A Country Doctor Writes:

Archive Page 151

It’s Time We Talk: A Doctor is a Doctor is a Doctor, Right?

Published December 13, 2014 "It's Time We Talk..." 1 Comment

I am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

In many of today’s medical practices, the doctors’ names aren’t on the front door, office letterhead or company advertisements; they’re often not even in the phone book. A group of employed doctors these days can consist of multiple personality types with disparate treatment philosophies and clinical styles. I once worked with a doctor who would give patients with upper respiratory infections half a dozen prescriptions while I would say “go home and get some rest; it’ll go away”. Not knowing what the two of us were like, patients could end up choosing the doctor whose style didn’t meet their needs.

I have worked with colleagues who view every laboratory abnormality as an ominous threat and pursue each one to the ultimate degree, making even the healthiest patients uncertain about their chances of survival. Some of the same doctors also insisted on seeing even patients with mundane medical conditions on a tight schedule in order to monitor them for unforeseen medical disasters. In today’s generic clinics, patients may not know if their new or covering doctor is a reassuring pragmatist or a consummate worrywart. Worse yet, they may be shuffled back and forth between doctors with opposite styles.

2) Training Differs

In Primary Care, we have MD’s and DO’s, Family Physicians, Internists and “Med-Peds” physicians. Each training is inherently different, further complicated by differences between schools, regions and countries.

Internists, trained to treat diseases of adults, are sometimes asked to treat children in the government-sponsored type of clinic I have spent most of my career in. They are also oftentimes faced with treating conditions in ophthalmology, otorhinolaryngology, gynecology and orthopedics – areas where they may have little experience. Their residency training may have been entirely urban and hospital based, but in today’s American job market, the demand and opportunities tend to be in more rural areas, particularly for visa applicant physicians from third world countries, where academic hospital medicine may be fairly similar to US healthcare, but where small town and rural medicine can be very different.

3) Culture Matters

As an immigrant physician with English as my second language, I had to work at speaking comfortably with rural American patients, many of whom were of French-Canadian origin. It must be a bigger challenge for physicians from further away than Sweden. Language is only the beginning. How different cultures view life events and medical conditions can vary greatly. I am told that the Japanese don’t have a word for hot flashes and that in Tibet, most people aren’t familiar with the notion of depression.

People in this country often talk about how doctors need to be sensitive to minority patients’ culture. Less is said about minority physicians’ familiarity with the American majority of patients; whether we are from Sweden, Japan, Tibet or India, we each have a learning curve for understanding those we are here to serve as personal physicians.

I remember one internal medicine physician from a Muslim country who found out that his American employer expected him to perform routine gynecological exams including Pap smears on his female patients. Not only had he never been trained to do any of it, he also had to wrestle with overcoming what his his entire upbringing had told him was improper.

4) What is a Good Doctor?

The industrial view of healthcare imagines that it consists of standardized processes that are easily measured: What is the average blood sugar, or glycohemoglobin, of Dr Andersson’s and Dr Singh’s patients? Their pneumonia immunization rate? How many of their heart failure patients are on a beta blocker? How many seniors have had a fall risk assessment? How many obese patients have an obesity action plan documented in their medical record?

Nobody talks about this, but all those quality indicators make less difference for individual patients’ longevity and for entire populations’ health than healthy lifestyles do. For individual patients’ health as it relates to healthcare, accurate diagnosis of new symptoms can amount to an all-or-nothing disparity between health and disease, even between life and death.

Some of the most basic measurements of physician quality are surprisingly irrelevant: Beta blocker therapy in heart failure patients only increases average survival 6-12 months, it takes 50,000 pneumonia vaccinations to prevent one pneumonia death, and prostate cancer screening, once a basic minimum requirement for men’s health care, is no longer even recommended.

