Team Huddles Make for a Satisfying Day!

Five minutes before my day begins I discover two patients scheduled for ER followups don't have the hospital records yet in the chart. Can we get those, please? My nurse points out that Mrs. Jones, who just lost her husband, is coming in today. Good to know. My office manager asks if we can work in a late caller from the day before with a rash. Yes, let's do that at, umm, 2 pm. The scheduler says "Mr. Robert's wants to know if he can have his testosterone checked with his regular blood work?" Yes. Anyone else? OK, let's do this!

Sometime in 2012 I heard about using the Huddle Technique in medicine. When The Happy MD's blog post on the Team Huddle hit my mailbox last year I considered trying it but, not having my own medical assistant at the time, I delayed. Several months later at the ACE conference in Chicago, Marijka A. Grey presented on Care Teams using the Huddle and standing orders. I decided to implement them both in my office early September. I've been blown away by how it improves my ability to efficiently provide care. And my staff loves it.

Every morning, I go up front where my office staff is gathered. For about five minutes we inspect the day's schedule, check for issues, make sure we have the necessary referral information, look to see if an appointment's purpose is unclear and generally try to make the day smoother. For the first month, we only huddled in the am. Now my nurse and I meet in the afternoon to review the day and see where we need to follow up with a call to see how the patient is doing in the next day or so.

In regard to standing orders, we have begun slowly. My nurse determines that all patients are up-to-date on their immunizations and if not, offers to provide them with the appropriate vaccine that day. Our Zostavax (shingles shot) rate is up at least 50%. Having her review this information is much more efficient than me trying to remember it along with all the other distractions in the "fifteen minute" visit. Since our EHR is still not capable of "pop ups" that remind us when a patient needs an immunization this is working well. 

As I stated on Twitter--why didn't I think of this 25 years ago?

A * Readable * Usable * Patient Note

It's not just the clicks. It's creating a Readable.Usable.Note.[1][2] It is embarrassing to look at a patient chart and read: "Your HDL (good) cholesterol is excellent but your LDL (bad) cholesterol is too high. I would recommend trying to reduce sure fact food intake." What? Oh, yeah, reduce your fatty food intake. Or worse: "She wanted me to know that she had a laparoscopic hysterectomy and in for reck to me over the summer." That one took a while to figure out. What I dictated was "she had a laparoscopic hysterectomy and oopherectomy over the summer." Ouch. I read over my notes before I sign them but between the rush of seeing patients and the problem with editing your own notes within the horrible output that electronic records produce, it's easy to miss your own mistakes.

The notes are built to maximize the billing that we do. But frankly, even though I revisit a patient's chart and check their past medical history, update their meds, update their family history, review their social history, etc. IT DOESN'T NEED TO BE REPEATED IN THE NOTE! However, if I don't rewrite all that, Medicare or the insurance company doesn't believe I did it and I can't charge for it. As a consequence everything is repetitive and finding the little gem of information one needs to care for the patient becomes more and more difficult. As anyone who has ever received the reams and reams of paper from an ER with an electronic health record (EHR) that has no discernible font changes or indentation can tell you, it is next to impossible to determine why the patient was there, what treatment they received and what followup they need. 

To counteract this I dictate my medical reasoning in the discussion box at the end of the note. Next visit that's where to look to find the important stuff. Of course this increases the amount of time documenting, taking away more precious moments I have to spend with the patient creating inelegant notes that are one step away from being worthless for subsequent treatment.  

What if we could create two notes for every patient. One that went in to the billing records for auditing purposes and one culling the important stuff into a true "patient care note". Surely there is software that could help us with that.

To quote Dr. Vartabedian: What do you think?

1. We need to reassess the patient note. http://www.kevinmd.com/blog/2013/08/reassess-patient-note.html
2. The doctor will see your medical record now. http://www.slate.com/blogs/future_tense/2013/08/05/study_reveals_doctors_are_spending_even_less_time_with_patients.html

Are Doctors the Ultimate Engaged Patients?

