“Thanks for Your Time”: Einstein’s Relativity in the Clinical Encounter

In business literature I have seen the phrase “getting paid for who you are instead of what you do”. This implies that some people bring value because of the depth of their knowledge and their appreciation of all the nuances in their field, the authority with which they render their opinion or because of their ability to influence others.

This is the antithesis of commoditization. Many industries have become less commoditized in this postindustrial era, but not medicine. Who in our culture would say that a car is a car is a car, or that a meal is a meal is a meal?

The differences between services with the same CPT code for the same ICD-10 code aren’t, hopefully, quite that vast. But they’re also not always the same or of the same value. There is a huge difference between “I don’t know what that spot is, but it looks harmless” and “It’s a dermatofibroma, a harmless clump of scar tissue that, even though it’s not cancerous, sometimes grows back if you remove it, so we leave them alone if they don’t get in your way”.

I always feel a twinge of dissatisfaction when, after a visit, a patient says “Thanks for your time”. It always makes me wonder, on some level, “did my patient not get anything out of this other than the passage of time, did we not accomplish anything”?

It reminds me of a phrase from an ancient Swedish language course on cassette my first American girlfriend played over and over (she eventually became fluent, but only by living in Sweden): “Vad kostar tre minuter?” (”How much is three minutes”, referring to operator connected long distance phone calls.)

Three minutes of static on a phone line or three minutes with a dear one can never seem like the same three minutes, so thanking a doctor for his or her time only makes me think of an almost wasted encounter, almost like “thanks anyway”.

Now, one thing about charging for time that isn’t completely ridiculous is the fact that you can charge even if you don’t do a physical exam if “greater than 50%” of the visit was spent on “counseling and education“, which is pretty much the majority of what we do in primary care.

We are all familiar with Einstein’s formula E=mc2. He showed that energy equals mass times the speed of light squared.

Einstein’s formula, if you allow speed to be variable, also applies to calculating the impact of head-on motor vehicle collisions or the stopping distance of a freight train.

In medicine, just like in physics, the energy (impact) of a visit and the mass of its actual, meaningful medical content are really just different manifestations of the same thing. Their conversion factor is time.

When calculating the stopping distance of a train or impact of a head on vehicle collision, the speed means a whole lot more than the weight (mass) of the moving object. In our business, energy and mass are presumed constants and therefore time is thought of as the variable, especially when it comes to provider scheduling.

All of us intuitively know that a ping pong ball traveling at many times the speed of a slow moving freight train would still never cause similar damage on impact.

Similarly “Mass” in medicine (or “amount of clinical information considered or conveyed”) can vary enormously and isn’t always what it appears to be. Let’s say an unknown, untrusted clinician speaks at length, using many big words and all the patient hears is the “static” of one of my three minute phone call examples above.

What if “Mass” in these sample formulas is not what the provider THINKS (and documents) is delivered, but actually what the patient receives or “HEARS”?

It seems as if the staticky three minute phone call is like an office visit with a provider with lower credibility due to less relationship or shared history, resulting in less therapeutic weight and impact.

To quote myself:

“Medicine, at least in the non-procedural specialties, is a relationship based business. If a hostile stranger spends fifteen minutes trying to change your behavior, is that more effective or more valuable than if a trusted doctor, friend or admired mentor mentions the same thing almost in passing?”

So, instead of thinking of TIME as the variable, as in 15, 20 or 30 minute visits, we need to look harder at the “Mass”, or what might be called effective content of a visit.

Let’s think of time as a constant and accept that during their career, clinicians have the same number of hours available to them every week.

Let’s think more about the two things that are the value laden variables in Einstein’s theory:

E (Energy, or therapeutic impact) = M (Mass, or ACTUAL effect of our attempted clinical interventions).

If we counsel smokers at a rate of a hundred every month and none of them actually quit, does anybody really believe that is that better than succeeding a dozen times a month with fewer patients?

Health care should not be a speed contest. That would be like saying we could increase cardiac output in heart failure patients by increasing their heart rate. We all know from medical school that this isn’t true if their heart rate was normal to begin with. Like I explain to my patients: if you try to flush your toilet too frequently, each flush will become less effective.

So, while speed in medical encounters may not be a absolute constant, its variability is definitely limited, and as we approach that limit, we risk becoming less and less effective.