My uncle had waxing and waning paralysis of his left arm, but his doctors never checked his carotid arteries, and soon thereafter he had a stroke. My aunt had a cough for well over a year, but because she never smoked, her doctor didn’t order a chest x-ray until it was too late and her lung cancer was inoperable. This happened in Sweden, where the average life expectancy is the 6th highest in the world, 3 years more than 32nd ranking USA. It could have happened anywhere, because doctors are people, each one different, and the real quality of their work cannot be measured, let alone regulated.

Employers and bureaucrats may think a doctor is a doctor is a doctor. My aunt, for one, doesn’t think so anymore.

Three Dimensional Doctoring

Published December 8, 2014 Reflections 1 Comment

“I keep six honest serving-men
(They taught me all I knew);
Their names are What and Why and When
And How and Where and Who.”

Rudyard Kipling

Medicine has become a very complex, multifaceted science, ranging from pharmacogenetics to psychoneurobiology. Doctoring, however, is increasingly viewed as so simple that you don’t actually have to be a doctor to know how it should be done.

What else could explain why IT people tell doctors what “workflows” to follow, instead of doctors telling them “we need computers that do this in this kind of way, so that we can better take care of our patients”?

What else could explain why the quality of our work can be measured by only a handful of parameters, all simple numeric indicators? Never mind that the target numbers change from time to time, and never mind that even well established individual targets sometimes disappear from the checklists.

What else could explain why it is the government that defines the overarching goals of health care in this country, and probably many others?

I’ve been thinking a lot lately about what it means to be a doctor, and particularly a good one, in the present era and from a historical perspective. Also, I have started to formulate a definition of what it takes to make doctoring a sustainable lifetime vocation in these times.

I think doctoring occurs on three levels, each one necessary for the physician to engage on:

1) The “How”

The most visible, and perhaps most intuitive, level is that of solid clinical knowledge and proficiency. This, of course, takes different forms in different specialties. Knowledge and proficiency are not enough, though. Judgment and critical thinking are essential but seldom emphasized in the lay debate on medical matters. The clinical art of medicine involves an infinite array of decisions about when general principles apply to the individual patient and when they do not. It also involves staying current with medical science and viewing claims, be they by drug companies, medical or political authorities, through the lens of the scientifically trained clinician. Today’s emerging practice of applying genetic research to individual treatment decisions moves us away from blindly following “guidelines”and validates the traditional importance of considering each patient’s unique social and biological makeup as manifested in their family history.

If the “How” of medical practice truly was as simple as some say today, guidelines and “best practices” would largely eliminate the need for independent, critical thinking and make a university education and the years of rigorous clinical training and practice unnecessary for delivering what we call health care today. Obviously, this is far from the truth.

2) The “Who, What, When and Where”

But doctoring goes beyond the technical proficiency and the scientific thinking that goes into each patient encounter. Borrowing from Kipling’s expansion of journalism’s “Who, What, When, Where, Why”, the first level of doctoring is the “How”. The technical “How” cannot be viewed in isolation. The “W” words of analyzing the locus of complex issues date back to Hermagoras’ “seven circumstances“, two thousand years ago.

A doctor doesn’t work without context or in complete isolation, although my wife sometimes (lovingly, I believe) calls me a Martian, implying that I somehow just landed on this planet as a doctor, ready to serve patients. Each doctor usually has a place of practice, a schedule, a way of collecting money for services rendered and these days also assistants, nurses and people who carry out administrative tasks.

In today’s society, doctors are increasingly separated from this necessary aspect of the practice of medicine. As employees of large organizations, they have their office hours, the length of each appointment and the number of patients seen on any given day determined by other employees.

Equipment purchases, from EMR’s to surgical instruments, are made by managers and supervisors with only varying degrees of physician input. And support staff are usually hired, trained and evaluated by management, not by the physicians.

In the day-to-day work of physicians, the seemingly inconsequential practical aspects of how a medical office functions can be significant impediments to good care as well as to both patient and physician satisfaction.

