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

Friday, July 12, 2013

How I realized I am a senior (doctor)

It has been creeping up on me for the past year or so, but I think it really hit me today. I am a senior (doctor).

I don't mean to say that I am old. If anything, I feel younger than I did a year ago, having had a rejuvenating surgery for sciatica only this past April. What I mean to say is that I have achieved the status of venerable, sometimes crotchety, and even "old-fashioned."

The evidence has been accumulating but today was the tipping point.

It was a simple term of address. We doctors often address each other as Doctor, especially if we are strangers, out of respect. But after having worked with a colleague more than a few times, I usually say, "Please, call me David." But lately, the new hospitalists are addressing me as "Dr. Sack," and when it happened today, I found myself free of the urge to correct her. It has become apparent to me, astonishingly, that the junior staff really respect my wisdom.

And speaking of wisdom, that's another thing. I have started to dispense it. And doctors and nurses have been actually listening lately. I'm not used to that. (My wife sees to it that I don't get accustomed to it at home.)

I am even noticing that I am dressing old-fashioned. When I started out as a medical student, doctors wore ties. Some eccentrics sported bowties, but everyone put on a tie. This dress code was fairly well observed when I was an intern and resident. Most everyone I worked with after I became an attending maintained this practice. There was the occasional out-and-out rebel/weirdo that wore a bolo tie. (There was even for a time an ER director who wore a cowboy hat on the job.) Naturally, surgeons were permitted scrubs in their offices.

But over the past ten years, I have noticed that the necktie is becoming an endangered species among my colleagues. Most of my gastroenterologist colleagues are either wearing their shirts open or are wearing surgical scrubs. Same for the hospitalists. Some specialties at my hospital seem to be holding the line: our nephrologists, oncologists and cardiologists (all serious specialties). Perhaps dealing in serious illness demands dress standards as serious as one's demeanor. Yet here I am, knotting a tie most mornings. Lately, I must admit, I have been dispensing with the necktie on days that I will be doing procedures all morning. The patients are all too anxious beforehand or dopey afterwards to notice.

And recently I realized that my attitude about how a history and physical exam should be written, and how to interpret it, is utterly antiquated. I was taught in medical school to follow a certain order for recording the history and physical. With the advent of the electronic medical record (EMR), I now note that the traditional order has been ceded to the province of computer programmers instead of doctors and is now completely and, for all appearances, arbitrarily scrambled. It has seemed to me an abomination but today I realized that the traditional order is really only arbitrary. Why should I be bothered if the chief complaint and present illness appear on page 5 after a listing of patient's habits, prior surgeries, native language, and whether they wear seat belts? I'll find the information I want sooner or later if I just keep looking. I'm just being a curmudgeon, right?

For that matter, the physical exam itself reveals itself as a telltale about my antediluvian attitude. And this particular item is really what originally inspired me to write this post.

Up until this month, I have been locked in combat with the "physical exam" section of the progress note in my EMR, which is so unwieldy to alter from the default normal that I end up swearing at times. I find myself spending precious time tailoring an organ system's examination in the note, only to find all my free text gets erased when I try to amend it further. The menu tree is a shriveled excuse for a multiple choice device and takes more effort to enter the pitiful data that it does accept than it does to just free-text it. My EMR doesn't even allow me to copy the previous visit's exam components that are unchanged. Even my primitive "non-qualified," "non-meaningful" EMR I installed in 2002 had that feature! Don't I sound like an old curmudgeon complaining about these "new-fangled contraptions"?

So I have sometimes taken to simply opening a text box at the bottom saying: "EXCEPTIONS," by which I mean "ignore all the useless drivel above." After all, it was only put there to satisfy the bullet points required to code for the visit at a level appropriate to my effort and time. No one reads these exams; not referring doctors, not doctors who I send patients to, not patients themselves, not, God forbid, insurance company auditors, who might count bullets. The sole exception is me, doing my proofreading.

So why bother? I have come to the realization that most of my colleagues have long since recognized that this is nothing but a charade. If I spend my time perfecting a note in an EMR, I will have no time left to treat the patient. Anyway, most of the visit is always spent in counseling and coordination of care anyway, and I code it so. But it really would be easier to just click the box that says everything is normal. I know many doctors that rely on their memory for the real exam and do just that for the note. As Julia Child famously asked, "Who's to know?"

Remember the movie Fail-Safe? The subtitle, as I recall, was "or how I learned to stop worrying and love the bomb." It was about simply surrendering to the absurdity of the doctrine of "Mutual Assured Destruction," or MAD, as it was referred to. Yes, I am old enough to remember the Cold War, and believe me, that notion was the foundation of our strategy for keeping the peace by nuclear deterrence.

At least I am trying to stay current in my medical knowledge and continuing education. So far at least this habit has not gone out of style.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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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.

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 Iowa City, IA, 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.

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.

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.

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).

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.

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