My nose and sinuses feel like they are about to explode. I am moving into the third week of this and it's getting old. At first I thought that my cold had morphed into allergies but now it is apparent that two viral loads in a row have slammed me, both affecting my upper respiratory tract. If a patient walked into my office as miserable as I am right now my advice would include a steroid dose pack to shrink the swelling, some decongestants, lots of fluid and rest. Since it has been going on for so long if the patient insisted I would probably toss an antibiotic in there as well though it is clear (to me) this is not a bacterial infection. I am using a multi-symptom nighttime OTC cocktail along with a topical antihistamine at night and a decongestant with a expectorant during the day. I have no fever and there is nothing to suggest a bacterial component.

Reflecting on my illness, it occurs to me that one of the reasons doctors are uncomfortable taking care of doctors is that we are the ultimate e-patient. We are participatory, we understand the underlying disease processes and we often waver between allowing the treating doctor to be in charge and taking charge. We want to be partners in our healthcare because we have the training for it and yet hesitate because that's not the way it's done. It brings to mind a moment in my first pregnancy (in eastern KY) when my nurse midwife told me to skip the hospital prenatal courses because I needed to be a patient, not a doctor, and the classes would thrust me into a difficult role in such a small community. I remember feeling relief and feeling good about "only" being a patient. 

Those times when I have needed to be a patient my choices in physicians have assured me that I would be a partner in my healthcare decisions. Most doctors find taking care of other doctors, or their family members, challenging. This can be both self-inflicted and patient-generated. As patients become more engaged in their healthcare perhaps taking care of our own kind will become less anxiety-producing. We will feel confident that no one is "only a patient" because all patients will be partners if they so choose. 

What would you do?

A text lights up my phone late in the evening. It's from someone who is a patient but we've been together for so many years I consider her a friend. She has my phone number from other times she's needed medical advice. She knows me well enough that she can assume I am adept at texting though we've never communicated that way before. The patient is immune deficient and somehow managed to scratch her leg. It didn't originally look all that bad but in the last hour or two it has become red and swollen around the scratch and she is concerned about cellulitis. 

There are no Immediate Care Centers open this late on a Sunday night. It is not clear to me from the description, even after speaking with her on the phone, if it is bad enough to need hospitalization. If not, the best care would be to start an antibiotic tonight and check it in the morning. My choices: send her to the ER at the height of flu season (a terrible idea for anyone but especially an immunocompromised individual), have her wait eight hours until morning and I can see the wound, treat it empirically, or have her send me a picture. The picture can't be in a text because that's not HIPAA compliant. It also can't be email because that's not HIPAA compliant. SKYPE? Maybe but I'm not sure how good the encryption is. 

So I sit on my couch and weigh options--all the while thinking, "How did we get in such a quandary, where taking the best care of the patient is not first on my list of considerations? Where common sense is delegated to the back of the bus behind government regulations and insurance rules? And where the technology to make all this simple can't be utilized to help my patient or me?" Patient portals are great but can she figure out how to load the picture on it? And our portal only accepts up to a 50 MB file. What if it's larger? Will she know how to reduce the size? Yes, I could do what my 1950's MD ancestor would do, which is hop in the car and make a house call, but he only saw 12 patients in the office the next day and made relatively leisurely rounds at the hospital. Not the frantic 20+ I'll see tomorrow, needing all the rest I can get. 

What would you do?

Saying Goodbye

It's Friday afternoon and I check the day's schedule. A name jumps out at me and I groan a little and worry--what am I going to say to someone I've treated for twenty years, who's my age and just been admitted to hospice care? If this is goodbye, how do I as a physician, who is more than an acquaintance but not quite a friend, handle this appointment?

All kinds of things go through my head. Do I really want to charge for this? How bad will he look? Can I keep from crying? Is there anything I can do for him anyway? Will I ask the right questions? Will I say the right things?

He comes with a relative. He is living alone but they have found a nursing home that he liked today and he hopes to transition there quickly. He has one sorrow and one fear. He needs to find a home for his dog of 14 years. He shows me a picture of a cute lap dog of some sort. Amazingly, during his last hospital stay he met someone who is willing to take care of the dog. His fear is how breathless he will be near the end. I reassure him that every effort will be made to make him comfortable and he should not suffer.

We talk a little about his parents, with whom he has been estranged for some time. He assures me that he has spoken with them. They are older and have had their own medical challenges. I cannot imagine how they feel. He jokes a little about his relationship with them.

Finally it is time for him to go. He looks tired, but not that ill. He asks me if he should try to eat, he doesn't have much appetite, and I encourage him to eat whatever he wants. He stands up and gives me a hug, whispering "I love you" in my ear as he does. After reminding me that the phone is a good method of communication, he leaves.

