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The Ghosts in the Exam Room – Part 2

Even Hippocrates acknowledged that medicine is not practiced in a vacuum. He didn’t use the word vacuum, of course, as it first came into use in medieval times. But he did speak of the individuals that influence doctor-patient relationships. He called them “the Externals”. I have referred to them as “the ghosts in the exam room”.

In my previous post I wrote about how Medicare is now scripting entire visit types – don’t follow the script for the “Annual Wellness Visit” and risk having to return your payment from Uncle Sam. Medicare is certainly a ghost in every exam room in today’s medicine.

There are other ghosts that whisper threats or temptations in both our patients’ and our own ears as we talk to each other. All insurance companies try to do what Medicare is doing but most of them don’t have the same clout. From drug companies to malpractice courts there are countless external forces that make their presence known in the physician-patient encounter. We are all aware of this and do our best to still provide a private, impartial space for our patients to share their concerns with us.

But not all ghosts in the exam rooms are authority figures that try to promote their own agendas in our patient encounters. We all bring our own private ghosts in the form of, for us physicians, patients we have learned from or whom we have failed – making us more cognizant of our personal and professional limitations. Most of us also carry the spirits of our mentors with us as we close each exam room door and open our senses and our hearts to each of our working day’s fellow human beings in some sort of need.

I often think of those patients who I knew had something dreadfully wrong with them, even if I didn’t at first know exactly what. I think about the High School senior who came in with a rash on her legs a few days before graduation and turned out to have acute leukemia. I think about the woman who wouldn’t let anyone else biopsy the small lymph nodes above her collarbones, which proved to be metastatic lung cancer. I think about the rugged motorcycle-riding deer hunter who blamed his widespread muscle pains on falling out of a tree stand a week or two earlier; he also had lung cancer. I also carry with me the vivid recollections of patients who made their own diagnosis once I let them speak uninterrupted.

In many difficult visits I also call on my mentors. Sometimes when I seem to be treading water, I think of Professor Boström, who sat in the corner of the exam room crushing tongue depressors during my final exam patient interview at the end of my internal medicine course. When I find myself getting flustered or feeling hurried, I think of Bob Gordon, one of the specialists at Cityside, who never seems to be in a hurry and never seems overwhelmed, even though he sees more dramatic cases than I do. And when I feel pulled between the conflicting agendas in today’s health care – when the ghosts in the exam room won’t stop chattering – I think to myself: “What would Osler do?”

Thinking and reading about the great masters throughout the history of medicine is as important as keeping up with the leading medical journals.

Practicing medicine without understanding, or at least respecting, the history of our profession and the changing nature of scientific knowledge is like sailing on the ocean without charts, compass, or GPS for that matter. You will begin to just drift with the prevailing wind.

Remembering that ours is an ancient calling that has existed in many cultures and under many rulers is necessary when so many forces are vying to redefine our profession.

We need to make sure the scary ghosts don’t outnumber the friendly ones. Because it is very obvious these days in our line of work: We are hardly ever alone with our patients.

The Ghosts in the Exam Room – Part 1

The Medicare Annual Wellness Visit

One of the ghosts in every exam room is the institution that pays many private doctors over ten million dollars, the authority that determines that you can order a BNP (brain natriuretic peptide) to look for heart failure in patients with shortness of breath but not when they have leg edema – you know who I’m talking about – Medicare.

Medicare is not only deciding what services to pay for; they are also scripting entire doctor-patient visits.

As Medicare goes, so goes the nation’s healthcare. Except when it comes to annual checkups. For decades, just about all insurers except Medicare covered annual exams, and even paid pretty well for them. Now that the US Public Health Service Task Force on Prevention has stopped recommending annual exams, Medicare – read Obamacare – has started demanding them. However, they are not paying for the kind of exams patients have come to expect, but a watered-down, scripted event in the spirit of the “Welcome to Medicare” exam that at least yours truly refused to provide from Day One.

