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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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, 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.
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Suneel Dhand, MD, ACP Member
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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.
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One of the most popular anonymous blogs written by an emergency room physician.