I am lost in thought and emotion but still have two more patients to see. I take a breath, walk into the next room and apologize for my tardiness. It's probably obvious that I'm upset but the rhythm of seeing patients takes over and somehow, reassures me.

Patient Access to Their Data

The Open Notes initiative has created a flurry of interest in the on-line medical community but not even a blip that I can tell in my personal world. Patients appear oblivious. The story was not covered by our local newspaper. No physicians are nervously or otherwise discussing it in our doctor's lounge.

Despite Meaningful Use criteria breathing down our organizations's neck, which includes patient portals with the capability to obtain their records electronically, no one is talking about this important study: three healthcare systems, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in  Pennsylvania, and Harborview Medical Center in Seattle participated. This included 105 doctors and more than 13,000 patients. When the study was finished 99% of patients surveyed wanted continued access to their notes and NO DOCTORS opted out. 

The last phrase is the most important one to me as a physician. In my world doctors are often very nervous at the thought of patients obtaining access to their own records even though technically the patient owns the record. Yet the more I see of charting, especially electronic charting, the more important it is that patients have the ability to access and help us improve their records. 

As an example, I recently had a new patient who related being involved in a motor vehicle accident many years ago. He'd had surgery shortly after but he wasn't sure whether or not he'd had his spleen removed, though he knew it had ruptured. This is important because individuals who have no spleen are at increased risk of certain kinds of infections and need routine and regular followup vaccinations to protect them. The first thing I did was access records from an abdominal hernia surgery he'd had just a few years ago, to repair a hernia he had as a result of the first surgery. The operating doctor dictated in his note that the patient had had a splenectomy. I wasn't convinced so I dug a little further and fortunately the hospital still had records of the first surgery (by law the hospital does not have to keep records from over twenty years ago). The patient did not have his spleen removed and thus needs neither recurrent vaccinations or  expensive imaging to figure out the answer. But what if I'd just taken the mistaken word of the second surgeon? How much better if the patient had been given easy access to his records years ago when he'd first wondered? 

Soon, patients will have access to their own charts and will be capable of giving much better histories or better yet, will have their medical stories in their own Personal Health Records. This can save a lot in time and unnecessary tests, not to mention improved accuracy in patient records. Because after all, who has more at stake in the accuracy of the record than the patient? Or as e-Patient Dave deBronkart says: 

Communicating via Patient Portal

It's Saturday night and I'm tying up loose ends, signing off patient referral letters, sending messages to staff to do on Monday and "playing" in the test environment of our EHR to try to better understand it. My husband is working a 12-hour shift at an immediate care clinic, my daughter is with a friend and the cats are not trying to get in my lap right at this moment. The house is quiet, with nothing but the soft swishing noise the dishwasher makes and for some reason, that always soothes me. Maybe because cleaning is happening without my active participation. It occurs to me that I haven't checked RelayHealth.com, our patient portal, since early yesterday morning. 

RelayHealth.com

I log on and there are two messages. One from a patient that needs her atorvastatin refilled. I thought it had been done at the time of our visit yesterday but when she arrived at the pharmacy only her blood pressure pills were there. Apparently I neglected to check the drop down box in the prescription area of our EHR. In her case the default setting was "record" instead of "send to retail pharmacy" (it varies per patient for some mysterious reason) and I missed checking ONE of the three prescriptions correctly. This is a system problem that needs to be addressed but in the meantime my patients will sometimes get less than all of the multiple prescriptions they need refilled. The good news is that she figured out how to use the portal, sent me a message, I read it and immediately logged back into the EHR system and sent the prescription to the pharmacy. Then I messaged her back to say the prescription should be ready in the morning. COOL!

The second message is from a patient who has found data regarding the use of metformen and psychiatric disease. She is tech savvy and figured out how to scan and send me a PDF file of the published research. COOL! Now I'm learning from my patients even when I'm not in the office. I send her a message promising to read the article and get back to her and jokingly tell her that I hope all my patients aren't as smart as she is or I'll be inundated with reading material. Tomorrow I can respond to the article.