I have been brushing off the Annual Wellness Visit (AWV) until now, but it has become a quality indicator that our clinic has to report statistics on, so I need to change my ways.

For the past few days, I have been studying the scripts for the AWV. I have printed up the forms I will need in order to follow the script, since our EMR only has a template for the “Welcome to Medicare” visit, but not for the Annual Wellness Visit.

I have scratched my head about the covered baseline EKG when the USPHS recommends against it, the PSA screening when the evidence doesn’t support it, and several other items on the checklist.

I have duly noted that some clinics, after being audited, have had to call patients back in at no charge to complete missing items on the checklists. I have also noted, although I’m not sure I can comply with, the requirement that any actual physical exam performed during one of these visits requires the patient to sign an ABN (Advance Beneficiary Notice) that they might get a bill that isn’t covered by Medicare. I think I’ll just listen to some hearts and lungs without telling Uncle Sam about it.

Actually, I am a bit surprised that the roll-out of this scripted non-physical didn’t cause more of a stir when it happened. I was only vaguely aware of it. It is quite remarkable that a payer is now micromanaging what happens in the exam room to such an extreme degree.

I am figuratively holding my breath to see what my patients will think of this regimented encounter; they are used to me letting them speak, and me only gently steering the conversation in the exam room. I expect many will feel uncomfortable about the obvious presence of the ghost of the Government in what used to be our private space.

The Broken Promise of Computers in Healthcare: A Doctor From the B.C. Era Explains

B.C., or “before computers”, medical charting was quick and information retrieval in small practices’ paper charts was effortless. Younger clinicians who never experienced well organized paper charts have been brainwashed to believe they were always chaotic and inadequate, perhaps like children born after the communist revolution in China… Oh, never mind.

With larger clinic sizes and with outside forces, Medicare, Medicaid, insurance companies and middlemen, demanding more and more statistics, computers became the only recordkeeping modality that could deliver to all those “stakeholders”.

Clinicians like me were told that computers would make our charting, data retrieval and lives in general much easier. That was stressed more than the fact that all those people looking over our shoulders would have an easier time doing what they do.

For several years now, with the painful introduction and abandonment of one “new and improved” EMR and chaotic adoption of another even more complex one, I have had reason to think about how much longer it takes to do my work than it used to.

I posted once about how quickly I retrieved medication information from a handwritten medication list inside an old paper chart in my clinic. I have also written about how simply we entered INR values and Coumadin orders on paper flow sheets and how cumbersome it is in the EMR. To this day I have a (secret) reddish three ring binder with a flowsheet for each Coumadin patient I have.

I think I am particularly bitter about today’s EMR’s, their clumsiness and their intrusiveness because I was around before they came about (and happy with the paper charts) and because I was fed manipulative misinformation that they would make my life easier when the main purpose was to help the onlookers, the Wizards of Oz, the men behind the curtain and the ghosts in the exam room.

If you grow up with something that was there before you entered the picture, I don’t think you expect much more from it than what it is. But if you watch the introduction of it after listening to all the promises and then see how those promises were broken, you are more likely to be critical about its shortcomings.

But lest y’all think I’m an old Luddite who could never love a computer, or an EMR at that, let me tell you about the Saturday 5 years ago this month in Bucksport when I saw 27 walk-in patients in 7 hours, charted them all in eClinicalTouch on my iPad Mini and walked out the door 20 minutes after my last patient:

Driving my Mini (iPad)

Hippocrates’ First Aphorism

“Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals cooperate.”

Hippocrates was a wise man. In an era where the causes of most diseases, even the functions of many organs, were unknown, he made detailed and astute observations that allowed him to become a master of prognosis.

His first aphorism is not often quoted in its entirety. When I first read it, I was struck by especially the last two words, “externals cooperate”. It makes me think that perhaps doctoring a few thousand years ago might have been a lot like today. We aren’t the first physicians to deal with demands beyond those of the clinical circumstances, the patient and his or her family.

