ACP Internist Blog

Friday, July 19, 2019

If they care for their employees, health care organizations should be doing more of this

At the beginning of this year, I wrote an article about how health care organizations should be doing a lot more to promote employee health and wellness. Within the last several months, my beliefs have not only been reaffirmed, but magnified. We are absolutely terrible in this area—when compared to what other companies across America are doing with their professional staff. I regularly meet people in a wide variety of other industries—consulting, finance, technology—you name it. When the subject of health care comes up, all I keep hearing about is how large companies are putting in a huge amount of effort into their employees' physical and mental health. They are giving employees yearly complete physicals, sending regular emails about wellness and stress management, financial encouragement to use apps and different health trackers, and even bonuses if they meet certain goals. As a physician who is into well-being and preventive medicine, I am always delighted when I hear these stories. But I can't help wondering—what on earth is going on with health care organizations? Isn't it a bit ironic that out of all industries, this is the one that appears to be putting the least effort into employee wellness? And that doesn't just mean the odd administrative email every now and again, as some organizations may think is enough. It means a real concerted effort.

We know that physician job dissatisfaction and burnout rates are soaring (more than 50% of all physicians burned out). A quick Google search will point you towards a ton of articles addressing this subject. Nurse morale is not far behind either. In this new world of regulatory requirements, ridiculously bloated electronic medical records that suck the joy out of medicine, and constant clashes with administrators who are heavily focused on the bottom line—it's not easy to be practicing at the frontlines of medicine. A recent viral New York Times article, which I really encourage anyone to read (click here), put it really well with a statement that whatever “excellence in patient care” there is in health care (and organizations boast about)—exists only because of front-line clinicians striving on a daily basis to go above and beyond—doing the right thing for their patients. Health care organizations therefore actually owe a focus on mental and physical wellness to their employees.

According to the CDC, approximately 70% of the United States is overweight or obese (defined as a BMI greater than 25). Shockingly, statistics suggest that for physicians, the figures are also above 50%, and for nurses it hovers around 55%. Physical and mental health are also intrinsically intertwined.

Unhealthy employees, whether due to physical or emotional health, dramatically reduce productivity and have other enormous downstream effects for any organization. That's why we're seeing so many industries take employee well-being very seriously indeed, especially during busy and stressful jobs. So if we are going to live in a world of health care corporations, mega-mergers, board rooms and CEOs making big and bold decisions, I request every CEO in the country do this: Look at what other big companies are doing across America, and make employee wellness a priority.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Thursday, July 18, 2019

Why patients avoid colonoscopies, a plea to choose wisely

Exercising good judgement can mean the difference between life or death. Life can be unforgiving of the choices me make. As we all know, many life events are beyond our control and understanding. But, there is much we can do to shape our personal paths to a brighter destination.

Consider some of the choices listed below that many folks make every day. Are any of them familiar to you?
• Texting while driving.
• Riding a motorcycle.
• Riding a motorcycle without a helmet.
• Lifting an object that we know is too heavy for us.
• Getting into a car when the driver has had one too many.
• Driving a car when we have had one too many.
• Giving your social security number to a caller who is promising you a tax refund.
• Responding to an email from Nigeria alerting you to a wad of cash waiting for you.
• Using your date of birth as your password for your on-line bank accounts.
• Rushing through a yellow light so we won't be late for a movie.
• Eating street food in a foreign country that appears undercooked.
• Skipping a ‘flu shot’ and other recommended vaccines.
• Getting chest pain for the first time after shoveling snow and decided it was just heartburn.

Get the point?

All of the above activities can end tragically depending upon the choices we make. But, they can easily end well for us. Every day, we confront forks in the road when we must make choices. Sometimes, we choose the wrong road. Sometimes, we make no choice at all. The point here is that we have a choice.

I see this issue in my gastroenterology practice. I've done about 30,000 colonoscopies in my career, a number so large, that I can barely believe it myself. Fortunately, the results of nearly all of them are normal or show benign findings. Telling a patient and their family that all is well after the procedure is a pleasure that hasn't changed over the years.

But, not every colonoscopy result is innocent. As you might imagine, I have confronted a lot of colon cancer in my career. When I discover one, I am aware that life for that person and his loved ones is about change profoundly. Life changes in an instant.

While colon cancer affects the patient and his family most deeply, it's a heavy day for the gastroenterologist also. We are human beings. What makes the day even darker for us is when the patient had faced a fork in the road, but made the wrong choice. Consider the following examples which I have seen repeatedly in my practice.
• A patient turns 50 but chooses not to have a colonoscopy, against the advice of his doctor.
• A patient has rectal bleeding and ignores it.
• A patient was told of hemorrhoids years ago. Rectal bleeding develops and he assumes that his hemorrhoids are active again. He does not consult his physician.
• A patient's bowel changes, but he decides that this must be a side-effect of new medication.
• A patient has a large colon polyp removed by his gastroenterologist. He is advised to return in a year for another colonoscopy, but he does not do so. He is too busy.

Colon cancer, unlike so many other cancers, is a preventable disease. I am not suggesting that modern medicine can prevent every case of colon cancer. It can't. I am stating that the majority of colon cancers that I have discovered were in people who did not choose wisely when they should have. They ignored. They denied. They delayed.

