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!