Physicians

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.

Continue reading “A Ray of Light at the Brigham”

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.

Continue reading “How to Avoid Being a Dumb-Ass Doctor, Blog Edition”

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.

Continue reading “My Doctor Just Gave Me His Cell Phone Number …”

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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.

Continue reading “The Myth of Doctors Getting Overwhelmed by E-mail”

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.”

Continue reading “Please Choose One”

GundermanDo physicians in training take better care of patients or perform better on their exams when their work hours are restricted?  Two recent studies in the Journal of the American Medical Association suggest that the answer is no.  In one, patients of surgery residents showed no difference in morality or postoperative outcomes after duty hour restrictions were implemented.  Their test scores did not improve either.  In the other, hospitalized Medicare patients being cared for by physicians working shorter hours experienced no improvement in mortality or readmission rates.

US resident duty hour restrictions were born in 2003, when the ACGME, the organization that accredits medical residency programs, capped the work week at 80 hours.  It also mandated that residents have 10 hours off between duty periods and a 24 hour limit on continuous duty, with 1 day in 7 free from patient care.  In 2011, the organization revised its policy, further restricting the total number of continuous duty hours for physicians in the first year of training to 16.

How could well-intentioned attempts to ensure that hardworking young physicians get sufficient rest fail to benefit patients?  To begin with, simply restricting duty hours does not guarantee that residents will use their extra off-duty time to sleep.  They might, for example, use it to study, exercise, or socialize.  It is also possible that the outcomes being assessed by these studies are influenced by so many factors that merely changing duty hours is insufficient to cause a change.  Yet if such changes do not benefit patients, how strong is the case for their implementation?

Some educators worry that duty hours restrictions are undermining the quality of medical education.  For example, a survey of surgery program directors published last year showed that 21% believe that residency graduates are unprepared for the operating room, 30% believe they cannot independently remove a gallbladder, and 68% believe they cannot perform a major procedure unsupervised for more than 30 minutes.  Another survey showed that 38% of residents themselves lack confidence in their preparation even after 5 years of training.

Continue reading “Does Restricting Physician Duty Hours Improve Patient Care?”

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New York Post reporter Susan Edelman revealed on January 4 the name of the unfortunate anesthesiologist allegedly present on August 28 at Yorkville Endoscopy, during the throat procedure that led to the death of comedian Joan Rivers. She is reported to be Renuka Reddy Bankulla, MD, 47, a board-certified anesthesiologist from New Rochelle, NY.

Having her name made public will be a nightmare for Dr. Bankulla, as investigators will certainly target her role in Ms. Rivers’ sedation and the management — or mismanagement — of her resuscitation.

When the news of Ms. Rivers’ cardiac arrest and transfer to Mt. Sinai Hospital became public, many of us guessed that there might have been no qualified anesthesia practitioner — either anesthesiologist or nurse anesthetist — present during the case. The gastroenterologist and then medical director of the clinic, Dr. Lawrence Cohen, argued famously that the sedative propofol, which Ms. Rivers received, could be safely given by a registered nurse under his supervision, and that no anesthesiologist is necessary.

However, with the publication of the Centers for Medicare & Medicaid Services (CMS) report of September 5, it became clear that an anesthesiologist was definitely present. The anesthesiologist was identified only as “Staff #2″ in the report. She was interviewed by the CMS surveyors four days after the event, but said she was “advised by her legal representative not to discuss the case.”

Key pieces of information about what happened still haven’t been made public. Nonetheless, the surveyors gathered enough information to reach this conclusion:  “The physicians in charge of the care of the patient failed to identify deteriorating vital signs and provide timely intervention during the procedure.”

By any standard of care, the anesthesiologist clearly would be one of the physicians in charge.

Continue reading “The Anesthesiologist’s Story: New Details Emerge In the Joan Rivers Case”

By MARTIN SAMUELS, MD

Martin SamuelsI am a doctor today because of Dr. J.W. Epstein, my pediatrician in Cleveland in the 1950s.   An immigrant from the Nazi terror in Europe, he had trained in Vienna and   spoke English with a Germanic accent.  His house calls are etched permanently in my memory.  His visits were heralded by a fury of activity, led by my mother.  “The doctor is coming!  Put on clean underwear.  Clean the house.”  Water would be set to boil on the stove, in case the doctor should need to sterilize a needle for an injection.  Up would drive his broken-down jalopy, which he would park directly in front of the house.  No need to worry about getting a ticket.  The police knew his car and would never issue a citation to The Doctor.  No one – not the mayor, not the governor, not even Al Rosen, the venerated third baseman for the Indians – would have received such a royal welcome.

In he would come, wearing a suit and hat, carrying a worn black doctor’s bag.  “Mudder, ver is da boy?”  ”He’s in his room upstairs with a rash and sore throat.”  He would put down his bag, sit on my bed, and ask me if the teacher had sent home the homework.  He wouldn’t want me falling behind in my school work.

That might interfere with my becoming a doctor.  Then came the ritual of the examination.  Say aah; schtick out your tongue; take some deep breaths.  “Gut… gut…zounds normal” as he listened with his stethoscope, feeling gently on my belly and then finally tap on some reflexes with his tomahawk hammer.  “Mudder, it’s da measles, plenty of fluids, back to school in a few days.”  “Veel zee you in da office next fall for da usual checkup.”  “Mudder; don’t vorry, it isn’t polio.”  No time for a cup of tea today; too many other house calls for this afternoon and off he would go.  The enormous feeling of relief, transmitted from my mother to me, had me on the mend in no time.

This is what I wanted to do:  be the agent of relief, the repository of medical knowledge, the most respected figure in the community.  Some years later, as a teenager, I was waiting in Dr. Epstein’s office for my annual checkup before school started in September.  I was surrounded by little babies and I realized that I might be growing out of Dr. Epstein.  As he was tapping on my back in the usual reassuring fashion, I said to him,  “How long can you see me as a patient?”  “ Until you’re a doctor.”  How could I fail him?

Continue reading “Rediscovering Medical Professionalism”

flying cadeuciiI am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

Continue reading “A Doctor is a Doctor is a Doctor, Right?”

GundermanThe competition to get into medical school is fierce.  The Association of American Medical Colleges just announced that this year, nearly 50,000 students applied for just over 20,000 positions at the nation’s 141 MD-granting schools – a record.  But medical schools do not have a monopoly on selectivity.  The average student applies to approximately 15 schools, and many are accepted by more than one.  Students attempting to sort out where to apply and which admission offer to accept face a big challenge, and they often look for guidance to medical school rankings.

Among the organizations that rank medical schools, perhaps the best-known is US News and World Report (USNWR).  It ranks the nation’s most prestigious schools using the assessments of deans and chairs (20%), assessments by residency program directors (20%), research activity (grant dollars received, 30%), student selectivity (difficulty of gaining admission, 20%), and faculty resources (10%).   Based on these methods, the top three schools are Harvard, Stanford, and Johns Hopkins.

Rankings seem important, but do they tell applicants what they really need to know?  I recently sat down with a group of a dozen fourth-year medical students who represent a broad range of undergraduate backgrounds and medical specialty interests.  I posed this question: How important are medical school rankings, and are there any other factors you wish you had paid more attention to when you chose which school to attend?

Continue reading “Secrets to Choosing the Right Medical School”

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