ACP Internist Blog


Thursday, August 17, 2017

Is the search for employed physician job satisfaction fool's gold?

Discussion about physician job satisfaction and burnout is all too common within medical circles. Every doctor at the moment knows what a huge issue this is, and how the numbers seem to be getting worse (some statistics suggest a burnout rate well over 50%). It's also no small secret that this depressing trend coincides with the huge loss of autonomy and independence suffered by physicians over the last couple of decades. As more and more doctors seek the safety of employment by large healthcare organizations instead of owning their own practices (as they previously used to, but is now made almost impossible from a bureaucratic standpoint), the feeling of a loss of control over their own destiny becomes more entrenched.

I grew up in England, and after going to medical school, worked briefly in the National Health Service (NHS) before moving to the United States. I therefore still have lots of friends and former colleagues over there, and it's been interesting to see exactly the same phenomenon of physician burnout and dissatisfaction play out in the United Kingdom as well—albeit for different reasons (heavily centralized big government control with excessive interference in work patterns and pay scales).

Since being in the United States, I've witnessed at close quarters the dwindling of private practice groups and the proliferation of big corporate medicine. In my travels up and down the East Coast, I've had the privilege and honor of working with so many fine colleagues, and heard many differing perspectives about what life is like for doctors and the challenges we face practicing medicine in this era. The consolidation of health care organizations, the widespread disruption to physician practice caused by policies such as Meaningful Use, all against the backdrop of an increasingly rancorous political debate, has taken its toll.

This may seem almost defeatist to say—and I hope I'm proved wrong—but I have come to a simple conclusion: there may unfortunately be no long-term physician job satisfaction for full-time physician employees. The loss of autonomy and control suffered in a controlled corporate environment, is directly related to physician dissatisfaction. The happiest doctors I ever saw were the ones who owned their own practices and essentially ran their own small businesses. Although they nearly always worked harder and longer hours, they did so “as their own brand” and on their own terms. They were not told by non-clinical administrators what they could or couldn't do, enjoyed long term relationships with their patients, and always seemed to go the extra mile. If you worked hard as an independent doctor, you were rewarded appropriately. In a corporate environment, would any physician really want to go the extra mile knowing that the rewards will be going to the CEO and other executives?!

The employee mindset that is human nature in any industry, works against physicians and will eventually make them miserable and their job unsustainable. It's only a matter of time before employed physicians will have some sort of negative experience or administrative clash that will make them not like their work and seek something different. Are there exceptions to this? Absolutely, there always are. But that's my basic observation. The only happily employed physicians practicing clinical medicine I see these days are broadly in the following three categories:
1. Physicians who are in academia, devote their career to research or working in a teaching hospital, and are okay with sacrificing salary for academic medicine
2. Physicians who are working towards something else, like an MBA or another non-clinical route, with that end-goal in mind
3. Physicians who work only part-time, with or without other creative ventures or entrepreneurial activities the rest of their time. Similarly for locums or moonlighting physicians, who can work somewhere and not be as “tied” to the organization with all of the associated administrative headaches and heartache.

When I think of all the hours of studying, sleepless nights, sweat and toil it took to become an Attending physician, it really has been an astonishing amount of work. This is not to say that medicine in not an immensely rewarding career, or that I have any regrets doing it (because I certainly don't and really do enjoy my work as a physician and everyday patient interactions)—but merely to state that the inevitable push towards having 100 percent employed physicians will have consequences for a group of professionals as smart and creative as doctors are.

I would love to live in a world where physicians, administrators and big corporate health care would all get on well and look out for each other with the patients' best interests at heart, but that seems like something of a fantasy right now, with so many conflicting interests and incompatibilities.

As much as I hate to say it, if the goal is long-term employed physician job satisfaction, it may be akin to searching for fool's gold.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Monday, August 14, 2017

The doctor's perspective on after hours and weekend medical care

Today's patients must adjust to seeing many physicians, many of whom are strangers. If you need a doctor on the weekend, at night or just need a same-day appointment, you may very well not be seen by your physician. This is not your father's medical practice. The days of the physician house call have vanished. There are many reasons responsible for this evolution (devolution?) in medical care. Patients have by and large adjusted to this new reality.