I can only imagine who the externals were in Hippocrates’ time, but I am thoroughly familiar with who they are today: They are insurance company doctors and executives, pharmacy benefit managers and others, who say yes or no to our diagnostic and treatment plans. They are the ghosts in the exam room when patients and doctors try to make plans together.

The phrase “experience perilous” seems to imply that the gaining of experience is fraught with danger, but an alternate interpretation is that relying only on one’s own experience can be misleading. Hippocrates often emphasized the need to apply the known science to the practice of medicine.

The central point is that it takes time and effort to learn the art of medicine, which is sometimes glossed over in our fast moving society.

The volume of known science has obviously multiplied since Hippocrates’ time, and we can each know only a small fraction of it. But with all the available information now instantly searchable, we can become dangerous to our patients if we apply things without knowing them well through education and experience.

So, in the spirit of Hippocrates:

The artful practice of medicine requires understanding of the science, technical mastery of the craft, and wisdom

           and

Facts can be learned by anyone; experience is earned through years of practice; wisdom is granted to us only if our hearts and minds are open, in our practice of medicine, and in our lives.

Ten Building Blocks of Therapeutic Relationships

It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word.

This has been the bread and butter of counselors for years. People will faithfully attend and pay for weeks, months and even years of therapy visits just to have an attentive and active listener and to feel like they have an ally.

We also have data that shows that adherence to treatment plans is dependent on how patients feel about their provider. One problem solved can build an ally for life

Primary care medicine is a relationship based business. I don’t know how often that basic fact is overlooked or denied. Whether you are trying to get another person to alter their lifestyle, take expensive medicines according to inconvenient schedules or even just trust and accept your diagnosis, you have to “earn” the right to do those things. Our titles and medical accoutrements give us a foot in the door, but they don’t usually get us all the way into peoples inner circles of trusted advisers.

In this age of corporate medicine, there is a belief that patients attach themselves to institutions and networks because of their trust in the organizations, and that therefore the connection with their individual providers is secondary.

I think that is a factor mostly when someone is looking for sophisticated specialty interventions, often one-time-only, like “where’s the best place to go for high risk cardiac surgery”.

When looking for primary care, people still tend to ask, “who’s a good doctor”, rather than “which is the better primary care group, Uptown Medical Associates or Statewide Primary Care”.

How do you as a clinician in today’s restless and mobile society earn trust and build therapeutic relationships in fifteen minute visits with several visible and invisible intruders in the room – the computer and the insurance company, for starters.

I have previously reflected on how to prepare yourself for beginning a clinical encounter. My ABCs are Attention, Behavior and Connection.

But where do you go from there, how do you continue, grow and nurture a therapeutic relationship over time in the kind of environment most of us work within?

Here are a few lessons I have learned myself:

1) Listen and respond. How many times do we hear that patients don’t get to speak for even a minute before we interrupt them? If you hear something that immediately requires clarification, do what you would do in a social situation. Say that what the other person just said is important or interesting, reflect back what you think you understood and then be careful not to give them too many yes or no options, but invite them to continue their story. Imagine that you’re meeting an interesting person at a dinner party, not leading a legal interrogation.

2) Set an agenda. Almost every time I ignore this little rule, I get burned. Patients may not reveal their real concern when making an appointment and their priorities may have changers since then. Going all-in with what you think is their main issue and saving “do you have any other concerns” until the end of the visit is a recipe for disaster. That agenda-setting may need to be addressed right away or after hearing a little about the main concern. If you don’t ask what people need from you, how can you ever hope to fill your role as their provider?

3) Budget time. Don’t act frustrated about the reality that time is at a premium, and don’t declare that you have too little of it until you know how serious or urgent your patient’s concern is. The person with a seemingly trivial concern may need you to help them with the biggest or worst problem of their life, so invest your time and attention on listening and understanding early on in the visit. By acting unhurried at first, you are more likely to create an atmosphere of trust and caring; once you know your patient’s concern and their diagnosis or differential diagnosis, if they feel heard, you can move more quickly to wrap up the visit if you need to.

