Monday, December 9, 2013
Things are going well with the practice, but I am being wrung a bit dry. That’s the reason for my dip in writing. I am putting a lot of energy and emotion into the practice, and I don’t have a whole lot left at the end of the day. I have always been one to write out of passion and convictions. I write because I believe what I am writing, and this practice is taking much of that passion and grinding it out of me.
Again, things are actually going well. I’ve finally been able to take a salary from the practice (imagine that!) and have been seeing a steady growth in numbers. Patients from my old practice keep on contacting me to switch back to my care. I think they realize that this practice is not a sign that I have changed, but that I am unwilling to change despite a system that tried to take my focus off of the patient.
Through all of this, I’ve learned some valuable lessons. I think if there is anything I take pride in, it is not what I’ve accomplished (since I’ve not yet built a self-sustaining business), nor is it the attention and acclaim I’ve garnished. The thing that gives me the most pride is the way in which I’ve changed. I realized this as I got through a particularly hard day, one in which I did tasks I usually procrastinate or pretend I don’t have to do. I didn’t good after that day, in fact, I felt pretty tired and blah after gritting my teeth and doing what had to be done. But my reflection on that day was that I just had a very good day. It was good, not because of the positive emotion or good interactions; it was good because I grew stronger.
I was recently listening to a TED talk on a podcast about the subject of “success.” I actually have resisted listening TED talks because they seem to contain a lot of intellectual self-back-patting and are anything but practical. They seem to be the secular version of the “prosperity gospel” that preaches: “Just believe in yourself enough and you can accomplish anything” (substituting “yourself” for the “God” used by the pandering preachers). That may be unfair, but it is common in this venue.
The speaker (winner of the “McArthur Genius Award,” ugh) was talking about what characteristics of people lead to “success” in the real-world, and she (being a “genius”) noted that the students who were at the top of the test-scores were not the ones who were the most successful. She postulated (ingeniously) that the students who were largely successful at school were not called upon to deal with something very important: their failures. This ability, which she labeled as “grit,” is the key to true success.
While I would call this “perseverance” or “resilience,” I see how this is true in my life. The past 12 months has given me a whole lot of chances to fail, and a lot of cause for self-doubt. I recently was turned down for a small business loan (apparently you need to have enough money for them to justify loaning you money). Being turned down felt a lot like someone had called my kid ugly. What do you mean my idea is not so compelling that you want to throw money at me? What do you mean that you don’t think I’ve got what it takes to make this succeed? Yet in my heart I was wondering those same things. This is hard, and no amount of good ideas and hard work will alone lead to success of this project. I do think it will succeed, but I am by no means confident of that fact.
No, it is not the clever who inherit the earth. It is not those who win “genius awards” (OK, I admit I am a bit jealous) who change everything. True success takes the long road through failure, learning to use the lessons of what doesn’t work, what causes pain, and what our own weaknesses are, to give a much more solid kind of success. It is through endurance of troubles and personal failures, not their avoidance that true strength comes. At that point, it doesn’t matter how many people are telling me I have good ideas or that they think I will succeed. All that matters is that I can now stare failure in the eye and see it for what it is: a chance to grow stronger.
No, I’m not dumb enough to want things to remain this difficult. If anyone wants to throw money at me, I’d be happy to oblige that desire. Endurance, by definition, is not fun, and I hope things ease up soon. But after I was turned down for the loan I got advice from the wisest person I know: my father. He told me to not get too down about this, to not react right away, but to wait and see what God was doing in this. He told me of the times when things seemed the bleakest for him and how he was tempted to shake his fist at the heavens, but that after enduring the pain and seeing things in perspective, how he concluded that this was for the best.
That’s wisdom. That’s true genius. Endure, don’t avoid. Embrace failure to succeed.
Gotta go. There’s work to do.
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.
Presenting on a consult service: Rule number four
A while back, I posted three “rules” of presenting on a consult service. I’d now like to add a fourth rule.
Rule Number 4: In patients with chronic disorders, consider more than simply a “disease flare” in your differential diagnosis.
This rule follows up on Rule Number 3. The rule is most relevant to patients with underlying chronic disorders (e.g., inflammatory bowel disease, emphysema, ischemic cardiomyopathy) and is important for fleshing out a broad framework for a differential diagnosis.
After you have gone through a detailed presentation of a patient with a chronic disorder, the path of least resistance when a patient presents with similar signs, symptoms, and findings, is to diagnose a “disease flare.” However this knee-jerk reaction excludes a number of other broad options that may be going on.
Here is the framework I suggest in considering your differential diagnosis in a patient with a chronic underlying disorder. The presentation could be caused by:
1. the disease,
2. a complication of the disease,
3. a complication of the treatment of the disease, and/or
4. a completely unrelated disease.
In virtually any patient, this general schema can be helpful to make sure that you do not anchor your diagnostic possibilities on the chronic disorder.