Involvement and input into the workings of the medical office are important aspects of being a doctor. Why would Michelangelo not care and instead have someone else pick out his paints and brushes for him? If a company of firefighters were issued pairs of only two left boots, would they perform to the best of their abilities, running toward the fire?

Another aspect of “Who, What, When and Where” is how medical practices relate to their customers, their physicians’ patients. All physicians, I believe, should be involved with how the office treats its patients, from telephone triage to billing and collections practices. Those things frame the office visit and may determine its outcome in many instances.

Only a one dimensional, disillusioned physician would have no interest at all in what happens in the medical office outside the exam room and the allotted fifteen minutes of appointment time. No disease can be effectively treated out of the patient’s context, so how can we imagine treatments working entirely without considering the clinic’s context?

Sir William Osler said: “The good physician treats the disease; the great physician treats the patient who has the disease.” The patient relates and reacts not only to the physician, but also to to the organization that employs the physician and defines the terms of engagement between doctor and patient.

3) The “Why”

The government wants most people to be healthy enough to be productive citizens, so it has defined health care with that purpose in mind and will sacrifice individuals to protect the collective. This happens when we go to war, too, for example.

Physicians generally feel a very strong obligation to their individual patients, and seldom face the choice of helping one patient over another.

So, why do doctors take on such obligations as their vocation?

I see doctoring as a calling with a higher purpose. My main professional motivation is to relieve suffering. In some specialties the purpose may be finding ways to enhance well-being, something I do to a degree as well.

Then, what defines a doctor?

The word “doctor” is derived from the Latin “docere”, which means “teacher”, and can also mean someone who has been taught, or educated. And if we think about this, every physician has been taught by another physician, which is the way it has been for thousands of years. Even though the profession has changed, just like the science of medicine, we are still carrying the legacy of those who went before us.

I really didn’t just arrive one day as a fully capable doctor from another planet; I went to a five hundred year old university, home of Linnaeus, Celsius, Ångström, Berzelius and Bárány. I owe whatever acumen I have acquired to the dozens of teachers and mentors, who shared their knowledge with me.

In a moment of passion, I thought of the phrase “The Apostolic Nature of our Profession”. It points out that physicians today are still carrying out an ancient tradition and also a fundamental role in our society and in people’s lives.

That sense of our place in history is necessary to navigate the rapidly changing currents in health care today. Without it, we are just technicians with ever-changing repair manuals, while our patients, just like patients two thousand years ago, are looking for a “docere” – someone learned, who knows not just the facts, like Google or Wikipedia, but understands their context and can help weigh their significance.

When the increasingly complex “How” of daily practice doesn’t always make sense, and when the “Who, What, When and Where” doesn’t take physicians’ accumulated experience into account, the “Why” is the ultimate question that defines us and our place in society as well as in history. All three sets of questions demand consideration as we think about our vocation as physicians.

Sir William Osler also spoke of three dimensions of medicine. His eloquent words define three somewhat different aspects than my musings, but the idea is still the same: Doctoring is something that takes place simultaneously on many levels. He placed doctoring in the arena of disparate definitions of medicine (religious in his day, political in ours), in the cross point of art and science and in the realm of morals and noble ideals:

“The critical sense and sceptical attitude of the Hippocratic school laid the foundations of modern medicine on broad lines, and we owe to it: first, the emancipation of medicine from the shackles of priestcraft and of caste; secondly, the conception of medicine as an art based on accurate observation, and as a science, an integral part of the science of man and of nature; thirdly, the high moral ideals, expressed in […] the Hippocratic oath…”

Physicians in today’s politicized, technocratic and materialized society are at constant risk of becoming one dimensional robotniks in a healthcare machine whose purpose is not the same as our ancient forbears’. We need to always remember “Why” we are here; we must be a strong voice in all discussions about “Who, What, When and Where”; and we need to guard our scientific integrity as we practice the “How” of our profession.