4) Manage the perception of time. If I am running late, I often enter the exam room and demonstrably sit down, take a deep breath and relax my posture as if I am finally arriving at the most important appointment I have all day. That slowing down gesture helps me to undo my patient’s fear that I’m going to be rushing them along. If they think I’m not going to meet their needs, their memory of the visit will likely be just that, even if I do a pretty good job technically for them.

5) Don’t be a hero. My 2018 post “Be the Guide, Not the Hero” points out the fact that everyone is on heir own journey in life and we are at best guides in our patients’ pursuits. If we try to be the hero in their stories, we create unhealthy, dependent relationships that often lead to patient disappointment or even resentment. As guides instead of heroes, we also remind ourselves that we are not the ultimate experts on what is best for our patients. Since our patients are the heroes of their own stories, they must ultimately decide which piece of advice from which guide they will choose to follow.

6) Be true to yourself. On the one hand, I believe we must adapt our demeanor to the situation – reassuring, motivating, inquisitive or sometimes decisive – but we must stay within the range of our real selves. I can be jovial only to a point or I will seem and feel like I am pretending, for example. People can usually sense falsehood a mile away.

7) Balance disclosure. We can not build therapeutic relationships as only technicians; we must engage as real people and you can’t be real without showing emotion, genuine interest, engagement and a good amount of humility. We have to be careful to show that we are fallible like everybody else but also that we ultimately have our act together. Nobody wants a self absorbed, overconfident guide, but nobody wants a weak and insecure one either. If we say we never had tough choices to make or regrets we carry with us, how can we expect patients to allow us to be close enough to build trust?

I tell people things they could relate to that I don’t think would come back to haunt me. I tell them how many miles I have on my car, but not how much money I spent on repairs. I tell them about my life lessons from being a Boy Scout or going through basic training in the Swedish army, the antics of the beagles I’ve had in my life or the way my one-time vegetarian diet made me put on weight. I tell them I was homesick at my first scout camp, but I don’t talk about things that could distance patients from me; not that I am a golfer or a sailor, but pictures and magazines of such things will alienate as many patients as it might build relationship with. My Arabian horses didn’t cost much money, they were adopted from a horse rescue and simply needed a home. Our relationship with animals, I believe, is more likely to show that we have the capacity for relationship building with humans, too.

8) Build continuity. From one visit to the next, find a thread to follow. For some patients, it is their chronic disease, for others their family or their hobby. Reconnecting about what you talked about last time is a powerful and quick way to reestablish the fact that you know each other and that you care about your patient. It brings you straight into a space where you are ready to do the work you do. Even if you have to pull up their last visit in the EMR (maybe even looking at the screen together), that quick reconnection that begins every visit helps make you seem better prepared; maybe you don’t remember the details of the last visit but you do remember your patient very well.

9) Solicit participation. When it’s time to formulate a treatment plan, don’t be too quick to lay it out as if there is only one way to do things.

10) Plan when and how to reconnect. “Followup PRN” isn’t usually the best way to conclude a visit in your mind or the EMR. Friends don’t usually leave each other saying “I’ll see you around”, that’s more for casual acquaintances. It’s important to agree on what to do after the test results come in, when the antibiotic runs out, if the rash doesn’t go away or when to meet up if everything is going well. Not making such plans devalues the relationship and makes you look as if you don’t care about your patient.

Everything on this list is about how we interact with the people we engage with frequently or infrequently. We must always look beyond the diagnosis and the Chief Complaint (which should be Chief Concern – where did “complaint” come from?). Remember Osler:

The good physician treats the disease; the great physician treats the patient who has the disease.

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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”.

BOOKS BY HANS DUVEFELT, MD

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