Friday, February 3, 2012

The Good Things in Medicine #1: The Exam Room

I said I would do it and I will follow through with it: I am going to talk about good things about my job. I must confess, however, that finding 53 of them might be difficult at this moment, as I am overwhelmed with the craziness and stupidity of the system. I must also confess that I can't find a whole lot of good things to say about our system. I fight the system and its foibles all day long, and try to practice good medicine despite the way I am forced to do it; so finding good stuff about the structure of our payment system will be difficult, if not impossible.

Maybe it's just me and my current mindset. I hope so. Unfortunately, it is how good the good is that makes the bad all the worse. The fact that the system itself stands in the way of the good in medicine makes the system all the more broken.Anyhow, I do have things that I really, really like about medicine. I've got to have them, as I could not deal with these negatives if I didn't have a reason to stay that was at least as strong as my reason to leave. It's like the nucleus of an atom. We know that the forces holding the protons together is strong, because they repellant force of two positively charged particles is very strong. There must be a stronger force keeping them together.

Likewise, I am drawn to medicine in a very strong way, and nothing draws me back more than the exam room.No, I am not talking about the table that is too high for my old people to climb on, out-of-date magazines, or the smell of rubbing alcohol. I am talking about the interchange I get to have every day with people. To me, the exam room encounter is medicine. It is the Holy of Holies, the sacred part of a secular system. The practice of medicine can be boiled down to a single thing: the interchange between a person with a need and a person who tries to meet that need.

While this is actually the description of all commerce and much of human interaction, it is the nature of the interchange and needs that make it so special to me. Here are the things that make this encounter so unique and so (in my mind) sacred:

It is personal
The patient does not need an object or a luxury item. They don't want to be entertained. The things the patients need are themselves. They want to live and to be healthy. They want to have a good life and to be out of pain. Our possessions are not what define us, but to a large degree, our bodies do. We are what is confined in that package of flesh. Our time on earth is defined by what that body does, and how long it does it. So, to come asking for care for our bodies is intimately personal, a fact unfortunately forgotten by many in health care.

It is private
The door to the exam room is closed and I am committed to keeping what goes on in the room closed off to others. The more that I can assure the patient that their privacy is safe, the more they will expose their needs to me. We humans don't like to share our needs with many people, as it exposes our weakness and vulnerability. We also feel that we are intruding on others' lives when we ask them for help. So, actually asking for help is only possible when done in a situation of great trust.

The fact that people can be asked to get naked in the exam room is evidence to the degree of vulnerability they are exposing to me. The nakedness extends to the emotional realm, as boundaries that are expected on the outside are not present behind the closed door.

It is relational
The thing that is so sacred about the exam room to me is not the fact that it's private or personal, however; it is that I am asked to be with them in that vulnerable moment and hear the weaknesses. The relationship is physical: I listen to what they say, look at what they are, and feel their bodies with my hands. It is mental: I listen to them, think about them, and help them decide what to do. It is emotional: I hear their sadness, fear, and relief; I feel emotion as I hear their emotions; I try to help, heal, or comfort them. This is the sacred, as it is human relations stripped to the core, free from most of the pretense and facades that are there in nearly every other place.

It is meaningful
I take great comfort in the fact that what I do has meaning. When other parts of my life are difficult, I find refuge in the opportunity I have every day. When I am feeling sad or anxious about other things, feeling insecure in my relationships or in my future, or regretting my decisions, I heal myself in the exam room. It's not that I see that my life is good compared to my patients--that's no comfort at all--it's that I get to do and to give to other people; and while I can lose relationships and material things, nobody can take away the good I have done.

It's really an honor to be a part of the exam room encounter every day. It does take its toll on my emotions, and it is a convenient escape when I'm avoiding other areas of my life, but I know it's where I need to be. I am glad that I am a doctor. I really lucked into the profession I chose, as I didn't know most of the good things before I enrolled in medical school. It's good for me to remember this good, as I can get lost in the struggles and troubles that the other part of my job brings. Our system needs to do everything it can to enable more real exam room encounters, and remind health care providers that they do more than just work at their jobs; they heal.

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.

Labels: guest post, More Musings, patient communication, Rob Lamberts

'I'm your cook, not your doctor'

Celebrity chef Paula Deen confirmed she had type 2 diabetes. She was diagnosed three years ago, but only decided to come out recently. She also mentioned that she is a paid spokesperson for drug company Novo Nordisk, maker of several diabetes drugs. (Click here to view Al Roker's interview).

When the news started breaking earlier this week, I had mixed emotions about Deen as a spokesperson for diabetes. Blogger and health care marketer Richard Meyer at worldofdtcmarketing.com posted This is a spokesperson for Novo? Deen is of course known for her southern style of cooking, which typically involves very fattening ingredients. At one her restaurants she famously serves a hamburger with bacon and egg on a donut instead of a bun.

Rich correctly asks, "What message does this send to people ? That it's OK to eat really bad food because diabetes can be treated with Rx drugs ?"

I commented on his blog that if Deen actually changes her ways, and focuses on healthier cooking, providing healthier recipes to her fans and other diabetics, she might actually make the perfect spokesperson. Americans have not been paying attention to what we eat and obesity has now become an epidemic, leading to increasing numbers of patients with type 2 diabetes.