Equanimity and the 25% Rule

Published November 26, 2014 Progress Notes 1 Comment

A Country Doctor and his horse, Thanksgiving 2012

Equanimity eluded me the other day after a string of challenging visits that each ran over its allotted 15 minutes. There was the man with a nonhealing lip ulcer that might be cancer, the elderly woman who decided to stay with her abusive husband, and the depressed pain patient whose lumbar steroid injections had not helped.

“Can I see you for a second”, Autumn said, peeking her head in after a discreet knock on the exam room door. She told me that Mauritz Blair in Room 1 had already left his room twice to express his dissatisfaction with my running late. I looked at my watch – only twenty minutes behind schedule.

“He said he’ll give you a few more minutes”, Autumn said. I shrugged and went back in the exam room with my waiting pain patient.

“I’m sorry about the interruption”, I said as I sat back down on my stool.

A few minutes later, I crossed the hall to Room 1. Mauritz Blair had been in a couple of weeks before with a longstanding, strange pain in his upper abdomen. I had ordered tests, which were all normal. I needed to come up with the next step in his workup. I wasn’t sure what to do next.

I knocked on the door and entered. Mauritz stood in the middle of the room with his arms crossed and turned an angry stare in my direction.

“What’s going on”, I said.

“Where have you been? I’ve been standing here without hearing any sign of life in this office for a long time. I was beginning to wonder if you were even here.”

I felt my indignation rise and heard myself blurting out:

“I’ve been seeing patients all day. Do you really think I’d keep you waiting on purpose? I had patients with big issues that needed some extra time. I’ve done that for you sometimes. Don’t you think I always do my best?”

He uncrossed his arms in surprise and I composed myself, trying to rescue the visit that had started with the two of us suspicious of each other.

I motioned toward the two chairs in the room and we sat down next to each other. I showed him the printouts of his tests and explained what each one meant.

“This could be what’s called Splenic Flexure Syndrome”, I began, and went on to explain the condition and some strategies to treat it. He listened quietly and I never did get a sense whether he thought my assessment and plan were reasonable.

“Why don’t you try these things for a couple of weeks, then we can follow up and see how they worked”, I said and entered my follow up request in the EMR.

He left without making another appointment.

That visit hung over me the rest of the day and after supper I confessed to my wife that I had failed in a visit by reacting with selfish indignation instead of trying to understand a frustrated patient. He could have been more worried than I realized, he could have had something else bothering him, or simply just been in a hurry. Just because he is retired, that doesn’t mean he doesn’t have time pressures just like I do.

I found myself, not for the first time, openly confessing to my wife that one of the few things about myself that I take too seriously is my commitment to my patients and my profession. I admit my procrastination at home, my vanity, my bad posture and all my annoying habits, but I have trouble accepting that some patients don’t think I try hard enough.

My wife listened patiently to my monologue. Then she spoke. I expected her to quote something from her Buddhist readings, which she did. But she first told me something evangelist Joel Osteen had said:

Only 25% of people really like you no matter what. 25% won’t ever like you. 25% like you conditionally, and 25% don’t like you unless you work at it. If you expect better odds, you’re unrealistic.

The Buddhist wisdom she shared about equanimity, one of the immeasurable qualities, was:

Equanimity in Buddhism means to have a clear-minded tranquil state of mind – not being overpowered by delusions, mental dullness or agitation. For example, with equanimity we do not distinguish between friend, enemy or stranger, but regard every sentient being as equal.
The near enemy is indifference. It is tempting to think that just ‘not caring’ is equanimity, but that is just a form of egotism, where we only care about ourselves.
The opposite of equanimity is anxiety, worry, stress and paranoia caused by dividing people into ‘good’ and ‘bad’; one can worry forever if a good friend may not be a bad person after all, and thus spoiling trust and friendship.
A result which one needs to avoid is apathy as a result of ‘not caring’.
Equanimity is the basis for unconditional, altruistic love, compassion and joy for other’s happiness and Bodhicitta.
When we discriminate between friends and enemies, how can we ever want to help all sentient beings?
Equanimity is an unselfish, de-tached state of mind which also prevents one from doing negative actions.