We physicians have had to adjust as well. Formerly, we took care of our patients exclusively, with rare exceptions when we were out of town. If you went to the hospital, we were there. Same day appointment needed? We squeezed you in. There was no nurse practitioner to pick up the slack. While I'm not making a judgment on the medical merits, physicians of yesteryear were more devoted to their patients and their profession than they were to their own lifestyles, a fact that their families would attest. Times have changed.

Nowadays, physicians regularly see patients whom we do not know. Consider that for a moment. On a regular basis, doctors treat patients whom they have never seen. While this challenge is obvious from the patient's perspective, it's not easy for us either. In my own practice, this experience usually occurs on the weekends when I am covering my partner's hospitalized patients. This is much more complex than if I were seeing my own patients whom I know well. Here's why:
• I have no personal relationship or rapport with the patient or the family. If I have a serious recommendation, such as surgery, will I have sufficient credibility?
• I may be reluctant to aggressively intervene on a Sunday morning, opting instead to tide the patient over until Monday, when my partner who knows the patient will be back on the case. This phenomenon of a benevolent stall is commonplace when a doctor is temporarily on the case.
• Although I may be in charge of the patient on the weekend, I am not as knowledgeable of the nuances of the medical situation as would be the doctor of record. For example, if I palpate a patient's abdomen on Saturday morning, and it is tender, it may be very difficult to ascertain if it is worse or better, as it was someone else's hands that were on the belly on Friday. Additionally, doctors who are active on the case have knowledge of the patient that can never be recorded in the medical record.

When a patient meets me for the first time, he may be wary as I have not yet earned his trust. I understand this. Similarly, when I see another doctor's patient for the first time, it is harder for me as the covering physician. How could it not be? I'm not sure that patients reliably recognize this, assuming that the covering doctor can cover it all.

We covering doctors do our best on the weekends, but it's not ideal. In a perfect world, every physician who sees a patient would know all. But, the medical world must operate in an imperfect system and with imperfect professionals. If patients and physicians both accept this, then our doctor-patient relationships will be more robust. Let's all keep our expectations in the real world.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Friday, August 11, 2017

The vegan argument

Can we say whether or not a well-balanced, vegan diet is BEST for human health? I will tell you the answer momentarily, but first- reasons for posing the question now.

A recently released documentary called What the Health reportedly makes the case for vegan diets, arguing that the attendant benefits are among the best-kept secrets of the medical-pharmaceutical complex. I say “reportedly,” because I have yet to see the film, although it is on my to-do list. A number of my friends and colleagues are featured.

The film came to my particular attention in a roundabout way. A video blogger with a MD degree and a sharp sense of humor, along with, apparently, a quite unprepossessing career in medicine- decided to assault the film for the entertainment of his social media followers. Colleagues of mine saw the critique, and gave as good- or better- than they got, in both video and print. References to, and remnants of the exchange made their way into my in-box. Rather like Mel Gibson's character in The Patriot, I felt obligated to enter the fray when the battle line rolled up to my front door.

Can we say whether or not a well-balanced, vegan diet is BEST for human health? No. But we can't say it isn't, either. And when other considerations are factored in- such as the ethical treatment of other species, and environmental impact- the arguments for well-practiced veganism are extremely compelling.

Why can't we say, for sure, that an optimized vegan diet is the single best choice for human health? Quite simply, the study required to prove that has not been done, and almost certainly never will be, because it is well-nigh impossible to conduct.

To prove that any one, specific diet is truly “THE best” requires comparing it to all other diets that are valid contenders. In this case, that could reasonably include, at a minimum, comparably optimal representations of Mediterranean, vegetarian, pescatarian, and flexitarian diets. Randomization should ideally happen at birth, or even in utero, and the outcomes that prove a diet is best- the combination of longevity, and lifelong vitality- require that the study run for entire lifetimes.

