American College of Physicians: Internal Medicine — Doctors for Adults ®

Advertisement
Friday, May 31, 2013

Telling a good story

My patients are amazed when I answer their emails or (even more surprisingly) answer the phone. "Hello, this is Dr. Lamberts," I say. This usually results in a long pause, followed by a confused and timid voice saying something like, "Well ... uh ... I was expecting to get Jamie." Yet I am often able to deal with their problems quickly and efficiently, forgoing the usual message from Jamie to get to the root of their problem. It's amazingly efficient to answer the phone.

Financially, the new practice has been in the black since the first month, and continues to grow, albeit slowly. The reason for the slow growth is not, as many would predict, the lack of a market for a practice like mine. It's also not that I am so busy at 250 patients that growth is difficult. In truth, when we aren't rapidly adding new patients, the work load is nowhere near overwhelming for just me and my nurse. In that sense I've proved concept: That it's not unreasonable to think I can handle 500, and even 1,000 patients with the proper support staff and system in place.

Which brings us to the area of conflict, the crisis point of this story: the system I have in place. The hard part for me has been that I have not been able to find tools to help me organize my business so it can run efficiently. I have well documented my realization that the electronic medical record (EMR) systems I've tried have not met my approval. [Author's Note: To those who are students of writing, I just used a literary device called irony, specifically the irony of a ridiculous understatement. I was able to use the term EMR without descriptions like "sucks at high decibel levels" or "crappier than a Carnival Cruise ship." Other example of this type of understatement include calling the Korean war a "Police Action," and referring to Congress as "a bunch of mindless fools."]

I've tried multiple solutions to this problem, only to have found little to improve my efficiency. Sure, I can handle the current load of patients with the (non) system I have, but what happens when I grow? I'm trying to build something that can grow, and something that others can emulate. It's obvious that I need a better system than I've found up to now.

So what do I need? Surely the freedom from both E/M coding and the utterly ironic "meaningful use" criteria have made documentation of care much simpler, which they actually have. The thing that most EMR systems devote 90% of their energy, documentation of office visits, is one of the smaller problems I face. This has caused some readers (not on my blog, thank goodness) to conclude that I don't need computers at all! I can go real "old school" and return to the days of paper and illegible handwriting. These folks are morons (and they get me very irritated) because they aren't willing to think about what health care could look like if it weren't corrupted by our pitiful system. But, I ask, would they ask their bank to stop using computers and keep their financial records on paper? Would they go to a travel agent instead of booking their flight online? My suggestion that they write their comments to my posts on paper and mail them to me has not been met with any understanding or aplomb. Sad.

Perhaps the problem is that I still use the term "medical record," or (worse) "EMR," to describe what I am looking for. While computers have been an important part in the corruption of the system, they have not been the cause of the screwing up, they have simply made the screwing happen at a much faster rate.

So what am I looking for? The same thing I look for in a good story. The best stories excel in three areas:
--Back Story. What happens before the crisis? How did the person get to the crisis? What are the motivations? What are the inner conflicts? What is at stake?
--Narrative. How well does the story-teller communicate what's happening during the crisis? How well do they describe the setting, the action, the dialog? Do you feel what they feel? Do you believe what they say?
--Resolution. How does the crisis get resolved? Does it make sense? Does it satisfy the listener?

These are also important parts of good medical care for any given patient at any given time:
--Back story. What has happened to the patient in the past? Do they have diabetes? Do they smoke? Did their father have a heart attack at age 45?
--Narrative. What is going on now? What are the symptoms?
--Resolution. What is the plan to get their problem resolved? Does it make sense? Does it satisfy the patient?

So what system am I looking for to help this?
--Back story. Organization of data is key here. The information needs to be complete, but it also needs to be well-organized. It needs to prioritize important things (like the father with a heart attack at 45), and allow me to get a quick, accurate idea of who I am dealing with. Real world examples: Evernote, Wikipedia, Google.
--Narrative. Communication tools are key here. While a typical EMR product stands in the way of communication, focusing instead on obfuscation by documentation, a good system would improve communication. This has been the easiest to attain, using online communication tools and simply being free to answer the phone. Real life examples: email, Twitter, Facebook, iPhones.
--Resolution. This is perhaps the hardest part (as it is in story-telling), and the worst done in our current system. I am looking for a robust task-management system that can organize what needs to be done to get to where I need to go. Examples: Wunderlist, online calendars.

This is a simplification of what really goes on, but it gives some idea of where I am heading. My goal is not software, it is good medical care. I am financially motivated to keep patients well, to efficiently answer their questions, and to handle their problems early, as it means I have more time and can handle more patients. Keeping patients well and at home was bad business for me in my former life (good riddance to that), but it is what patients want. The more efficient I can be at meeting that desire of my patient, the better off both me and my patients will be.

They still will call, though. I think they get a kick out of me answering the phone.

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: , , , , , , , ,

0 Comments:

Post a Comment

Subscribe to Post Comments [Atom]

<< Home

Share

 

Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand 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.

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.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
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 Infection Prevention
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.

Suneel Dhand, MD, ACP Member
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.

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
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.

Informatics Professor
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.

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, 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.

More Musings
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).

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.

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) 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.

Peter A. Lipson, MD
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 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.

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.

Powered by Blogger

RSS feed