ACP Internist Blog


Thursday, August 22, 2019

Thoughts after a year of podcasting

Twelve months of podcasts, two per month, are now available at Annals on Call. During those 12 months, I have learned a lot from my guests and learned a great deal about podcasting and interviewing.

Many have asked me to tell them the story of the podcast. How did it come about? How long does it take to podcast? How do I pick guests and topic? So here is my story.

A couple of years ago Christine Laine, MD, MPH, FACP, the excellent editor of Annals of Internal Medicine, asked me if I would do something “social media” for Annals. We talked about blogs and podcasts. For the next year, we decided to design a podcast.

Over the past four to five years I had become a podcast devotee. Listening to various podcasts, I understand the various styles. Here are my three categories. Some podcasts resemble magazine articles. Good examples are Malcolm Gladwell's “Revisionist History,” Adam Grant's “Work Life,” Adam Rodman's “Bedside Rounds” and “CoreIM.” These are heavily produced and scripted. Next are the bar discussions. In these a group discusses a topic, sometimes with questions. The Curbsiders and Freely Filtered have this vibe. Finally, we have the interview – usually a 1 on 1 conversation about a topic.

While I like all three types (forgive me if I omitted an important type), I personally thought I was best suited to the interview style. Back in 2008, Annals had a deputy editor who interviewed authors about their articles. I was the guest on one of these interviews in 2009, “Sore throat.”

Rather than try to duplicate those interviews which came out concurrently with the present issue, we decided to pick articles both new and old from Annals. This podcast format allows me to consider a variety of Annals articles and topics. Sometimes an article catches my eye and I consider that it would make an interesting podcast. A great example is ”Relationship of Interleukin-1? Blockade With Incident Gout and Serum Uric Acid Levels: Exploratory Analysis of a Randomized Controlled Trial,” which stimulated this podcast, “Understanding Gout Pathophysiology.”

Sometimes I find a topic that intrigues me, and then I look for an appropriate article. A great example is diagnostic error. I wanted to interview Dr. Hardeep Singh, so I searched the Annals for an appropriate article. Lo and behold I found a 1957 article that led to ”Reducing Diagnostic Error.”

Often I peruse the In the Clinic section and find a topic that I find worth discussing. Thus far, a variety of strategies have helped me find many great topics to discuss.

The podcast has developed in ways that I could not have predicted. Many authors, when discussing their novels, mentioned that the story often goes in directions that they did not expect. So too does a podcast. My selection process has matured and hopefully improved my topic selection.

Recording and producing each podcast is somewhat time-consuming. I spend a couple of hours each week reading Annals, looking for appropriate topics. I focus on topics that I find interesting, either because I want to better understand the topic (think the gout pathophysiology podcast), or because I find that learners often have some difficulty with the topic (think diuretic resistance and acute kidney injury).

Once I have picked an article, I need a discussant. I vary these with people that I know, colleagues at my institution and authors (sometimes a discussant fits more than one of these categories). So I email or call a person to see if they are willing to spend some time discussing the article(s).

Once we pick a date, I reread the article and develop an outline of the topics that I think we should cover. I share this outline with the caveat that the discussion sometimes raises more questions. This process usually takes another hour or so, although I am not counting thinking time, as I often ruminate over a topic for several days prior to developing the outline.

The day of recording, we spend less than an hour talking. My philosophy is to provide the listeners the conversation, mostly unedited. I do not use excerpts to make my own points, but rather to allow the conversation to go where it takes us.

I then spend around two hours listening to the recording (I use Skype and Call Recorder), doing minor editing, pick out excerpts (teasers) to put in the intro, and developing my intro and outro (Bob's Pearls). I use Audacity for these tasks.

Finally the great staff at Annals (I must give a shout out to Patrick Whelan, Thomas McCabe and Bernie Turner) add the music and sound effects. They released the podcast to all the podcast providers and publish the links on the Annals website. Dr. Laine provides valuable feedback and input. She also writes the questions that allow listeners to gain both CME and MOC credits if they are ACP members.

Thus I estimate five to six hours spent per episode.

When I started I had great hopes that we could create a worthwhile podcast. After a year, I am encouraged with many great comments from listeners and colleagues. I now recommend specific episodes to my students, interns and residents.

I have a new, greater appreciation for the power of podcasts in medical education. We aspired to create something both entertaining and educational. I think we exceed my original expectations. I am so grateful to Christine for giving me this wonderful opportunity. The guest experts have graciously donated some time to have these discussions teaching me and many listeners.

