Physicians

Physicians
The doctor is in ...

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Richard Gunderman goodLife is tough for physicians in solo and small group practice.  The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases.  “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive.  And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.

Of course, such requirements are not being imposed solely on solo and small-group physicians.  In many ways, they affect all physicians alike.  Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues.  Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.

Such challenges are not just raining down –  they are pouring down on the heads of physicians.  Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business.  And the problem is not just the money.  It’s also the time.  Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data.  We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.

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A cell phone snap of an California Emergency Room physician reacting to the death of a young patient in his care went viral on Reddit after a EMT posted the picture to the social media site on Friday.

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flying cadeuciiMany people believe that neurologists are particularly attracted to detail.  I prefer to think of the issue as one of precision rather than pointless obsessiveness.  Some years ago, I was asked to discuss a case for the New England Journal of Medicine’s series of CPCs called the Cabot Cases.

In preparing the case for publication, I found myself in an argument with the editor about the placement of an apostrophe. There were two diagnoses in this case: aphasia from a cardiac source embolism to the left cerebral hemisphere and hypercoagulability as a paraneoplastic syndrome. In my view, aphasia is a Trousseau syndrome (i.e., the word “aphasia” was suggested by Trousseau), whereas hypercoagulability as a paraneoplastic syndrome was Trousseau’s syndrome, because Trousseau both described and suffered from the disease. I am very much opposed to the trend to remove eponyms from the names of diseases and syndromes as to do so strips medicine of some of its most illustrious history.  But, only a handful of eponymic disorders deserve the apostrophe. Antonie van Leeuwenhoek’s disease (diaphragmatic myoclonus) is another example.

History in medicine is not a mere avocation. In addition to the old saw of helping to prevent the same errors from being repeatedly made, it provides us with the perspective needed to approach diagnostic and scientific challenges in our own era. It also combats hubris. In carefully researching my eleven New England Journal CPCs I have never encountered an idea that had not evolved from those before it.

In grand rounds, in medical journals, and particularly in the lay press, we are regaled with “revolutionary” ideas, but that they are completely new is an illusion. Throughout history, people have always been on the “cutting edge” and have repeatedly believed that they had some sort of huge advantage over prior generations.

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The History of the Problem 

Martin SamuelsThe European University (e.g. Italy, Germany, France, England) descended from the Church. The academic hierarchy, reflected in the regalia, has its roots in organized religion.

The American University was a phenocopy of the European University, but the liberal arts college was a unique American contribution, wherein teaching was considered a legitimate academic pursuit.  Even the closest analogues in Europe (the colleges of Cambridge and Oxford) are not as purely an educational institution as the American liberal arts college.

The evolution of American medical education (adapted and updated from: Ludmerer KM. Time to Heal, Oxford University Press, Oxford, 1999) may be divided into five eras.

I.  The pre-Flexnerian era (1776- 1910) was entirely proprietary in nature. Virtually anyone with the resources could start a medical school.  There was no academic affiliations of medical school and no national standards.

II. The inter-war period (1910-1945) was characterized by an uneasy alliance between hospitals and universities.  Four major models emerged.  In the Johns Hopkins model, led by William Osler, the medical school and the hospital were married and teaching of medicine took place at the bedside. The Harvard model in which the hospitals grew up independently with only a loose alliance with the medical school, represented a hybrid between pre- and post-Flexnerian medical education.

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flying cadeuciiRight now there are two patients in every room. One is made with flesh, bones, and blood. One is made with a monitor, a mouse, and a keyboard.

Both demand my time.

Both demand my concentration.

A little over two weeks ago I wrote the short story Please Choose One. I posted it online. The response it generated exceeded anything I could have ever imagined. It struck a nerve. People contacted me from all over the world, from all walks of life, about the story. Everyone, it seems, can relate to the challenge of having to choose between a person and a screen.

People sent me all kinds of suggestions and ideas. A few sent words of encouragement. Yet, what struck me the most about the people who contacted me was what they did not say. Not a single IT person argued the computer was more important than the patient. Not a single healthcare provider stated they wanted more time with the screen and less time with the patient. And finally, most importantly, not a single patient wrote me and said they wished their doctor or nurse spent more time typing and less time listening.

Medicine is the art of the subtle- the resentful glance from the mother of the newborn presenting with the suspicious bruise, the solitary bead of sweat running down the temple of the fifty three year old truck driver complaining of reflux, the slight flush on the face of the teenage girl when asked if she is having thoughts of hurting herself. These things matter. And these same things are missed when our eyes are on the screen instead of the patient.