Because the comparison is among diets that are all optimized, and because other health practices would have to be standardized and comparable across groups, those lifetimes would likely be rather long, and the between-group differences small. Imagine, for instance, conducting a study intended to show the differential effects on longevity and vitality of running 35 miles a week, versus 32 miles a week. There might well be a dose-response effect ensuing, but it would be very small in the mix of factors influencing health over a lifetime, and hard to spot. When outcomes are small and hard to spot, sample sizes need to be very large to magnify them, and make them visible.

Our diet study has this same liability. So, it would require a vast sample of people (and/or their pregnant mothers) willing to be randomized to a specific diet for a lifetime. It would then require adherence to the assignment for that entire lifetime, and routine measures to confirm it. The investigators involved in launching the study would need a mechanism to pass it along to successors, since they would all die of old age before the study is done. I trust at this point I need not say more about why such a study has never been conducted, and is more than a little unlikely.

At one extreme, then, the claim that veganism is established to be the single, best diet for human health is somewhat exaggerated. Relevant evidence cannot correctly be said to be more than “suggestive.” From my perspective, having reviewed the relevant evidence with as much renunciation of a priori bias as humans can hope to achieve- both for a commissioned peer-reviewed paper, and a textbook- there is nearly comparable suggestive evidence for several variants on the theme of wholesome foods, predominantly plants, in time-honored and sensible combinations. I have heard my more ardent, vegan colleagues claim that wild salmon is toxic food for people. I am aware of no epidemiological evidence to substantiate that claim, but I would readily accept their argument that being eaten is certainly toxic to the fish.

At the other extreme is the argument one tends to hear when veganism is being disparaged and ridiculed, generally by those who simply like bacon and baloney, or -more ominously- by those trying to sell you one or the other, that we “need” meat to be strong and healthy. This claim figures among the baloney.

What animals need to be big and strong is not foods that resemble the muscles they are hoping to grow; that is simple-minded mythology, perhaps aided and abetted by the beef industry. They simply need foods to which they are adapted. The mightiest muscles of any land animal, those of the elephant, are produced entirely on a diet of plants. The mightiest muscles in the sea- those of the blue whale- are produced on a diet of tiny animals, krill and copepods. Lions build their muscles from meat; gorillas all but entirely from plants, and horses from plants exclusively. The greatest of human muscles is inconsequential as compared to any of these.

Some species are obligate herbivores, and some others are obligate carnivores; neither has a choice about how to grow their muscles, because choice is constrained by their anatomy, physiology, and underlying adaptations. We humans are decisively omnivorous, meaning it's a matter of choice. We can grow our muscle, and even fuel world-class athletic prowess, with plant or animal foods. Any argument that meat is necessary is simply misguided, uninformed, and ignorant. Among factors that matter in the determination of human muscle mass, strength, fitness, and performance- meat is moot.

Thus fail the arguments at the extremes in either direction, from my perspective. But let's be clear that arguments for vegan diets at a time of climate change, drying aquifers, industrial farming, assaults on biodiversity, rampant chronic disease, and global population pressures are anything but moot.

Consider, for example, just these two facts. A study out of Harvard, published in 2010, compared various sources of protein in the diet with regard to cardiovascular disease in over 80,000 women. The single, greatest beneficial effect observed derived from the displacement of beef in the diet, by beans. A study out of Loma Linda University, published in May of 2017, projects that the routine substitution of beans for beef by Americans- independent of any other climate control strategy- could achieve over 50% of the greenhouse gas emission reductions targeted for 2020 in the Paris Accord we have since decided to abandon.

Just those two facts make for a formidable argument on their own: humans can choose to grow their muscles out of beans, or beef, and beans are almost certainly, massively better for the health of humans, and the planet, alike. Mic drop.

But, actually, there are reasons to keep talking.

Beans are a staple in the diets of the world's longest-lived, most vital peoples, among the more salient of themes running through the world's Blue Zones. While absence of evidence on behalf of other diets is not reliable evidence of absence, the fact is that only vegan and near-vegan diets have been shown to shrink atherosclerotic plaque; reduce LDL as effectively as statins; and modify gene expression in a manner suggesting the potential to prevent the development and progression of cancer. Maybe other diets can do all this- but the burden is on them to prove it.