So I plan to continue indefinitely. I hope the podcast helps listeners understand the wealth of Annals' articles. And if you listen, thanks so much. I will try to make every episode worth your time.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Friday, August 16, 2019

Humongous health care salary disparity is not OK

In 1980 I worked as a nurse's aid for a summer. It was a great job, in its way. I had no training and I worked nights in a nursing home. This meant that I rounded pretty much all night long, helping when people woke up and needed something and changing the sheets of the many incontinent residents. I would feel for wetness, then gently roll up the soiled sheets on one side of the patient, replacing them with clean ones, roll the patient over the lump, wrap up the dirty ones and tuck in the clean ones. (This was before high quality disposable diapers were introduced.) I would walk the lost insomniacs back to their rooms and reassure anxious people. I was paid next to nothing, I'm thinking maybe $6 per hour, but that's what I expected and it paid the rent. For me it was just a stop on the way to a job as a doctor.

Just last week I was at a singing camp with a bunch of people of various ages and backgrounds and got to know a woman who is an EMT (emergency medical technician) in a small community. She goes out on calls throughout her 56-hour shift to see patients who could have anything from a sore toe to a cardiac arrest. Many of the patients she sees she is able to reassure and not transport to an emergency department. Some of them are frequent flyers, people who live with a high level of anxiety about their health and call the ambulance for evaluation sometimes a few times a week. She is able to take their vital signs, check an electrocardiogram if necessary and assess their complaint, giving a recommendation to transport or to stay home. If there is a patient who is unstable or in cardiac arrest, she will accompany the patient to the emergency department after having started an IV and given the appropriate medications. If the patient is close to a cardiac or respiratory arrest she will sometimes place an endotracheal tube and attach the patient to a ventilator. She will then take the patient to the ER (emergency room) where she will help the doctor with the initial resuscitation since she and her colleagues do that sort of thing all the time and the emergency physician may have less experience. She makes $15 an hour. Plus benefits. And time and a half for the number of hours per week over 40, for which she considers herself lucky. She is very thrifty, but this is barely enough to survive.

When she first considered what she wanted to do after graduating from high school, she thought maybe she would be a doctor, but the cost of the education, first a bachelor's degree with four years of being unable to work full time, then four years of medical school followed by three of residency, was beyond what she could afford. She considered going to Europe, where she had family, to get her education, which would have been free. Eventually she decided to get an associate degree at a community college and become an EMT. She's now been an EMT for over 10 years. She likes her autonomy and the fact that her job is meaningful and never boring, but EMT's usually don't grow old in that job and she will need to find something else eventually.

The emergency physician she helps out with critically ill patients probably makes about $400,000 a year, more than 10 times what she does. It's true that the doctor had to complete four years of undergraduate education, four years of medical school and at least three years of residency in which he or she definitely made more than an EMT, though not a whole lot more. The doctor probably had a hefty loan to repay and had to compete for the spot in medical school with some of the highest achieving students at university. Still. This is a ridiculous salary disparity.

Here are some other numbers that are interesting:
1. Nurses, RN's or BSN's (bachelor degree in nursing) make an average of $83,000 per year. This is a four- year course of training in college or sometimes an accelerated three-year course.
2. The average physician's salary is $299,000, but this is a little misleading since it represents quite a range. Orthopedists make over $480,000 and pediatricians around $225,000, women make 27% less than men and some states pay more than others. Physicians who are self-employed make more than those who are employees. But all in all physicians make a lot of money. Per Forbes magazine, physicians have the highest paying jobs in the U.S.
3. The average pay for a nurse's aide is $26,000. Training is a six- to 12-week course after high school graduation or a GED.
4. The average yearly salary for an EMT is about $30,000. Training can take between six months and two years, depending on the level of training and type of program. There are also accelerated immersion courses.
5. The average yearly salary for a licensed practical nurse is $46,000 or so and requires a year of training.

It doesn't seem fair that a physician should make 10 times more than an EMT and I would like it if someone could magically make that shameful fact go away. But it is not going away because I wish it. Salary is determined by many factors, but not whether I personally think it is fair. Doctors get paid well because what we do is highly compensated by patients or their insurance companies. Compensation is high because as a country we have decided that it is OK to pay a lot of money for health care. This is partly because doctors have traditionally been highly respected and so carry significant influence in policy making, but also because innovative medical products such as device and pharmaceuticals are a large part of our economy, including our exports. These contribute to the market share of health care and are part of the revenue stream that allows us to afford to pay so much. (Also other factors … third party payment etc.) Demand for health care is high because there has been successful marketing of our products: high profile cures of dread diseases, the rise of preventive medicine and the devastating consumer appeal of opiates and other habit forming controlled substances. Demand is also increased by the aging of our population. As powerful people get older they need more medical interventions and effectively demand medical advances in order for them to remain powerful. Supply continues to be limited by the high cost of medical education, the years required to complete it and the stress associated with the job. Supply of primary care physicians is even more limited since doctors find that specializing pays more than primary care and is often less stressful.

