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Monday, September 9, 2013

Adventures in medicine, part 1

While hard at work at building a new practice and (in the eyes of some) on my insanely misguided effort to build a medical record, I’ve been thinking. Dangerous thing to do, you know. It can lead to scary things like ideas, creativity, and change. I know, I should be satisfied with the usual mental vacuum state, but I’ve found it a very hard habit to kick. Perhaps there’s a 12-step group for folks with ideas they can’t suppress.

Anyway, my thoughts have centered around explaining what I am doing with all of the my time and energy, and, more importantly, why I am doing all that stuff that keeps me from writing about important things like body odor, accordions, and toddlers with flame-throwers. I’ve really strayed from the good ol’ days, haven’t I?

The problem is, I’ve grown so accustomed to my nerd persona that I end up giving explanations that are harder to understand. To combat this, I’ve decided to employ a technique I learned from my formative years: stories with pictures. My hope is that, through the use of my incredible drawing talent I will not only explain things faster (saving 1,000 words per picture), but prevent my readers from falling, as they often do, into a confused slumber.

So, here goes.

Adventures in Health Care: Part 1–The Participants

This is a patient. Let’s call him “Chuck.” Chuck is not really a “patient,” he’s a person. Many doctors believe that people like Chuck don’t exist outside of their role as “patients,” but this has been proven false (thanks to the tireless work of Oprah and ePatient Dave). But since this story is about Chuck’s wacky adventures in health care, we will mainly think of Chuck in his role of “patient.”

Why are people like Chuck called “patients?” Some people think it’s to put them in their necessary subservient place in the system. I think it’s just to be ironic.

Chuck is a generally healthy guy, but occasionally he does get sick. He also worries about getting sick in the future, and wants to keep himself as healthy as possible. This is when he uses the health care system, and when he is forced to be “patient.”

This is Chuck’s Family. It’s the main reason he wants to stay healthy and avoid being a “patient.” He has a lovely wife, two adorable children, and a cat that likes to ride around the house on a Roomba. I suspect you’ve heard about the cat; he’s gotten pretty famous. Chuck’s family wants him to stay around for a long time so he can pay bills, share his expert opinion on whether an outfit makes his wife’s butt look fat, lecture the kids about the dangers of drugs and Cartoon Network, and answer his cat’s voluminous fan mail. He would also like to live to be able to see his grandchildren (although he’s not sure his kids will survive that long).

This is Chuck’s doctor, Dr. Ron. Dr. Ron is a “primary care provider,” or PCP. Ron never particularly liked being called a “provider,” but the peer pressure from the insurance companies and the other “cooler” doctors (specialists) have made Ron accept this name without thinking any more. Primary care doctors are also called “generalists,” but are known to hospital administrators, insurance company barons, and the “cool” specialists as:
1) referral sources
2) the ones to blame
3) cannon fodder for insurance contracts
4) the guys who can’t afford the cars we drive.

Like most primary care doctors, Ron is very, very busy. He doesn’t feel like he’s got much of a choice, as it’s the only way he can make enough to pay his student loans and still have enough for his loan on his Kia. This causes the following deadly consequences:
• Spending all day seeing patients in the office gives him little time for anything else;
• He doesn’t answer questions over the phone, instead making patients come in for anything that takes more than three words to answer;
• This makes his office visit workload even heavier, and makes the average visit be about less “exciting” problems; and
• Ron then wonders why his patients come to him for such small problems.

Last week, Chuck hurt his back (while trying to avoid his cat) and wasn’t sure what to do about it. He didn’t initially go to the doctor, but did what most people do when they have a question: checked the Internet. He doesn’t like doing this, though, as it usually confuses him more. Besides, he’s heard that doctors get mad if you look things up on the Internet.

He gave up trying to find answers on his own, called Dr. Ron’s office, and was set-up with an appointment. This meant that he had to take time off of work, wait in the office for a long time, and then fit all of his questions into the brief time Dr. Ron is in the exam room and not focused on documentation. This usually is about 30 seconds. But this is what Chuck, and everyone else in the country is used to, so Chuck puts up with the inconvenience this causes, dutifully paying his copay for those precious 30 seconds of attention.

In truth, Dr. Ron is not too happy with this arrangement. He went into medicine because he thought it would be cool to help people, have awesome knowledge nobody else knew, and to make his mom proud. He likes taking care of people, but is finding less and less of what he went into medicine for. Each year it seems like he spends less time with his patients, and more time with his computer.

This got much worse in the past few years as the government decided all doctors should be using computers in a “meaningful and useful” way. Unfortunately, “meaningful” and “useful are defined by the government, not doctors and patients, and Ron is not quite sure if the government wasn’t just being ironic when they decided on these definitions.

Despite the difficulties, Chuck likes Dr. Ron, who seems to spend more time with him and listen to his problems more than other doctors he’s had. A few times Dr. Ron spent a whopping 5 minutes talking with Chuck and answering his questions. This made Chuck feel a bit guilty, as Dr. Ron seemed pretty tired and stressed out.

(To Be Continued ….)

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.

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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.

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 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.

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.

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