As an illustration of how I use the framework on teaching rounds, I’ll describe a typical (made-up) case we might see on the gastroenterological consult service, a 25-year old man with Crohn’s disease and a possible flare. He was diagnosed 6 months prior with inflammatory ileocecal Crohn’s disease after presenting with right lower quadrant abdominal pain and watery diarrhea. The colonoscopy at the time revealed severe inflammation in the cecum and terminal ileum. He has been treated with steroids and infliximab, and was brought into remission within 3 months. Now, he presents with 3 days of acute watery diarrhea and recurrent abdominal pain. Without giving any more details, here is how I might break down my thinking:
1. The disease: Sure, it is easy to say that this is a “Crohn’s flare,” but then you’d have to ask yourself, “Why is the disease flaring?” Could the medications no longer be working? Has the patient been adhering the treatment regimen? Are the medication dosages too low? Nevertheless, this is an easy place to stop unless you consider the next 3 broad possibilities.
2. A complication of the disease: Crohn disease can cause at least 2 complications that can lead to similar presentations: fistulae and strictures. Of course, you could argue that these are the disease itself, but I would refute the argument because the treatment of these complications can be different from treating the underlying inflammatory process itself.
3. A complication of the treatment of the disease: As much as physicians don’t like to admit it, our therapies can definitely play a role in our patients’ worsening. Surgeons are quite attuned to looking for complications of their surgeries while their patients are recovering in the hospital, but medical therapies also have complications that should be considered, especially in the outpatient setting. In this case, the patient is on immunosuppressive agents. Could the treatment have led to an infectious disease, such as cytomegalovirus colitis?
4. A completely unrelated disease: Importantly, this element, sometimes known as ”true, true, and unrelated,” is how we are taught to think when we are creating differential diagnoses in medical school and residency training, but can often get neglected in the presence of a chronic disorder. Does he have a young child in preschool, who could have contracted a Rotavirus infection and transmitted it to your patient? Could the patient have taken an antibiotic for a sinus infection and developed Clostridium difficile colitis? Here the differential diagnosis can be quite broad, but should certainly not be overlooked when the patient has a chronic disorder.
Acknowledgement: Arvey I. Rogers, MD, FACP, my first clinical mentor, deserves the credit for teaching me this framework. He is a wonderful clinician, a thoughtful educator, and a gem of a person.
Ryan Madanick, MD, is an ACP Member, 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. This post originally appeared at his blog, Gut Check.
Why does computerized physician order entry take so long?
Computerized physician order entry (CPOE) is being rolled out across our nations’ hospitals. The old days of written, and often illegible, orders from doctors are fast becoming a thing of the past.
The potential for this measure to improve patient safety and transform medical practice is unquestionable. As a physician who has worked in several different hospitals since finishing my residency, my time in practice has coincided with the new age of technology in medicine (the iPhone was released as I was finishing my residency). Yet one common theme has been present in all of the hospitals I’ve practiced in. Despite all the promising technology, the computerized order entry systems that have been introduced have largely been slow, tedious and difficult to work with.
Having been intimately involved in CPOE implementation myself, I cannot help but feel slightly disappointed that it hasn’t lived up to expectations. The process can only be as good as the final infrastructure allows it, and unfortunately the implementation is frequently happening on suboptimal software platforms. It would be akin to planning a great traffic system over roads that are completely broken and don’t allow the cars to go at the desired speed. The wrong way round to do things! There’s a large dichotomy between the idea and the technology infrastructure. And to be fair to health care organizations, policies such as meaningful use have meant that hospitals have been forced into a corner of needing to roll everything out quickly in order to receive significant and much-needed federal incentives.
From my perspective as a hospital medicine physician, let’s go through a typical everyday scenario. This has happened in every hospital I’ve worked in, and is not unique to any one institution. The nurse will request an order from the doctor, who may need to drop whatever he or she is doing and find a computer to log into. Typically during the day, a free computer can be hard to find! Logging in will take several seconds, and booting up the system several more. Then we have to deal with a less than optimal interface, multiple clicking will be involved, typed data entry using a keyboard, then a password. Following this, a few seconds to make sure the order has “gone through.” This applies to something as simple as ordering a Tylenol. A complex scan or test that requires some “text entry” to make the order clear, can take minutes.
Why is order entry so cumbersome? It’s often quicker to buy an item online than it is to enter a simple order into a medical system! And whenever we do this it takes time away from our patients in an arena where time is already scarce. A recent study published in the Journal of General Internal Medicine revealed the disappointing statistic that medical interns now spend only 12% of their time in direct patient care, and up to 40% in front of computers. Slow order entry undoubtedly contributes to this.
And it’s not just doctors who are affected. The situation applies to everyone involved in the order entry and retrieval process. Every day, I also see nurses frantically wheeling around their portable computers for most of their shift, reviewing and confirming orders, frequently spending more time with their screens than the patients who truly need them.