I believe it is easier and more effective to work on increasing the value and weight of each of our clinical encounters. Then, and only then, might it be possible to improve our speed. This is where the idea of being paid for who you are instead of what you do comes in. One sentence of advice from a professor, judge, priest, guru, most trusted friend or personal physician could be worth much more than fifteen minutes with a generic health care provider.

A Country Doctor Reads: July 21, 2019 – Big Data

Big Data and the Patient in Front of Us

In recent weeks I’ve come across some articles in the “lay press” about Big Data that contained a couple of eminently quotable statements about BIG DATA.

First, let me present a brief patient vignette:

This physician in his 60’s was taking low dose aspirin because that, the data showed, would decrease his heart attack risk. He was in compliance with current recommendations, at least one of them.

After several nosebleeds, this physician stopped the aspirin. He was now out of compliance but free from his inconvenient apparent complication of treatment.

During the past year, the ASPREE study showed that aspirin would only benefit our hero if he had heart disease, which he doesn’t appear to have. He is now in compliance, doing what the Big Data is suggesting he ought to do.

Now, the two newspaper quotes that started me down this road of thinking:

1) “Data that doesn’t yield insight is just trivia.”
2) “Stories move data from the head to the heart.”

DATA WITH OR WITHOUT INSIGHT

An article in The Wall Street Journal describes how employers mine data from their employees activities, on their computers (sites visited, emails answered and so on), in their vehicles (speed, routes etc.) and on the phone (with whom, length of call etc.), but as one UPS representative pointed out, all that data isn’t worth anything if it doesn’t help you understand what’s going on:

“UPS confirmed it uses advanced analytics to sift through data in ways that help it better serve customers and drive efficiency. “Data that doesn’t yield insight is just trivia,” a spokesman says.”

https://www.wsj.com/articles/three-hours-of-work-a-day-youre-not-fooling-anyone-11563528611

STORIES MAKE DATA MEANINGFUL

The New York Times ran an article about “mystery shoppers” in healthcare facilities and how their work, which includes personal observations gathered while posing as patients and subsequent interviews with real patients in hospitals and clinics can make sense of otherwise confusing data:

Hospital leaders pore over reams of data. They review financial spreadsheets, patient satisfaction surveys and clinical outcome data. Secret shopper studies don’t replace that information. Rather, they attempt to give the data context.

“Stories move data from the head to the heart,” said Kristin Baird, president and chief executive of the Baird Group, a Wisconsin-based company that performs secret shopper and other consulting services for health care organizations. She has seen how patient stories that exemplify otherwise confusing trends in the data can influence health care executives powerfully.”

https://www.nytimes.com/2019/07/16/well/live/secret-shopper-hospital.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

This reading made me curious. As a simple country doctor, I wanted to know what we really understand about Data in Medicine.

THE 6 V’S OF BIG DATA: Volume, Velocity, Variety, Veracity, Variability and Value

I found a 2018 article by Ristevski and Chen in the Journal of Integrative Bioinformatics that nicely illustrates the many facets of what people lump together as Big Data.

Seeing the succinct summary of the meaning of these six V-words immediately helped me feel I have a better grasp and comfort level thinking about how to approach the data that is constantly bombarding me as a physician.

“The volume of health and medical data is expected to raise intensely in the years ahead, usually measured in terabytes, petabytes even yottabytes. Volume refers to the amount of data, while velocity refers to data in motion as well as and to the speed and frequency of data creation, processing and analysis. Complexity and heterogeneity of multiple datasets, which can be structured, semi-structured and unstructured, refer to the variety. Veracity referrers to the data quality, relevance, uncertainty, reliability and predictive value, while variability regards about consistency of the data over time. The value of the big data refers to their coherent analysis, which should be valuable to the patients and clinicians.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340124/

I will repeat and italicize the last sentence in this article:

“The value of the big data refers to their coherent analysis, which should be valuable to the patients and clinicians.”

So, how do we know how to apply all this Big Data, how do we make it relevant for the patient in front of us?

Harvard T.H. Chan School of Public Health posted this piece by Lisa D. Ellis on their website, describing a program called Measurement, Design, and Analysis Methods for Health Outcomes Research.

“Since diabetes patients act and respond differently to treatment due to many reasons, health care providers often cannot advise patients as to how they might respond given their personal characteristics simply because they do not have the required information,” Simonson points out.