So far not a large number of my patients know about or have bothered to sign up for the portal but I've been very happy with the interactions I've had on it. Earlier in the year a woman had an illness that seemed to linger forever. I was running tests and talking to specialists and was certain that this would pass but it was frustrating for her. I think it helped both of us that she could communicate directly with me throughout the illness and may have saved her some trips to the ER or Immediate Care Center because she had direct contact with me on a nearly daily basis. In return it was a relief to me to know how she was doing.

Physicians often hesitate to give this kind of access to patients because they are afraid it will be abused but that is short-sighted. Just like with the telephone, I have complete control over whether I answer or my medical assistant does. This way it can be done at my convenience and, in general, I hate communicating by telephone. Most patient messages are quick and to the point. If they need to be seen, I tell them so. It's a plus to patient care from my perspective and am pleased with the results. I hope my patients feel the same way. 

The Three "P"s of Mayo--Patient-centered, Physician-led and Collaborative Partnership

Last week I attended the Mayo Clinic's Annual Social Media Summit in Rochester. What most impressed me had nothing to do with the conference. On Tuesday afternoon before the Summit began I toured Mayo Clinic. It was supposed to be for an hour but lasted more than two because our group, consisting of one doctor and nineteen PR professionals, was so interested in the information being fed to us. I don't know why the publicity folks were so intrigued, but for me Mayo's philosophy of "patient-centered, physician-led" care hearkened back to a time when the patient-physician relationship was inviolate. It was stimulating to realize that my instincts of how medicine is best-practiced are right on target.

My myopic opinion regarding the fragmentation of healthcare sees the destruction of the patient-physician relationship by multiple entities, who are primarily interested in a piece of the economic pie, as central to our healthcare mess. At Mayo, no project moves forward unless there is a physician who champions it and it is the physician's responsibility to ensure that every project is dedicated to improving some aspect of patient care. Physicians are salaried so they spend the time necessary to care for patients and are not incentivized to increase the numbers of patients seen or do procedures to enhance the bottom line. 

Every person I met who worked for Mayo reiterated the importance of putting patient care and comfort first. It was incredibly refreshing. The Mayo logo emphasizes a patient-first policy as well. I'd seen the logo multiple times but somehow never thought about what the three shields represent. Our tour guide explained: Patient care, research and education. The educational aspect was obvious as we walked multiple floors of patient care areas. I noticed no TVs in patient waiting rooms but many had computer screens where patients could learn about their conditions. It is a refreshing and calming atmosphere without the cacophony of media noise. There is art everywhere. Waiting rooms are spacious and well-lit. Meditation rooms and educational spaces abound. 

Children's waiting area

Mayo has always represented excellent healthcare in my mind. Patient reports that come to me after a visit there are extraordinary due to the extent of the integrative care the patient experiences from multiple medical disciplines coming together. I expected to be impressed. I did not realize I would also be reassured. Putting patients first is what I'll continue to strive to do, despite insurance interference, governmental policies or EHR dysfunction.

Friday Morning Overload

Somewhere mid-morning on Friday I lost control. Things were perking along very nicely and then suddenly (or so it seemed to me), I was nearly an hour behind. Up until then even my EHR notes were signed at the end of each visit. Perhaps it is my German heritage, but my skin begins to crawl when patients wait more than fifteen minutes. For years it has been a matter of pride that they rarely waited longer than five or ten minutes and frequently they were seen within a minute or two of their appointment time. Nor did patients feel they were getting short shrift from me. My scheduling clerk knew her business and the patients well enough to pad an appointment when necessary. In the last three months that has not been the case. Hopefully this is temporary due to the extra time involved in learning our new documenting system but being behind brought me to a reflection on the importance of timely appointments.

Sometimes, no matter how good my intentions, the cards are stacked against me--Mrs. Jones lost her job and her mother in the same month; Mr. Bausier came in for a cold but just happened to mention the pressure sensation in his chest that seems to be more frequent and is associated with exertion; and in listening to Mrs. Roberts' heart it is obvious that the rhythm is just not right. And all in the same morning. Other times, it's more personal--I'm talking to a patient whose daughter went to high school with mine and we have to catch up or my favorite French national comes in who prefers to tell me her medical problems in her native tongue. Not because it's better for her but she knows I need the practice. 

On Friday, my schedule was so off that by the twelfth of thirteen patients that morning my sugar was low, my mood was cranky, and my thought processes had slowed to a crawl. Frustratingly, somewhere in the brain fog I recognized those last two patients did not get my best care. Did they recognize my distress or just think that Dr. Nieder didn't care about their needs? Statistically patients have a problem speaking up for themselves in a doctor's office[1,2] and in my own uncomfortable state of mind it is unlikely I would have picked up on their discomfort!