In our new technological age, here’s what we really need:
• touch screens, undoubtedly the future,
• quick password entry and rapid screen loading. We cannot afford situations where the software takes up to 30 seconds to load up,
• minimal clicking or scrolling to get to where we want within the program,
• a user-friendly interface, and
• ease of updating and modifying the system if problems are discovered after implementation. This is often very difficult to do, but a vital need for any health care institution
Many of our current systems utilize older platforms, require constant use of the mouse, and have a pretty terrible user interface! Cars, planes, our home devices—the mouse is on the way out, so why do we use them so much in health care? Other technologies have progressed rapidly, yet the health care industry finds itself behind the curve. Our computerized systems may be complicated and have a stringent need for security, but they are still too slow compared to where they should be. I once spoke to a physician administrator who was involved in implementing a hospital IT order entry system, who told me that it wouldn’t necessarily be designed to “save the doctor any time.” This seemed to be taken as a given. It shouldn’t be.
Computers and technology need to be optimized with the workflow of frontline physicians. Let’s view the clinical interaction with the computer as a triangle—the doctor, the patient, and the technology. Too often, it is a straight line with the computer coming in between the doctor and patient. This also means that the patient will not feel the full benefit of the new technology.
I’ve witnessed many IT project teams that will include as part of their clinical advisory group, physicians who don’t regularly practice medicine. I’m sure the idea of involving these physicians is well-intentioned, but how can someone who doesn’t see patients possibly be best placed to design a system for practicing doctors? Whether it’s order entry or data entry, we need to have frontline physicians with knowledge of IT at the forefront of software development, completely involved in every stage of design and implementation. Well before rolling out any new system, give other hospital clinicians a chance to test it out and provide feedback. To use Apple as an example, the initial designers were all users of the product they were creating, who understood the need for providing a good end-user experience. Successful products like the iPhone were the result of their endeavors. We need to adopt the same philosophy for health care technology.
Physicians should not be required to stop their daily workflow for anything longer than a couple of seconds to request orders. The final aim should be for the process to take not much longer than simply speaking. This applies equally to when the physician is entering any other orders, such as admission or medication instructions. Hopefully in a few years, this debate would have moved on when we’ve finally got some better systems in place. It’s probable that some of them are already under development, but we need them yesterday, not in 10 years’ time.
A handful of hospitals are already getting there, and enable order entry with a few touches of a smart screen device. That’s the way forward. Medical professionals must not be hindered by the computers which are supposed to help them. The successful health care IT of the future will be the software that enables the doctor or nurse to spend maximum time with their patients. Collectively we must do better, and doctors, IT experts and hospital administrators need to all work together to achieve this goal.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.
Friday, December 6, 2013
The long arm of medical ethics
Skid Row Study
The New York Times ran a fascinating piece about a dusty old medical experiment that was brought back to life recently after one of its perpetrators … err, researchers, decided to come clean to a medical historian after having read the book The Immortal Life of Henrietta Lacks.
The unnamed confessor was a surgical resident in the 1950s under Dr. Perry Hudson, the man in charge of the experiment. Dr. Hudson (a urologist, still alive at age 96, and adamant that he did nothing wrong) had funding from many sources, including the National Institutes of Health.
The experiment involved recruiting “skid row” alcoholics from flop houses in the Bowery, New York City, and offering them “free medical care” for their participation. The researchers made incisions in the subjects’ nether parts and took wedge-shaped biopsies of their prostate glands. Only problem with this was that the men were not given full information about what would happen to them. Their consent was coerced with false promises and not, as we like to say, informed.
The goal of the research was to learn how to diagnose and treat prostate cancer earlier in men, a worthy goal, to be sure, but handled in a very unethical manner.
The test subjects had their rectums perforated. Some got life-threatening infections. A third developed impotence, another third couldn’t control their urine after the biopsies.
Obviously the standards of the time were much different. But we would think that something like this could never happen after Nuremberg (Wait! this was after Nuremberg). How could an American surgeon, so soon after the horrors of the Nazi doctors, use vulnerable men in dubious research, research that wasn’t designed well enough to include a control group?
The Times article assessing this not-too-distant past ends with three paragraphs that are particularly haunting, in light of the Pandora’s Box that is our current state of the art in prostate cancer diagnosis and treatment:
A federal panel of experts recommended in 2011 that men no longer get the P.S.A. blood test to screen for prostate cancer because clinical trials had found that the test’s benefits are uncertain and its risks—treatments that needlessly cause incontinence and impotence—are severe.
But many urologists believe screening saves lives, and the American Urological Association recommends that men consider starting it at age 55.
“Ethical tragedies are difficult to recognize in the present,” [the author] wrote. “Future observers may view the massive evidence-challenged expansion of our screen-and-treat paradigm in prostate cancer in the same way as we now view the Bowery series practices.”
I think we all need to believe that as problematic and thorny as this issue is, men today are more informed than those of previous generations. But we must do a better job of giving the full picture of all the risks of not only treatment, but screening, too.
This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
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.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
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.
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.
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.
Mike Aref, MD, PhD, FACP, 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.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
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.
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.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
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.
Elaine Schattner, MD, FACP, 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.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
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
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
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.
Peter A. Lipson,
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.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
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.
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.
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.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.