The reason this crucial information is lacking is that “typically, no one clinical study can separate out the results by all the patient characteristics that might affect treatment,” Testa offers. “In addition, clinical drug trials do not typically measure how patients feel or how satisfied they are with their assigned treatment,” she says, adding, “In most clinical trials, the ‘true voice’ of the patient is usually silent.” To better capture this important component, Testa, Simonson, and their colleagues are pooling existing databases of diabetes patients with information gathered online and through social media.

https://www.hsph.harvard.edu/ecpe/value-of-health-outcomes-research/

Here, again, I will repeat and italicize the most salient sentence of my search result:

“In most clinical trials, the ‘true voice’ of the patient is usually silent.”

Not to get too heavily Jungian, but referring back to my recent writings about the Grail Legend and “Whom does the Grail Serve”, the obvious question here is “Whom does the Big Data serve?”

Primary care providers are perhaps the Parsifals of medical mythology.

“Central to the legend is that a simple man, a fool, needs to ask the simple question “whom does the Grail serve” in order for the wounded Fisher King to be healed. But Parsifal, who is such a person, heeded his mother’s advise “don’t ask too many questions” and missed his opportunity.”

https://acountrydoctorwrites.blog/2019/07/08/the-stages-of-a-mans-life/

Everybody Seems to be an Expert, Except Your Family Doctor?

It’s a funny world we live in. Lots of people make a handsome living, defining their work and setting their own fees and hours with little or no formal education or certification

There are personal and executive coaches, wealth advisers, marketing experts, closet organizers and all kinds of people offering to help us run our lives.

In each of these fields, the expectation is that the provider of such services has his or her own “take” or perspective and offers advice that is individual, unique and as far removed from cookie cutter dogma as possible. Why pay for something generic that lots of people offer everywhere you turn?

So why is it, in this day of paying lip service to “personalized medicine”, genetic mapping, the human biome and psychoneuroimmunology that we expect our healthcare to be standardized and utterly predictable?

And why is it that we are so willing to fragment our care, using convenient care clinics, health apps, specialists who don’t communicate with each other and so on? Does anybody believe it makes sense to have your life coach tell you to have a latte if you feel like it because it makes you happy and your financial adviser scorn you for wasting money, never mind your health coach talking about all those unnecessary calories?

In today’s world, almost all knowledge and information is available, for free, instantly and from anywhere on the planet. But this has not eliminated our need for “experts”. It used to be that we paid experts for knowing the facts, but now we pay them for sorting and making sense of them, because there are too many facts and too much data out there to make anything self explanatory.

The information explosion of our era has brought with it an implosion and a near extinction of common sense.

The facts contradict each other:

Eggs are good for you and bad for you. Almost everybody should take aspirin and most people don’t need it. The bread of life is the bread of death. Low LDL is desirable, low LDL confers risk of disease.

I think there are way too many non-medical providers giving medical advice and way too few medical providers daring and taking the time to do it.

Our nation’s doctors are busily checking virtual boxes trying to randomly cover way too much ground instead of meeting their patients “where they are at”.

Kenny Lin, a fellow medical blogger, has a perfect name for his blog, “Common Sense Family Doctor”.

We don’t need more “Experts”. We need well trained, experienced professionals with common sense. Like Family Doctors.

A Patient in the Lobby Refuses to Leave: Medical Emergency, Unhappy Customer or Active Shooter?

The receptionist interrupted me in the middle of my dictation.

“There’s a woman and her husband at the front desk. She’s already been seen by Dr. Kim for chest pain, but refuses to leave and her husband seems really agitated. They’re demanding to speak with you.”

I didn’t take the time to look up the woman’s chart. This could be a medical emergency, I figured. Something may have developed in just the last few minutes.

I hurried down the hall and unlocked the door to the lobby. I had already noticed the man and the woman standing at the glassed-in reception desk.

“I’m Dr. Duvefelt, can I help you?” I began, one hand on the still partway open door behind me.

The husband did the talking.

“My wife just saw Dr. Kim for chest pain and he thought it was nothing. He didn’t have any of her old records, so how could he know?”

While I quickly considered my response, knowing that Dr. Kim is a very thorough and conscientious physician, the man continued:

“Can we get out of here, and step inside for some privacy?”

My mind raced. This was either a medical emergency or an unhappy customer situation. We had the door locks installed not long ago on the advice of the police and many other sources of guidance for clinics like ours. It was a decision made by our Board of Directors. In this age of school, workplace and church shootings, everyone is preparing for such scenarios. We are always reminded not to bring people inside the “secure” areas of our clinics who don’t have an appointment or a true medical emergency.