Someday, hopefully soon, the office will find the right balance in scheduling for our new system. For now, I'm taking a lot of deep breaths and hoping that patients know I still respect their time and am struggling to give them good care under difficult circumstances. 

1. http://healthecommunications.wordpress.com/2010/09/01/five-reasons-why-people-do-not-ask-their-doctor-questions/

2.http://newsroom.pamf.org/2012/05/patients-fear-being-labeled-difficult/

Mission Accomplished

Mrs. Smith is adamant, "That amlodipine is making me tired! I can't take it." Ms. Smith is 86 years old and her blood pressure is reaching a systolic of 200. She's still mentally alert and volunteers at a local hospital every week, drives herself to places nearby and lives alone. It is scaring me because I don't want her to stroke. This is the third BP med she has rejected in as many months. I've checked for other causes but think her age is just catching up to her.  Previously she has had a systolic in the 150's and several years ago we tried several meds, all of which she refused to take. I gave up then but now I'm much more concerned. She has no family to speak of...we go over the pros and cons of the medication. She reluctantly agrees that if she dies from a stroke that would be fine but being in a nursing home unable to talk or walk would be horrible. She will try the medication for another month. "But doctor if I can't do the things I want to do, I am not going to keep taking it!" She agrees to try it and surprises me with a hug as she walks out the door. "It's OK Dr. Nieder, I'm not going to live forever."

Tim Jones slammed his finger in a door and sees the hand doctor on Monday for a non-displaced fracture of his little finger. He wants to ride this weekend in a 100 mile bike ride for some charity or other. "Honestly, what is the risk?" We discuss the fact that the ride itself could cause swelling of the fingers and lots of pain, not to mention if he falls and hits it. "They splinted it really well at the immediate care center. I promise not to take too much ibuprofen." I give my blessing and hope he is safe.

Mary White arrives, late as usual. My staff is used to that, so they try to schedule her at the end of the day. She has a short litany of minor issues, brings me up to speed on her minor medical problems with specialists, has her yearly exam, we discuss her perfect blood chemistries and she is out the door. 

After 25 years, my patients have me well-trained. And vice-versa--they only call me at night with true emergencies and they apologize when they wake me, they rarely call for last minute refills because they forgot, they bring their meds with them when they come for an appointment and they arrive on time because I'm on time (well, at least I was until Electronic Health Records began three weeks ago). Reflecting on my practice it occurs to me that this is what I hoped my patient relationships would be like at this point in my professional life. 

Mission accomplished. Wonder what comes next?

Burning Out on Friday Afternoon

Recently a Mayo Clinic sponsored study reported that the rate of physician burnout was much higher than other careers in the US[1], especially among front-line specialties like Family Medicine. This Friday afternoon in preparation to seeing my last patient it hit me "Is this sensation burnout?" Inwardly groaning--a new middle-aged woman with obesity and several psychiatric meds, my thoughts ran to "Who put her on my schedule damn it. It's Friday afternoon. What did they think they were doing? Doesn't anyone care about MY needs when they're scheduling" or words to that effect. For a few moments I pondered my office life.

Lately, my office looks cleaner, because EHR (electronic health records) hides the mass of unfinished charts instead of having them all stacked on my desk. Now there is no obvious sign of all the work I do--no notice to my employer that I am an important, busy and valuable doctor. Despite the reduction in mess, I rarely leave the office before 7, often am there until 9 and everyone keeps telling me that it will get better, since we're only four weeks "in". This is exhausting me but at least my husband frequently meets me at the door with a glass of wine in hand. For this I am grateful since sometimes I finish up my charts on-line from  the couch.

Then there's House Bill 1, the irritating and unfriendly-to-patient-care narcotic bill that takes up extra time and deprives my patients of therapeutic medications and remains a thorn in my side.

Add to those aggravations the everyday frustrations of practicing medicine in today's fragmented healthcare system and maybe I needed to worry. This line of thought hit me as  I took a big breath, walking in the door expecting the worst and spent the next thirty minutes with a delightful woman who was already taking steps to improve her health. She was working with a trainer, she'd already started losing about twenty pounds. She was upbeat and interesting and I walked out of that room energized.