“If one tries to befriend an enemy for a moment, he becomes your friend.

The same thing occurs when one treats a friend as an enemy.

Therefore, by understanding the impermanence of temporal relations, Wise ones are never attached to food, clothing or reputation, nor to friends or enemies…” (The Buddha)

(http://viewonbuddhism.org/immeasurables_love_compassion_equanimity_rejoicing.html)

Sir William Osler put it this way:

“Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaint.”

As I quietly pondered all this, my wife said:

“Maybe in the exam rooms, somewhere near where the patients sit, you could hang on each wall…”

“A clock”, my mind raced to fill in. I had resisted that impulse for thirty years.

“….a picture of P.”, she said, referring to my Arabian rescue horse, who taught me patience with animals and showed me how to build trust by quietly sharing each other’s territory.

She’s right, if I can carry more of that patience with me into the pressure cooker of my workday, I may be more able to walk in the footsteps of Sir William, if not the Buddha.

It’s Time We Talk: Why Should Doctors Treat the Well and Nurses the Sick? – Part Two

Published November 23, 2014 Progress Notes 3 Comments

A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Treating the Well:

In my early career in Sweden, well child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.

These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.

With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.

Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.

The same thing happens in primary care for adults; between checkups and chronic disease management, Meaningful Use and other documentation requirements, many primary care doctors are unable to see all the sick patients, who call for an appointment.

A simple calculation illustrates this phenomenon. If the ideal caseload for a primary care physician is 1,500 patients but commonly exceeds 2,000, only providing a 30 minute physical or “wellness visit” (not the same thing) visit once a year for every patient chews up 750-1,000 hours. Total “contact” hours for each doctor according to recruitment ads these days number 32 per week times 46 weeks, or 1,472 hours. That doesn’t leave very much time for treating the sick – less than 500 to at most 750 hours, to be exact. That’s a maximum of 16 hours per work week, most of which is spent on managing chronic conditions like diabetes and cardiovascular disease. Most of the time, this amounts to tracking and treating numbers in fairly asymptomatic people – blood sugars, glycohemoglobins, microalbumins, blood pressures, lipid levels and so on.

Treating Chronic Diseases Leaves Little Room for Diagnosing and Treating Acute Illnesses:

With primary care physicians’ time increasingly spent on the routinized housekeeping details of modern chronic disease management, their diagnostic and therapeutic skills are less often used on the front lines of sick-care. Their new role of managing populations is not making full use of physicians’ traditional diagnostic and therapeutic skills. Instead we are performing more nurse-like duties such as carrying out standing orders (read “following guidelines” and “practicing Evidence Based Medicine”), and keeping track of our patients’ scheduled specialist visits as well as their sick visits, not just at the local emergency room, but also at competing walk-in-clinics. Ironically, the doctor who was too busy to see that child with an earache must now sign off on the chart notes from the local Walmart. We also end up, unreimbursed, keeping track of and even rubber-stamping orders for immunizations given at pharmacies like RiteAid.

The elimination of the truly quick and easy visits from doctors’ schedules (the rashes that the experienced clinician quickly determines are not leukemia or ITTP) makes the daily load of chronic care management greater, and often decreases total revenue in a fee-for-service system. The truth is that a skilled and experienced physician can often handle “simple” medical complaints faster and with greater accuracy than providers with less training and experience. Equally true, Nurse Practitioners can be just as good at following clinical guidelines and counseling patients about blood sugar, exercise, smoking cessation and the benefits of aspirin as physicians are. The broader and deeper training of physicians comes to its best use in diagnosing and managing atypical or rarely seen symptoms and conditions, many of which present acutely with nonspecific symptoms.

Yet, because of the so-called “doctor shortage”, this is what sometimes happens:

In many states, Nurse Practitioners, even newly graduated ones, are asked to fill the role of primary care provider or urgent care clinician, while seasoned physicians with mature practices are increasingly spending their time on the routinized treatment of asymptomatic conditions that arise from the modern lifestyles of the western world.