There are also the dire ethical implications of animal food, mass-produced. The only way anyone who has ever loved a dog can think of bacon as the casual, fun garnish into which our culture has turned it is either willful hypocrisy- or this. Pigs are highly intelligent, often claimed to be more intelligent than dogs; are sociable and can form bonds with humans just like dogs; and are routinely slaughtered in callous cruelty to embellish our cheeseburgers.

Yes, it's true that vegans need to supplement vitamin B12. But so what? The argument that this requirement makes the dietary approach flawed or incomplete tosses out the baby for the sake of an inconsequential drop of bathwater, and fails the meanest test of parity.

These days, with marketing claims based on the gratuitous addition of vitamins to water, it's harder to avoid nutrient supplements than to acquire them. All routinely clothed, indoor-working, northern-living humans need to supplement vitamin D, one way or another. Most humans exposed to modern living, and certainly those exposed to the liabilities of mass-produced animal foods such as second-hand antibiotics, are apt to benefit from probiotics. Veganism obligates select supplementation little more than modern living does.

Can we say that a balanced vegan diet is the single, best option for human health? No, we can only say it is among the likely contenders. Can we say that veganism is compatible with the adaptations of our omnivorous species? Certainly yes. Can we say that it allows for peak performance and muscle mass? Certainly yes. Can we say that it reliably garners the votes of the climate, the pigs and all other animals, and the planet? Certainly yes.

Argue against veganism if you choose, but concede it is because you like- or are selling- cheese, or meat. Other arguments are mostly just so much baloney.

Editorial note: for those wanting to know, the author is not vegan, although he eats a diet of minimally processed foods, predominantly plants, and does not eat any mammals and most other animals for ethical reasons. He counts four 4-legged animals, three dogs and a horse, among his closest friends.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Thursday, August 10, 2017

5 communication mistakes doctors should avoid

Being a doctor is about as much of a social job as one can get. Even though computers and health care information technology mean that physicians are now spending a disproportionately large amount of their time staring at their computer screens, there's no getting around the importance of good old face-to-face interactions. That's also what's valued by your patients. In this time of great upheaval in healthcare, everything has changed apart from human nature. Here are five things that doctors should never do:
1. Keep turning around and looking at your computer screen when your patient is trying to talk to you
This is consistently one of the things that annoys patients the most. Of course, it's very difficult for doctors as well, who have a crazy high amount of bureaucratic “tick boxes” to satisfy, but try setting aside a dedicated amount of time to just sit face-to-face and talk the good old fashioned way.

2. Make it obvious you are in a hurry
Humans are perceptive animals, and we can all sense when someone is trying desperately to get away from us! Be aware of the subtle body language clues that will give this away, including starting to walk away (in a hospital), cutting people off, or worst of all—telling the patient how busy you are.

3. Asking only closed questions
There's often more grey in medicine than black or white, and there's not always a “yes” or “no” answer out there. A medical history is a story, not a robotic set of tick boxes. Open-ended questions typically start with a “how”, “what”, “when”—or a phrase like “Tell me about”. Closed-ended questions demand yes and no answers only, such as: “Do you have abdominal pain?” There is a way to balance open-ended questions with staying focused and time efficient.

4. Making it sound like a patient's problem is trivial
The amount of trust placed in physicians is humbling. Patients will pour their heart and soul out to you, and share their innermost secrets after knowing you for just a few minutes. If your patient is telling you something that's on their mind, never be dismissive

5. Not allow any time for questions
Remember health care is a matter of life and death a lot of the time. What could possibly be more important to either the patient or their loved ones? Of course they are going to have lots of questions, and it's a privilege to be in a position to answer them with your knowledge

The majority of physicians do a superb job in difficult and high pressure circumstances on a daily basis. We all fall short at times and can do a little better. Gentle reminders that we work in a unique and special profession, are always important.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.