Time after time, I have seen intelligent people who have had rectal bleeding for months before they decided to see me.

Every expert will attest that the earlier colon cancer is diagnosed, the better the prognosis will be. But more importantly, timely colonoscopy can prevent the disease altogether.

I haven't made perfect choices at every fork in the road that I've faced. But, when I turned 50, I did the right thing.

We can't control everything. But, there is much that we can control. For example, you have chosen to read this post. How you decide to use it is your choice.

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.
Monday, July 15, 2019

Understanding diagnostic excellence

When we think about clinical reasoning, most talks focus on diagnostic errors and the reasons for those errors. The legacy of Kahneman and Tversky focuses on errors and the many named mistakes we make. We focus on avoiding errors, but their work and too often our teaching does not focus on the road to diagnostic excellence.

Gary Klein, the pioneer of naturalistic decision making, has focused more on the road to excellence. These are not two sides of a coin, but rather separate important concepts for us to understand. The road to excellence is likely more challenging than the road to avoiding errors. The road to excellence develops “instincts” and type 1 reasoning. The excellent diagnostician feels uncomfortable first, and then can explain why. That diagnostician must resolve the uncomfortable feeling.

The problem arises from the complexity of human beings, interviewing skills, physical diagnosis and test interpretation. As I reconstruct my best diagnostic coups, the road to the correct diagnosis is rarely straight. Each diagnostic triumph takes a different looking path.

The first step towards diagnostic excellence requires an understanding that the simple assumptions (or at least previous assumptions) might need revisiting. Once we recognize the need to reconsider the diagnosis, then we have to use many skills.

Experts attack the diagnostic process like jazz artists attack a musical performance. In order to be a great jazz musician, you must first master the basics of your instrument, an understanding of scales, keys and tempo. Only then can you successfully feel the proper notes to play.

Likewise, learning to retake the history, refocus the physical exam, and reconsider test interpretation, requires that we know the basics, understand illness scripts, and then have the ability to think without hindrance of previous proposed diagnoses. The great jazz artist plays off other musicians. The great diagnostician plays off the data to reconsider diagnostic possibilities.

We all know great diagnosticians. Every medical school has these individuals, who seemed gifted. But like great jazz, while we know it when we hear it (think Miles Davis's “Kind of Blue”), we have difficulty explaining or measuring this excellence.

Like jazz or art, diagnostic stars emerge from hard work on the basics, and an ability to listen to their own discomfort with the diagnostic status quo.

Likely, we will never really be able to “measure” diagnostic excellence. Artificial conferences like CPC and CPS can showcase some of the reasoning skills, but they omit the skill of getting the patient to retell the story and ask the key questions. They omit the ability to “read the patient's body language”.

Many strive for diagnostic excellence, and some achieve it. It requires one to approach all clinical situations with appropriate, healthy skepticism. It requires one to challenge one's own assumptions, as well as others. But this skepticism is necessary to take that road less traveled. We must understand that the diagnostic process rarely resembles a symphony because it most often requires improvisation, like the jazz greats.

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.
Thursday, July 11, 2019

Why smart doctors are not enough

I've delved into the issue of medical judgment more than once on this blog. I have argued that sound judgment is more important than medical knowledge. If one has a knowledge deficit, assuming he is aware of this, it is easily remedied. A judgment deficiency, per contra, is more difficult to fix.

For example, if a physician cannot recall if generalized itchiness can be a sign of serious liver disease, he can look this up. If, however, a doctor is deciding if surgery for a patient is necessary, and when the operation should occur, this is not as easily determined or taught.

Medical judgment is a murky issue and often creates controversies in patient care. Competent physicians who are presented with the same set of medical facts may offer divergent recommendations because they judge the situation differently. Each of their recommendations may be rationale and defensible, which can be bewildering for patients and their families. This is one of the dangers of seeking a second opinion, as this opinion may not be superior to the first one. Patients have a bias favoring second opinions as they pursue them because they harbor dissatisfaction, or at least skepticism, with the original medical advice. If the second opinion differs from the original, it reinforces their belief that the first advice was inferior.

Here are some scenarios which should be governed by medical judgment.

A 70-year-old woman with severe emphysema uses an oxygen tank. She has never had a screening colonoscopy. Professional guidelines suggest that screening begin at age 50. Does a colonoscopy make sense for her considering her impaired health?

A 40-year-old man has had 1 week of stomach pain. This started 10 days after he took daily ibuprofen for a sprained knee. The physician suspects he might have an ulcer. Should this patient undergo a scope examination to make a definite diagnosis? Should the doctor prescribe anti-ulcer medication without determining if an ulcer is still present? Should the ibuprofen be stopped if the patient states he has significant pain without it?

An 80-year-old woman had some recent dizziness and nearly fainted. The doctor sees her in the office two days later and questions her carefully. He suspects that the patient was simply dehydrated. Should the doctor simply reassure the patient or arrange for a neurologic evaluation to make sure that a more serious condition is lurking?

Of course, you want your doctor to know a lot of stuff. More importantly, you want a physician who can give you sound and sober advice. Knowledge and scholarship are important physician attributes, but healing demands more. At least, that's my judgment.

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.

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.