I figured I had to find out more about this woman’s chest pain in order to make my decision whether to let her inside again; after all, she had just been evaluated.

“Ma’am, are you having chest pain right now?” I asked.

“A little”, she answered.

“How long have you had it?” I probed.

“A couple of years now.”

“And you just saw Dr. Kim?”

“Yes, and he said my EKG looked okay, but he didn’t bother to ask me about you heart valve operation three years ago in, Boston. He just said ’we’ll get those records’, and he told me I was okay today.”

The husband broke in, “It’s the same everywhere we go, everybody just says it’s not a heart attack, but we need more answers than that. we know what it isn’t, but we need to know what it is!” He added, again, “can’t we go inside for some privacy?”

“Have you been seen elsewhere for the same thing?” I said without answering the request.

“Yes, at the emergency room in Concord, New Hampshire when we lived there…”

“Did Dr. Kim have you sign a records release form so we can get the records from Boston and New Hampshire?” I asked.

“Yes”, the woman answered.

“Then that’s all we can do today,” I said. “I hear you telling me this is an ongoing problem, you’ve already been assessed today and Dr. Kim told you that you’re safe today and we’ve requested your old records. That’s what needs to happen.”

“You mean you’re not going to help us today?”

“You’ve seen Dr.Kim, your records will get here, I don’t know what more we can do for you today.”

“You’ll hear about this”, the husband said as they stormed out. Another man in the lobby introduced himself to them and said “I’ll be your witness.”

I closed the self-locking door and wished I had somehow been more skilled and more diplomatic, and I wished the world wasn’t the way it has become in just a few years, with more concern for bolted doors, gun violence and mass shootings than simple customer relations.

A Country Doctor Reads: July 12, 2019

Basch Unbound—The House of God and Fiction as Resistance at 40 | Humanities | JAMA | JAMA Network

The 1978 novel The House of God is a fictional account based on the internship experience of Samuel Shem (Stephen Bergman) at Beth Israel Hospital in 1973-1974.

I am more appalled now than in 1973 by our national politics, by the way house staff are forced to spend much of their time at computers, by the fact that patients have no idea that electronic health records are designed to optimize billing and insurance payments rather than their care, and by the way nonphysician executives at the top of hospital systems, having never been trained in patient care, dictate the terms of the profession.

Chekhov described the best of writers as those who convey “life as it should be in addition to life as it is.”3 The impulse to resist, reform, and create a view of life as it should be still inspires my writing and has carried me through everything I’ve done. I’m trying to hand that fight over now to the younger generation, in my teaching at NYU Med, in public speaking, and in a forthcoming new sequel to House called Man’s 4th Best Hospital.4 I talk to anyone who will listen about the electronic health record and the takeover of medicine by money and the opportunities that exist to resist it.

“We doctors are the workers, I tell them. Without us, there’s no health care.

We have power and can shape the fate of medicine.

My generation is almost gone, we’re out the door, so this is your fight now, your life.

What will you do with it?”

— Read on https://jamanetwork.com/journals/jama/fullarticle/2738069

The Stages of a Man’s Life

Moving always involves pondering book titles as you pack and relocate your library. This weekend I did my last walk-in Saturday in Bucksport and back in Caribou sixteen hours after starting out I randomly opened a box that contained my prized Osler biography, signed by Cushing, and came across the 80-some page monograph “He” by Jungian psychologist Robert A. Johnson. I wrote about this book here six years ago.

I have a couple of copies of this little book and I keep coming back to it. First published in 1989, just before I started a four and a half year stint at Cutler Health Center at the University of Maine during my first exile from Bucksport, it describes the archetypical journey most men must undertake as they move through the stages of life, referencing literary names like the Fisher King, Parcifal, Don Quixote, Garamond, King Arthur and the knights around his table, the Holy Grail and the Grail Castle.

The essence of Johnson’s book is that males during adolescence have a profound (Holy) Grail experience, too powerful for them to remain in but then spend the bulk of their manhood hoping to find again. They finally learn that they were never that far from it; it is just a short way down the road and to the left, and this time, if they have learned their life lessons, they can enter the castle and remain there.