Doctors' salaries have managed to float high on the waves of supply and demand. EMTs, not so much. EMT pay comes out of city or county budgets that also fund firefighters and police. Their services don't get paid by medical insurance. Nobody actually pays for the services they provide so there is no fat pot of money from which their salaries can come. They beg for a share of a communally funded pot along with the people who try to keep houses from burning down (firefighters) and the people who stand between criminals and those of us who would be their victims (police and sheriffs.) They usually come out with the short end of the stick.

Nurses, LPNs and aides suffer from some of the same problems. They, too, don't clearly generate revenue. They do many things that, if not done, would shut down a hospital or clinic's operation, but their work is not usually paid for by an insurance company (exception: the nurse visit for a minor procedure, but this is usually paid as compensation to the doctor for whom the nurse is working.) When a person's work is not obviously connected to revenue it is hard to make the case for higher pay.

There is a lot of money in health care, for good or bad. Somehow we need to divert it to our EMTs who, despite having less training than we physicians, provide care that would be handsomely compensated if we were doing it. Maybe hospitals should subsidize these services. Maybe EMTs should bill health insurance. I'm not at all sure, but it is not right that the professionals who we depend on to treat life threatening emergencies in the field don't make a living wage.

Update:

I just read in JAMA, the Journal of the American Medical Association, that the Center for Medicare and Medicaid Innovation has approved a 5 year experiment in paying emergency medical services for management of conditions which don't lead to transport to an emergency department. This is only for 911 calls, but may result in some improvement in payments. This could also lead to closer communication with physicians and maybe more training for EMTs to allow them to provide more accurate and complete care. This program won't fix the whole problem, but could provide better revenue and maybe higher pay for paramedics.

Janice Boughton, MD, FACP, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Thursday, August 15, 2019

Confirmation

“And who knows but that you have come to your royal position for such a time as this?”
—Esther 4:14 NIV

A door had closed before her. It seemed like there was no way out. Some way, somehow our paths crossed.

She was miles away on the eastern seaboard and had somehow found my email. “I went to Clark Atlanta,” she said over the email. And that was when I knew. This medical student looked like me.

No. She wasn't at my institution. But something about that message grabbed me that day. Was it the first such email I'd received asking for my help or attention? No. But something about this felt different. It's hard to explain.

I was in Jury Duty so things were still. Her email crossed my box during an idle period and, as fate would have it, afforded her my full attention. I don't think that was by accident.

Nope.

Emails went back and forth for about 30 minutes. Then this lady with a flat voice spoke into a microphone. She rattled off some names in a monotone voice. “If I called your name, your case has been settled. Thank you for your service.” One of those names was mine.

Yup.

An unexpected window. What to do? Call her. That's what God laid on my heart. Her number was at the end of the email. Before I could overthink it, o decided to be obedient.

What happened next—you wouldn't believe it unless you knew me personally. But here is what I will say: I've always thought that that, just maybe, that one moment in time was pre-appointed long before I ever even thought of becoming a doctor. Maybe even before I was born.

The best part is that I could feel it in that moment. I could feel that the universe was telling me loud and clear: This is your Esther moment. And so I held on tight to that idea and pushed. Trusting and believing and touching and agreeing.

But then? Just like that, the door that I thought I could open for her closed. I fell to my knees crying that day. “I did what You said!” I cried. “I was obedient!”

A friend told me to be still. So I did.

And then, a door opened. Not the door I expected. An entirely different door opened by someone entirely different—but to whom I was connected. She opened that door in a whole different state. We hadn't even been talking. I'd just been writing. And her reading.

Whew. It was so big, so divine that I still struggle to wrap my head around it. This wasn't MY Esther moment. It was OUR Esther moment. A moment for which we were BOTH created.

Yup.

That girl from Clark Atlanta who cold-called me all those years ago? She walked straight through that open door and never looked back. Wait—I take that back. She only looks back to see who's rattling the door handle trying to get in.

Today, as I was sitting alone quietly eating lunch at a soul food counter between rounds, guess who came up behind me and wrapped me in a hug? It was her. After all these years.

Dual-board certified. An assistant professor and full time faculty member. Living the dream. At Grady Memorial Hospital of all places. Took everything in me not to cry into my black-eyed peas and collard greens.

“Wow.” That's all I could say as she told me about all of the wonderful things she'd been doing.

“I will forever be grateful to you both. Forever I will.”

“And I will forever be grateful to God for letting us be there in that moment all together.”

She nodded and we hugged tight. Then I pulled her back, looked at her, and hugged her again. After that I snapped this picture to send to the other Esther so she, too, could feel all the same feels.

I do struggle sometimes with asks and recognizing my limitations. I can't be everything to everyone. Sometimes I can't be even a little something. But that moment taught me to just listen. Listen so that I know when I should.

