals who worked for less than they could have, I suppose because they thought we were doing well by our patients. But there were always problems that made you want to tear your hair out--one employee was rude and chronically late, one did not want to work evenings (we were open two evenings a week), one had a child that was ALWAYS sick; there were raises deserved that we couldn't afford to pay, there were people who needed to be fired that we didn't know if our documentation was good enough. It never seemed to end.

Our out-sourced billing advisor also helped us with accounts payable and we got very good at creative bill paying. Of course our staff's paychecks came first and they never did without except for our nurse practitioner who allowed us to postpone her pay four or five times. We made that money up to her but my partner's and my pay was lost forever. Bonuses? Who are you kidding. We went to plenty of coding classes but had no clout with insurance companies to maximize our reimbursement. We did not see too many patients without insurance but those we did seemed to have problems paying our bills. We learned early on to collect co-pays at the window before being seen, or we might never see that money as well. These were the kinds of issues that keep you up at night. At the worst, when my business partner and I thought we were going to have to declare bankruptcy, I remember having what psychiatrists call EMA (Early Morning Awakening--a classic depression symptom). At 4:30 or 5 I would give up and go downstairs to meditate for thirty minutes to an hour trying not to think about telling my children that we were losing their home. Sigh--those were the days.

So now I am an employee in a big hospital-owned group. Just a little cog, but it is sooo much better for my patients. They get my full attention when I am in the room, my brain is never worrying about bills being paid, staff being disruptive or sleep being lost. When I go on vacation, I get paid and if I am sick then I am only worried about how to get well. No, I'm not always happy with how the administration does things and sometimes the corporate bureaucracy, legalese and slow-to-change atmosphere makes me crazy. But my life is much easier so I try to keep my complaints to a minimum--as I tell my daughters when dealing with husbands and children "Choose your battles. They aren't all worth fighting."

There's a Physician Charter on Medical Professionalism?

Who knew? A friend sent me the link to an article in the New York Times entitled "Doctors Have Feelings Too" by Danielle Ofri. The subject matter of the article was interesting but what really caught my eye was the author's reference to a document entitled "The Physician Charter on Medical Professionalism" that was created in 2004 by the American Board of Internal Medicine, the American College of Physicians Foundation and the European Federation of Internal Medicine. This document has been endorsed by numerous medical associations including my own, the American Board of Family Practice. So how is it that I've never heard of it? 

The Charter catalogues the essential elements of my profession. The Preamble begins with the obvious, that the physician's contract with society demands that the needs of our patients are placed above our own needs. Judging by the stories I hear from patients who come to me and the letters I receive from specialists, this first responsibility is frequently lost in the noise of the economic, legal, political, technical and pharmaceutical messages that bombard us. Yesterday I saw the daughter of an 88-year old woman who broke her femur two weeks ago and had her leg stabilized with a metal plate. The plate has now slipped due to her severe osteoporosis and her orthopedist recommended that she undergo a total knee replacement. This recommendation was made in the context of a less than ten minute discussion with the daughter (her mom is too demented to participate). Thankfully, one of the nurses at her mother's nursing home was horrified enough to suggest that this line of treatment be reconsidered. I can't say what the orthopedist was thinking--my guess is that he is outrageously busy and therefore did not realize how demented the woman is, that the woman was unable to walk without assistance BEFORE she broke her leg and rehab following a knee replacement would likely be near to impossible. He didn't ask if she was having any pain (she isn't), he didn't ask about her mobility before her fall, he didn't think too hard about the morbidity associated with doing a knee replacement on this woman, he didn't go over the pros and cons of this type of surgery with her daughter, in short, he did not fulfill the first clause of the above mentioned contract. I wish I could say this is an unusual occurrence but unfortunately, it is not. Oh, and yes, his professional society has endorsed this charter. He's probably never seen it either.

After the Preamble is recorded the Fundamental Principles:

Principle of primacy of patient welfare. The principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

The first two of these are obvious but how many of us, myself included, are working hard enough on the last one? Just judging by the political slogans and candidates endorsed by the bumper stickers on the cars in the doctor's parking lot, I'm guessing that most of them are not all that interested in actively eliminating health care discrimination. It might cause some change in the distribution of their own private resources.

The next area addressed by the charter is Professional Responsibilities which include:

•  a commitment to life-long learning (seems obvious-who wants to go to a 20th century physician in the 21st century)
• honesty with patients (the topic of the NYT article mentioned above)
• upholding patient confidentiality (another obvious one but in today's world of social media and HIPAA it can be tricky. Sometimes the hardest thing is getting information necessary to treat from other providers who are terrified of breaching PHI)
• maintaining appropriate relations with patients (another straightforward responsibility--don't sleep with your patient or otherwise take advantage of him/her)
• commitment to improving quality of care and access to care. Quality of care seems straightforward but what about when doctors are seduced by peer-reviewed articles that encourage the use of pharmaceuticals that later are found to be no more improved than older medications or worse, more dangerous (see conflict of interest below)?
• commitment to just distribution of finite resources. This responsibility addresses cost-containment issues. Really? Not only did I not realize there was a charter, but in it is addressed cost-containment! Amazing and it was written eight years ago. Hmmm...like I said, most physicians don't know it exists.
• managing conflict of interest. We are supposed to make clear all interactions with for-profit entities. Apparently this remains a problem in even our most prestigious journals--for example the BMJ which had to discredit a widely publicized article on autism and vaccines. There is ongoing evidence that big  pharmaceutical companies routinely suppress or fail to publish data that does not look favorable on their drugs. Another link...As mentioned above, this impacts quality of care.
• a commitment to self-regulate. This concerns remediation, disciplining of failing physicians, and participation in the educational process both before and after a medical degree is conferred. 

Wow, this is a very complete document written by individuals who put a lot of thought into what our profession is about. I wonder if medical students are taught about it? Residents? I wonder if it was ever disseminated by my professional society, the AAFP. To repeat...who knew? Who knows?