This Friday I got lucky. Maybe next Friday I'll be drained. Reflecting on the end of my day I realized that's just how the rhythm flows in Family Medicine. Like most professions, some days are better than others, but looking at the averages, my curve is mostly on the up. I still like what I do.

1. Shanafelt, Tait D. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. August 20, 2012. http://www.webcitation.org/6AtdqOc4p

An EHR Obsession

My Saturday morning walking partner asked me yesterday, "So when do you get to quit being an IT professional and go back to being a doctor?" Wow, good question.

In the not quite three weeks of this new form of documentation I have been consumed with trying to understand and make the EHR work for me. No longer do I have to consult a "superuser" every ten minutes with questions but every day I'm trying to figure out the most efficient way to care for people using this frustrating new tool. The "muscle memory" is beginning to kick in thank goodness, so time per patient is less. Now my frustrations are more with what seems to be a very inefficient system. I struggle to determine whether I am the problem or the EHR is. Most likely it's a little of both. The term Mission Hostile User Experience coined by Scot Silverstein comes to mind. What is scary here is the potential for patient harm - between my distractibility due to the steep learning curve of the Allscripts system, the fact that no one has told us how to clean these "Toughbook" fomites that we carry from one patient exam room to the next, and the patient care error potential inherent in the software itself, these are the ever present worries that keeps me up at night.

On Thursday of this week, the EHR Steering Committee for my organization will meet and I will have the opportunity to present the go-live experience and make suggestions for improvement as other offices in the system go live. Throughout this process there has remained a sense of re-inventing the wheel, which seems odd considering that Allscripts EHR has been in existence for years, having gone public in 1999.

At any rate this blog is obsessed with EHR right now--but the essential question remains. When do I get to go back to taking care of patients?

Patient response to Electronic Records

Amazingly my patients have had a very patient response to the introduction of EHR (Electronic Health Records) to our office. They sit and watch me type and curse with an air of amusement and calm. More calm than I am feeling.

Yesterday began our third week of EHR. Muscle memory has kicked in and I saw 15 patients without running too far behind. Seeing 20ish patients daily again is starting to look feasible. Someone walking into my office no longer has to look over mounds of paperwork to see me. My only concern is whether my employers will cease to understand how much work I do if they can no longer see the physical evidence of it.

On an up note, there will soon be a couch in the area where the credenza is now. Since my colleagues warn me that it will continue to take longer to finish my charts it seems reasonable to have a comfortable place to do so. The main purpose of the credenza was to support the hundreds of charts I needed access to on a daily basis. The staff is very supportive of the change as well (wonder why...).

Many patients have followed me over the 25 years I've been in practice. While little has been different in the exam room until now, there have been lots of other changes--two previous locations, private practice to employed doctor, hospitalists, urgent care centers, and oppressive insurance controls to name a few. For the first time in two weeks, I was able to gauge patient reactions to this new-fangled way of documenting. Prior to yesterday I was too bogged down with clicking boxes, losing screens, figuring out where to put a new symptom the patient just threw at me, finding templates and vital signs and generally being absorbed by the Allscripts system to observe my patients (and please don't make me worry about what I may have missed in patient care over the last two weeks while I followed this steep learning curve).

Now I carry this new contraption in the room:

My younger patients hardly notice it. They would not have commented had I not explained its newness and why it was taking a little longer to enter information than usual. Older folks regarded it with expressions ranging from dismay to perplexity. Most of them commented before I did.

• "Do you like it?" 
• "Do you think it will ultimately speed you up or slow you down?" 
• "How hard is it?"
• "Did Baptist (my employer) force you to do that?"
• "What happens when the system goes down?" (I wonder about this one myself)

No one seemed particularly surprised or overly worried about my use of a computer to document their visit. They all seemed impressed when I stood up and said that their prescriptions were already at the pharmacy. 

At the end of the day what most impressed and humbled me was the sense that within their acceptance of this new device was a trust that regardless of the way I document their care, it would still be delivered in a way helpful to them.

At the end of the day, that's what it's all about, isn't it?