SO, WHO SHOULD DO WHAT IN PRIMARY CARE?

I have worked with many NPs who shoulder the responsibilities of frontline, independent, clinical practice very well because of their postgraduate experience and their personal qualities. But, “out of the box”, a new NP is not as well prepared for that role as today’s residency trained physician. The days of practicing general medicine straight out of school ended for American physicians in the 1950’s.

My point is that in today’s healthcare system, we are often asking the providers with the least training to see the unsorted clientele in “sick-call” while doctors with decades of experience may be limiting their practice to following insurance-mandated guidelines and care plans in treating non-urgent chronic medical problems and providing equally scripted wellness visits that may actually be better suited for nurses-turned Nurse Practitioners. I think the wisdom of this needs to be discussed openly. I think the perceived “doctor shortage” may just be an allocation issue.

Or, in one sentence:

If provider care teams are the way of the future, perhaps doctors should be handling more of the “sick-call”, and Nurse Practitioners more of the “maintenance“ of modern healthcare.

Let’s really talk openly about who should do what in primary care today!

It’s Time We Talk: Why Should Doctors Treat the Well and Nurses the Sick? – Part One

Published November 18, 2014 "It's Time We Talk..." 7 Comments

THREE PROVIDERS IN MAINE

Mary Hunt is a busy family physician with a full caseload. A twenty-five year veteran with an Ivy League medical degree and a residency training at an eastern seaboard tertiary care center, she has seen a lot, but she never jumps to conclusions or takes shortcuts. This makes her run late sometimes, but her patients don’t mind; they know she provides top-notch medical care.

Mary’s schedule is filled weeks in advance, and she seldom sees patients for acute illnesses. The bulk of her work is chronic disease management. Her EMR inbox is filled with prescription requests, results of standing lab orders, consultant reports, records from the emergency room, inpatient hospitalist service and the local walk-in clinic. Her office visits the past several years have become more and more scripted with checklists for the different quality measures from her Medicare Accountable Care Organization, NCQA and all the other agencies that measure her performance.

Almost every night after supper, Mary logs on to her EMR from home to finish office notes, go through results and answer “medical calls” from her medical assistant and her office case managers.

Megan Brown has been a nurse practitioner for two and a half years. She considers herself lucky to have Mary Hunt as her supervising physician. For the first two years after her graduation from her Masters program at the local branch of her state university, Dr. Hunt co-signed her chart notes and had weekly tutoring sessions, but now she is only available if Megan feels she needs help.

Megan has a small panel of patients of her own, but mostly she sees “acutes” down the hall from Dr. Hunt. She hates to interrupt the doctor because she sees how busy she is, but never feels put down for needing help managing a case. She often sees presentations that are unlike anything she has encountered in the four and a half years since she started nurse practitioner school. Before then, as a nurse, she was never exposed to the diagnostic process; she was more focused on assessing patients for comfort versus discomfort and for carrying out existing treatment plans.

Rhonda Smart has been a nurse practitioner for a decade. Before that, she was an emergency room nurse, which helped prepare her for a career as an independent frontline clinician. She has worked at a shopping mall urgent care center for three years now. She sees a fairly interesting variety of patients, but is starting to feel a little stale, because she rarely gets to hear how her patients make out. She sends her reports to the local primary care physician offices, but they never give her any feedback or updates. She does her shift and goes home and rarely spends much time with the other nurse practitioners who work at her clinic. She has no mentors and no peer group to share difficult cases or career conundrums with.

THREE QUESTIONS:

Is Mary Hunt doing what we want doctors to be doing in a way that is sustainable for her and her patients?

Is Megan Brown our best choice for first responder for undifferentiated medical symptoms and conditions?

Is Rhonda Smart growing in her profession or will her medical acumen shrink as she continues to work in the isolation of her storefront clinic?

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