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A Ray of Light

I work at the Brigham and Women’s Hospital in Boston. We call it The Brigham. A month ago we were subjected to a tragic murder of one of our doctors.  The winter has been brutal and unrelenting. Then, as I was walking to work the other day I was struck by a ray of light.

It was 7:30 AM and the morning light shone directly into what was the original main operating room of the Peter Bent Brigham Hospital, one of the parent institutions of what we now know as The Brigham.  Peter Bent Brigham was a restaurateur who left an endowment for a hospital for the poor. It was decided to site the Peter Bent Brigham in the Longwood area just behind the Harvard Medical School which had moved to this location in 1904.

After a national search, Harvey Cushing was selected to be the founding Surgeon-in-Chief.  Cushing, a native of Cleveland and graduate of Yale College and Harvard Medical School, had trained in surgery at the The Johns Hopkins Hospital and was in the process of creating the modern field of neurosurgery.  Between 1910 and 1913, Cushing worked with the architects of the new hospital and sited the operating room such that the morning sun would shine into its large window, thereby allowing the surgeons to see well with natural light.

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Evil Dr Rob Part 2It’s been two years since I first started my new practice.  I have successfully avoided driving my business into the ground because I am a dumb-ass doctor.  Don’t get me wrong: I am not a dumb-ass when it comes to being a doctor. I am pretty comfortable on that, but the future will hold many opportunities to change that verdict.  No, I am talking about being a dumb-ass running the businessbecause I am a doctor.

We doctors are generally really bad at running businesses, and I am no exception.  In my previous practice, I successfully delegated any authority I had as the senior partner so that I didn’t know what was going on in most of the practice.

The culmination of this was when I was greeted by a “Dear Rob” letter from my partners who wanted a divorce from me.  It wasn’t a total shock that this happened, but it wasn’t fun.  My mistake in this was to back off and try to “just be a doctor while others ran the business.”  It’s my business, and I should have known what was happening.  I didn’t, and it is now no longer my business.

This new business was built on the premise that I am a dumb-ass doctor when it comes to business.  I consciously avoided making things too complicated.  I wanted no copays for visits (and hence no need to collect money each visit).  I wanted no long-term contracts (and hence no need to refund money if I or the patient was hit by a meteor or attacked by a yeti).   The goal was to keep things as easy as possible, and this is a very good business policy.

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flying cadeuciiThat’s right…it really happened.

At the conclusion of a recent doctor visit, he gave me his cell phone number saying, “Call me anytime if you need anything or have questions.”

In disbelief, I wondered if this was a generational thing – and whether physicians in their late thirties had now ‘gone digital’.

My only other data point was our family pediatrician, who is also in her late thirties. Our experience with her dates back nearly seven years when my wife and I were expecting twins.  A few pediatricians we met with mentioned their willingness to correspond with patients’ families via email as a convenience to parents.  The pediatrician we ultimately selected wasn’t connected with patients outside of the office at that time, but now will exchange emails.

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”Email is the killer app of patient portals.”

I heard a variation of that quote when interviewing people for the patient-provider communication chapter of the book I co-wrote (HIMSS 2014 Book of the Year –Engage! Transforming Healthcare Through Digital Patient Engagement). For the organizations who’ve pushed patient portals the furthest into their patient base, email has always been the foundation. In other words, email is the gateway drug for patient engagement which Leonard Kish called the blockbuster “drug” of the century.

Physicians are understandably concerned about being overwhelmed by emails if they provide an option for secure messaging. As healthcare transforms, financial incentives have a big effect on the willingness to take on what many perceive to be “more unpaid work” (forgetting the fact that playing voicemail tag is also unpaid and frustratingly inefficient). Interestingly, the physicians who have given out their phone number or enabled secure email (without remuneration) haven’t found they are overwhelmed by any means. In the case of the groundbreaking Open Notes study, many of the doctors just heard crickets.

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flying cadeuciiPlease choose one:

The three words blink in front of me on the computer screen.

Please choose one:
Patient is-

Male     Female 

I click FEMALE.

I watch as the auto-template feature fills in the paragraph for me based on my choices.

Patient #879302045

Patient is: 38-year-old female status post motor vehicle accident. Please acknowledge you have reviewed her allergies, medications, and past medical history.

I click YES.

Have you counseled her about smoking cessation?

I click NO.

A little animated icon of a doctor pops up on the screen. His mouth begins to move as if speaking. A speech bubble from a comic strip appears next to it.

“Tip of the day: smoking cessation is important for both the patient’s health and part of a complete billing record.”