The Need to Blame the Doctor, not the System

Maureen Dowd wrote a thoughtful and thought-provoking article in the New York Times this morning entitled "The Boy Who Wanted to Fly". I had read about the incident in a twitter-linked article earlier in the week and my heart ached for everyone involved--the boy, the parents, the pediatrician, the ER docs and the staff treating him at the hospital. I know from professional experience how gut-wrenching this outcome is to the doctors and staff involved. As a parent I prefer not to imagine what the personal experience would be. It was hard enough to have stood beside friends as they moved through it.

Many of the comments below the article demonize the physicians involved in the care of this boy. That is an easy thing to do and seems to be a particularly American way of approaching a problem--find someone to blame and sue them. Unfortunately, this will do nothing to fix what is an increasingly common problem in our healthcare system today.

I don't know the specifics of what happened in this case. On the surface of it, the article and remarks about it emphasize many of the issues of our broken healthcare system. The comments engendered begin with 'hard-hearted doctors" and "sue the jerks". Perhaps the most thoughtful was the comment by Infectious Disease specialist Dr. Jonathan Rosenthal who said: "The average physician will never see a case of florid Group A Streptococcal septic shock such as this one in her entire career. One of the reasons these rare cases can be so lethal is that is can be enormously difficult to pick them out from among 10000 cases of viral illness in a Pediatric ER. Herculean efforts are made every day not to miss early sepsis. We can learn from cases like this but not if we are distracted by looking for the person to blame. This poor child was seen by a number of physicians - were they all incompetent?"

As a primary care physician some of my thoughts are: How busy was the pediatrician? How busy was the ER? Did they have the time and experience to pick up on those "soft signs" of sepsis that Sully Sullenberger alluded to? As an aviation safety expert he understands the importance of fixing the SYSTEM that is causing the problem, rather than placing blame on the individuals involved.

Patients live in a world where physicians are pushed to see more and more of them to pay the bills; where technology substitutes for stopping and really "seeing" a patient as more than a disease state; where the patient is seen only as a dollar sign by the healthcare administrators, insurance executives, employers, lawyers and politicians who crowd into the examining room as if they had a sacred right to be there; and where time, the most important commodity for good patient care, is stripped from those on the front lines because it is not valued highly by their own peers.

This case should be a rallying cry for patients (and we are all patients) to fix a badly broken, fragmented healthcare system where volume and technology substitute for care. Since this involves a political fix from a system equally broken and fragmented, a fix that must involve compromise from both sides of the aisle, I fear for the future health of my patients and my profession.

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!

Death of a radiology clinic

As usual, I was considering blog topics as I entered my office this morning. Looking down there was a letter sitting on my desk. It was from one of the stand alone radiology offices in town, the one I personally go to every year for my mammogram. I go there because they are accurate, friendly, and efficient. However, because they were one of the busiest in town I always got a first morning appointment. This past January when I went for my yearly exam the waiting room was empty. One person came in while I was in there. Because Dr. Irwin knows me I went back to the reading room while she looked at my "films" (they aren't really films anymore, they are digitized images). She quickly reassured me that my mammogram was normal then we moved on to other topics. We have known each other for years and we talked about our kids and spouses. Then she asked me how I liked being an employee for the hospital instead of private practice (and oh by the way--another day, another blog topic!). Admitting just how much I did like it, she smiled and said she was glad for me. Then she said, "All our referring physicians are being bought by the hospitals so all our patients are staying in those hospital systems for their radiologic procedures. I hope you can continue to refer to us." She didn't say it, but I heard, "They are killing us out here".

While researching today's topic I found this article by a financial  advisor who seemed almost gleeful to report that hospitals might be able to purchase freestanding imaging centers at "depressed" prices due to current market forces which include reduction in reimbursement and continued increase in expenses. Depressed is the word, as I see the end of physician entrepreneurs and the furthering of corporate entities in medicine along with most other industries in this country. (If you are interested in further reading, here is an excellent, albeit technical, white paper on the issue: DRA's Effect on Imaging Centers).

Is this for better or worse? Who can say. So far, it is difficult for me to see a clear improvement in my patients' lives by this industrialization of patient care. I know we are supposed to be moving toward patient-centered care with ACO's and the medical home. With these new ways of delivering care, reimbursement formulas will change and who knows if this will improve or worsen care? Those studies are in process.

Today I know patients are not better served by being forced to go to larger centers, i.e. hospitals, for their imaging studies. And tomorrow? I just hope HAL is not in charge of the ACO's pod bay doors.