Yup.

What an ordinary lunch at the Sweet Auburn Curb Market this started out as today. Just like that ultra ordinary day in Jury Duty back in 2012. Now I know that nestled in every ordinary moment is the potential for something extraordinary just waiting to happen.

And maybe—just maybe—you were created for a moment such as this.

Yeah.

Kimberly Manning, MD, FACP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
Monday, August 12, 2019

Time to listen

I'm back … again.

I think one of the reasons I have slowed down (big euphemism here) in my writing is that I feel like my posts are predominantly about how wonderful my new practice is. That does two things: it makes it seem like I'm just bragging all the time about how smart I am and how great my practice is, and it makes it seem like I'm saying the rest of medicine is lousy in comparison. This is not polite. This is not in my comfort zone.

But this is basically the truth.

OK, I guess I'm just a conceited SOB. Sorry.

I was struck by the difference between my care and that of the rest of the system as I cared for a patient recently. She was complaining of a strange pulsating noise in her ear that had started a few weeks before. We chatted for a while, as I asked about any sinus symptoms, if she'd ever had anything else going on like this, what other significant symptoms she was having (headache, other sensory changes), and just general medical questions. The diagnosis remained a mystery as I went to examine her. The exam was… not really helpful. She had no foreign bodies in her ear canal (something I was guessing I'd find), no fluid behind her eardrum, and basically a negative exam.

The diagnosis was “pulsatile tinnitus,” which is basically a description of her symptoms: a loud whooshing symptom in her ear. I've said in the past that one of the best tricks a doctor can do to bullshit patients is to use fancy words to describe exactly what the patient says to you. So when a person has a rash, you call it “dermatitis.” When they have a loose cough, you call it “bronchitis.” And when they hear their heartbeat as a “whooshing” in an ear, you call it “pulsatile tinnitus.” It offers absolutely no help to the patient, but it perhaps impresses them with your grasp of medical jargon and distracts them from the fact that you don't know what is going on with them.

Not satisfied, I chatted with her some more, talking about tinnitus, something that I've had for the past 15+ years. It came on suddenly in my 40s and was associated with the sudden inability to hear words in a crowded room. This is one of the few bad things I've inherited from my now 92-year-old dad. I talked to her about the frustration of this condition and how certain things make it worse. One of the main things is when other people mention the ringing in their ears. It makes me so aware that the volume of my tinnitus is turned up to “high” (it is very loud as I type these words). Another thing that makes tinnitus worse, I mentioned, is aspirin therapy.

She interrupted my rambling. “Wait. Aspirin makes it worse? I just started on aspirin therapy for my knee a couple of weeks ago.” And that is pretty much exactly when her pulsatile tinnitus began. This was about 20 minutes into my time in the room with her. Let me clarify: she had spent 25 minutes in my office, 20 of which was spent discussing her situation with me. She didn't wait to see me, and I didn't spend my time staring at a computer screen making her answer questions to satisfy data quality measures. I just talked to her, and this fact came out at minute 20 of that discussion. That's a moment in the exam room that doesn't happen often: after 20 minutes of discussion.

This is one of the reasons I believe this practice model is clearly superior to the “care as usual” with the assembly line/hamster wheel care that is done by most primary care doctors. I have time. I can listen. I can chat with people until important information emerges. In many, if not most, primary care practices, this patient would've been referred to ENT for a workup that may have possibly resulted in lab testing and likely CT scans or other testing.

Having the time to listen was superior to an ENT consult, labs, or a CT scan. Time is something, even after growing my practice to 800 patients, I have for them. I give patients 30 minutes of my time for normal visits, and 60 for complex care or new patient visits. Often the time I spend is shorter, but that time is available. This is exactly the opposite of what happens in most primary care settings. I used to have only 15 minutes set aside for people, much of which was devoted to documentation, and had to stretch that out to 30 or more minutes to get in the basics of care for complex problems.

With so much attention to physician burnout and the high cost of care, the discussion spends far too little time talking about the lack of time most primary care docs have for their patients. Before I left my old practice (nearly seven years ago!), I was increasingly burdened by the fact that I was increasingly being robbed of the time necessary to give good care. I was spending too much time dealing with red tape from the insurance companies and from the rules from the government aimed at “improving care.” Since quitting, I've yet to see more than 15 patients in any given day, and am often reminded how much my patients appreciate the time I can spend with them.

It doesn't matter to me how we accomplish it — whether by the direct care model or another — but we must fix this problem. Primary care just had its worst year in matching residents from medical school, this at a time when we need more primary care doctors and less specialists.

My decision to practice this way has saved my career, has healed my heart, has saved money for my patients, and has given me the time to listen, the time to care for them.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.