Central to the legend is that a simple man, a fool, needs to ask the simple question “whom does the Grail serve” in order for the wounded Fisher King to be healed. But Parsifal, who is such a person, heeded his mother’s advise “don’t ask too many questions” and missed his opportunity.

As I reread the book this time, a sunny Sunday morning over several mugs of coffee, I reflected on how much I have changed in the thirty years since I first read it.

One of the themes throughout the book, woven through the Grail legends, which exist in several cultures and languages, is man’s relationship to his inner feminine, one of the strong elements of Jungian psychology.

Johnson lists six basic relationships a man shares with the female world. All are useful, but they must not be confused with each other: His human mother, his mother complex, his mother archetype, his fair maiden (Jungian speak for inspiration), his flesh and blood wife or partner and Sofia, the goddess of wisdom.

Johnson explains the difference between mood and feeling. Feeling is the ability to value and mood is being overtaken or possessed by a man’s inner feminine.

I am still working on reigning in my tendency for moodiness on some levels, and I am working on letting go of my Americanized idea of “the pursuit of happiness”.

Johnson, as many other thinkers says that happiness is, linguistically and philosophically, living in the present, with “what happens”.

He references Alexis de Tocqueville:

“One cannot pursue happiness; if he does he obscures it. If he will proceed with the human task of life, the relocation of the center of gravity of the personality to something greater outside itself, happiness will be the outcome.”

Here I am, unpacking boxes, mending fences, cleaning stalls, reorganizing closets and cupboards; life is happening in a humble red farmhouse with peeling paint and a sagging front porch. It feels a lot like moving out to camp every summer when I was a young boy, before I started to think I had to be a knight and a dragon slayer…

To quote James Taylor, not for the first time:

“The secret of life is enjoying the passage of time. Any fool can do it. There ain’t nothing to it.”

A Country Doctor Reads: July 6, 2019

Time and the Choice to Listen

This week, again, I ran into a couple of articles about the inordinate amount of time doctors spend on charting and reading chart notes. Each of my reads made the point that it is better to listen to the patient.

When you find yourself in a position of rendering a second opinion, do you read through old notes and test reports or do you put all that aside and listen to the patient tell their story from the beginning?

Osler himself said “Listen to your patient, he is telling you the diagnosis”.

Raphael Rush, MD, has a thoughtful essay in The New England Journal of Medicine, titled “Taking Note”:

I turned my chair away from the computer and angled toward her. My stethoscope weighed on my neck and I removed it, along with my smudged glasses, which forced me to lean in. I picked up a pen and some paper, ready to transcribe whatever she said.

After a moment, she took off her jacket and settled into her chair, resting her coffee cup down on my desk. She seemed to relax. I confirmed her name and date of birth, and then we began.

“I have a lot of records from your other doctors,” I said. “We’ll review those together in a bit. But I want to hear your story again, in your own words, if that’s OK. From the beginning.”

http://www.nejm.org/doi/full/10.1056/NEJMp1816537

JAMA Network Open featured a piece this spring by Pieterse and colleagues titled “Shared Decision Making and the Importance of Time”

Clinical encounters, although uncommon in the lives of many patients, offer a place and time for clinicians to gather insight into what matters to each patient and for patients and clinicians to co-create care that fits each patient’s situation. Time during encounters is usually set by the schedule, which is the result of algorithms that prioritize meeting the demand for access to available clinicians over offering enough time for unhurried consultations. The completion of recommended tasks and of clinical and administrative documentation further taxes the time in consultations. Clinicians often feel hurried and interrupt the conversation with a patient, on average, within 11 seconds.4 When lacking time, clinicians may present information with a complexity or tempo that may easily overwhelm the attention of patients who are ill and worried. Information is then lost on patients, and time is wasted. Clinicians may not allow for a silent pause and miss key patient disclosures or questions.

Conversely, wresting unhurried visits from a system that overbooks clinicians occurs by accident, such as, for example, when a patient does not show up for a visit, or requires a conspiracy between patients and clinicians to lengthen the visit and spend the necessary time together. The resulting delay may offend other patients who are waiting and frustrate the staff who will have to stay late at work.

https://jamanetwork.com/journals/jama/fullarticle/2731737

And in my own archives I have a piece from 2017, titled “Did You Read My Chart?” about a woman with a chronic problem I saw one busy Saturday (No, I did not read it):

https://acountrydoctorwrites.blog/2017/02/28/did-you-read-my-chart/


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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