After seeing the Today show video, I remain on the fence. Her interview was not the redemption story I was hoping for. Give journalistic kudos to Al Roker, who pressed Deen on whether she had changed her ways or changed her cooking. She responded essentially stating that she has always eaten (and suggested others eat) in moderation, claiming that her weekly cooking show is only 30 days out of a full year and that no one should eat that kind of food every day. According to Deen, when asked a similar line of questions from Oprah, she responded, "I'm your cook, not your doctor."

Deen did state that she and her sons would work to come up with lighter recipes (available on Novo's website) and recommended people go to their doctor, get tested and "get on a program." On the website diabetes in a new light, Deen does say that she had to give up sweet tea. In fact, rigid diet and exercise programs do not work all that well in reducing weight or improving diabetes, since patients have a hard time sticking to them, so her mantra, "I wasn't about to change my life, but I have made simple changes in my life" may have some merit.

However, I believe there is still a difference between promotion of healthy lifestyle and realistic changes in diet and exercise and "everything in moderation" and "it's OK to have that little piece of pie." Paula doesn't have to become the next Richard Simmons or Jillian Michaels, but I would have liked to seen a little more "mea culpa."

I am interested to see how this plays out in the media and in public opinion. This is a terrible disease and the prevalence is getting worse. Ms. Deen has the potential to make a major impact. I hope she takes her spokesperson role seriously.

Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.

Labels: Diabetes, diet, Dr. Mintz' Blog, drug companies, guest post, lifestyle, Matthew Mintz, obesity, pharmaceuticals

QD: News Every Day--New technology takes the blame, yet gets the credit

New technology is offering doctors in small and medium practice an easier time with practice management, according to survey results of the users of a free electronic medical record product.

Practice administration has been difficult of late, and electronic medical records have taken some of the blame. They're expensive, they're time consuming and they require at least two weeks of training to properly implement their advanced functions.

In short, new technology hasn't always been popular among physicians.

Still, Practice Fusion, a company offering a free, web-based electronic medical record, surveyed 1,000 of its users online and said in a press release technology has made things easier for physicians in private practice:
--45% of doctors report that their practice is doing better this year compared to last year while 14% report that their practice is doing worse and 33% report no change.
--26% reported that their practice was doing better than the year before, while 41% reported doing worse.
--60% of small practices report that new technology has made things easier.
--26% of practices use computers that are less than a year old. 38% report that the computers in their practice are over three years old compared to 73% the previous year. 7% of practices have computers in the five to six-year-old range, down from 21% in 2011.
--89% of doctors report being satisfied or extremely satisfied with their career despite challenges, a 20% increase from the year before.
--Top pressures on the practice as a business included insurance and reimbursement (69%), patient compliance (64%) and practice administration concerns (48%).
--Top improvements were advancements in medicine (68%), patient compliance (53%) and improvement in the health care workforce (51%).

Labels: EHRs, electronic medical records, new technology, practice management, QD

Rising physician referrals are sometimes desperation passes

According to a recent study from the Archives of Internal Medicine, primary care physicians are referring more patients to specialists than ever before. In fact, the rate almost doubled in the 10-year period between 1999 and 2009. This drives up the cost of care, as specialist consults tend to be more expensive than primary care visits. Furthermore, specialists tend to order more advanced diagnostic tests.

It's pretty easy to see why this is happening.

Back in the days of capitated care, there was pressure from HMOs to reduce the amount of referrals, as doctors were given a set fee to manage each patient. A referral meant a financial hit to the practice. But the HMO model was rejected by patients, who didn't like their choice restricted and accused doctors of holding back care.

So, fee-for-service medicine continued to grow, and there was little incentive to scale back referrals. In fact, as a New England Journal of Medicine study revealed a few years ago, the Medicare patients saw an average of seven doctors: two primary care physicians and five specialists.

According to the lead author of the Archives study, Dr. Bruce E. Landon,: ... medicine has become more complex, with specialists and subspecialists seen as expert in the latest treatments. "Medicine is becoming increasingly technologically sophisticated," he said in an interview.

But Dr. Landon also points to the "tyranny of the 15-minute visit," during which the average primary-care physician does not have the time or resources to delve into any potentially complicated medical condition.

The last point rings particularly true. As patients become more complex and time pressures grow, many doctors simply take the path of least resistance and refer out.

Sarah Kliff, who blogs at the Washington Post's progressive-leaning Wonkblog, adds that money is a factor: ... part of it likely has to do with the economics of referrals: Doctors who have an ownership stake in their practice are 50 percent more likely to refer to a specialist, which would increase the total revenue generated by a given patient.

That's dubious. I don't have a financial incentive to refer to specialists. Most of my colleagues don't either. And with more doctors exiting private practice and into salaried hospital positions, that reason will become less relevant.

I'll add one more reason that hasn't been mentioned: defensive medicine. Although the threat of a malpractice lawsuit is typically associated with ordering potentially unnecessary tests, making a specialist referral is simply another variation. When primary care doctors see "failure to refer" as one of the leading reasons why they get sued, it's no wonder why more are doing so.

Physician behavior is governed, to a large degree, by incentives. Given the incentives that doctors face in our health system today, there's little surprise why more are referring patients out to specialist care.

Kevin Pho, MD, ACP Member, is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn. This article was originally published on KevinMD.com.

Labels: defensive medicine, guest post, kevin md, malpractice, practice management, referral

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

David Katz, MD
David L. Katz, MD, MPH, FACP, 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.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, 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.

Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

ACP Internist and ACP Hospitalist also contribute to and draw upon content from Get Better Health, a network created by Val Jones, MD, to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the clinician's point of view on health care reform, science, research and patient care.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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