Archive for the 'The Art Of…' Category

The Art of the Message

Sometimes I wonder if I am wired differently from other doctors, in terms of what I remember on my own and what I need some help with.

The other day I got a “medical call” that simply said, “Mr Brown called to report his blood pressure is 120/80”.

With more than fifty calls in my inbox and no memory of what the issue was with Mr Brown’s current blood pressure, I replied “seems like a random fact, is there a back story?” I never heard back.

Seeing up to thirty patients a day and receiving at least fifty each of EMR “documents”, messages and lab results, my mind doesn’t retain the details of each clinical plate swerving in the air above my head. Mr. Brown could have stopped his blood pressure pill because he was lightheaded with a low blood pressure, or he might have stopped his valsartan because he was caught up in the fears of cancer causing ingredients in Chinese generics, or he could have had an abnormal potassium and stopped the medicine that could influence potassium levels. Or, perhaps he got a home blood pressure cuff to prove that he has white coat hypertension.

In my world view, in light of the productivity requirements in primary care, messages need to be anchored in a clinical scenario so that the provider can make a decision without doing several minutes of research during time stolen from scheduled patient visits, lunch, bathroom breaks or life in general.

“Tell me why you were asked to call in your readings” would have been the way to handle that call, but I have a vague suspicion that the medical assistant who took the call felt pressured by the list of other calls that needed attention, for example the mandatory ER Followup calls that are a quality indicator for us. The quality of clinical calls doesn’t count, so they might be a lower priority. Everyone in the medical office has their own hoops to jump through and sometimes we are tempted or have no choice but to do the minimum and pass the buck just to get through our day.

I had hoped, naively as many readers commented back then, that the Patient Centered Medical Home concept would foster a reengineering and a clearer focus on what really matters. Like so many other quality enhancements in medicine, it has created another layer of superficial check-offs that has made it harder to see the patient and the clinical issues at hand.

I still wonder what the deal was with Mr. Brown, which is not his real name; I forgot the name the instant I hit “reply” and got the incoherent message off my already full plate.

The Art of Covering

I was a little taken aback when Dr. C. changed my patient from warfarin to one of the “Novel Anticoagulants”, and one I seldom use, at that.

I have only worked with her for about three years, and we seem to come from the same mold, seasoned family docs with a penchant for teaching and patient empowerment. I had not imagined she would step in and completely change my treatment plan when she was just covering for one day.

As far as which is safer, warfarin with variable therapeutic effect and fluctuating INRs or Novel Anticoagulants, which have hardly been studied at all in patients on dialysis, you won’t see test results that may worry you, but the unknowns are still there.

It was a judgment call, and she took it upon herself to change my treatment. She may never see that particular patient again, but that brief doctor-patient relationship has changed my patient’s risk of stroke, to the better or to the worse, I don’t know which way.

As we are now adding a couple of new providers to our clinic, I think back to discussions we had 20-25 years ago, when we had another major influx of providers.

We met back then to talk about what we all wanted from each other when “covering”, and we were all pretty clear that, even though we might feel tempted to tweak blood pressure medications, diabetic regimens or other things while treating an acute problem, we wouldn’t necessarily appreciate if someone did that to our patient and our treatment plan.

So we had a truce: We would deal with the problem at hand and suggest that the patient talk to their PCP about adjusting their treatment. As far as the acute situation, we agreed to emulate each other’s style a little. Dr. Z often gave very explicit advise on over the counter and alternative treatments for more or less self limited illnesses, while I have always been inclined to say, “those things won’t make this go away any faster, they just keep you busy while you wait”. I did a lot more handholding when I covered for Dr. Z. and I think she was less adamant about my patients spending money at the health food store.

Doctors aren’t all the same, and patients usually gravitate to providers who meet their needs. And, I hope this doesn’t surprise anybody, there are many different ways to treat the same problem. Trained “abroad” and old enough to have seen medical “facts” come and go, it has been obvious to me for a long time.

I think there is a balance here. A patient who seems dissatisfied with the status of their condition or its treatment deserves to hear that there are options, and a covering provider can point that out, but to offer such advise unsolicited can do more harm than good. We shouldn’t try to look smart at the expense of our colleagues. It may be better to approach that colleague privately and say, “do you still prefer warfarin over Xarelto in dialysis patients?”

I’m still thinking about that one.

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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