Thursday, January 24, 2019

Physicians

Physicians
The doctor is in ...

My Side

5

I was planning on leaving behind the seriousness of the past few posts and going back to my usual inane writing, but some of the comments have made it too hard for me to keep quiet.  The response has been largely positive, and overall it has been overwhelming.  More people have read or commented on my letter to patients with chronic disease than any in recent history.  I am grateful that it is circulating around the web for others to contemplate, perhaps understanding the intent of what I wrote and improving their relationship with their doctors in the process.

The purpose of the letter was to give some helpful insight into the emotion on the other side of the equation.  I can’t understand what it is like to have a chronic illness without having the disease, but it is still fruitful for me to try to figure this out.  In the same way, patients with chronic illnesses benefit from a better understanding of the doctors they see so frequently and depend on so greatly.  I can sympathize, but I can’t feel the pain.  Still, I do need to listen closely to patients so I can have the best relationship possible.

Some folks felt that I was saying that doctors need their egos stroked and to be treated special, but that is not what I meant to say.  Each person needs to be understood and treated as their situation dictates.  People with chronic illness want to be understood (as witnessed by the incredible response to my letter!) and treated based on that understanding.  Doctors want to be understood as well.  So let me tell you my side of the story.  What is it like to sit in my chair?  I don’t say this for sympathy or pats on the back, I say it to be understood.  If I am better understood by my patients (and readers), my relationship with them is better, which is good for both of us.  I think I represent a fair percentage of primary care docs in these ways.

1. I care about my patients – As hard as I try to “just do the job,” and not expend the emotion I do during the day, I couldn’t live with myself if I let my patients down.  They depend on me for a lot, they pay for my service, and they deserve my best.  I’ve been told I do this to a pathological degree (along with my llama obsession), but it is there.  I want to help them.  I get frustrated at my powerlessness and am genuinely happy when they do well.

2.  I am tired – Each day demands an emotional price.  Some days the demand is not so high, others suck the life out of me.  Being “needed” cuts two ways; on one side it is nice to truly help people when they need the most help, it’s satisfying to see your life making a difference.  On the other side, it is a never-ending river of need, pain, and crises to be handled.  Being patted on the back (or patting myself) is nice, but it doesn’t mean anything for the future.  Each day brings new hands to hold, needs to meet, problems to be solved.  Each day is as much a burden as it is an opportunity.  That burden won’t leave me until I take down my shingle, yet the opportunities to make a difference will make it hard to take that shingle down.

3.  I also run a business – In terms of priorities, I need to pay my staff, pay the rent, and pay my personal bills to even have the chance to take care of patients. I get frustrated when patients insinuate that I value money too much.  I get very frustrated by that, actually.  People seem more willing to pay for cable TV, cigarettes, or eating out than to pay me for what I do.  I earn less than most other medical specialists, yet some people resent my income.  The mess of a system we have works against primary care and works against complex patients.  If I spend 30 minutes with a complex patients (I do spend 30 minutes with people regularly), I am paid about 50% more than if I see a 5 minute ear infection visit.  Doing the math says that my mind is not valued and that I should see more ear infections and less chronic patients.  All of this adds to my daily stress.

4.  I am actually a person, not just a doctor – I have four children and a wife, and being a dad and a husband isn’t easy when I come from work with the emotional life sucked out of me.  I struggle with my own emotions and I get sick.  I worry a lot about money, and I feel insecure about the fact that despite being a doctor, I am not saving enough.  Hence I also struggle with working too much.  Life’s not easy for anyone, and despite my title I am not exempt.

5. I hate bad doctors – Many of the comments to the letter I wrote were lamentations about doctors who suck.  Unfortunately, doctors who take bad care of their patients make my life miserable too.  I have to clean up their messes, I have to re-teach their patients on what medicine should look like.  I have to wean their patients off of addictive drugs that they didn’t have the guts to deny. I am personally frustrated when I send a person to a specialist and they don’t do anything or upset my patient, and I hate the fact that they almost never communicate with me.  It makes my already hard job even harder.

6. My blog is a refuge and a tool – I am thankful that I have this blog as a means to vent, to use another part of my brain (some may argue that point on some of my posts), and to make a difference.  I actually have a voice in the whole healthcare reform debate.  I actually can reach a large number of people and make their medical experience better (which was the most gratifying thing to hear in the comments to my letter).  I’ve made practically no money doing this, but I’ve gotten a whole lot out of it.

That’s my story.  Like it or not, it is what it is.  I am just a guy who happens to be a doctor – the same as the rest of the doctors out there.  There will always be angry people and idiots on both sides of the doctor/patient relationship, but no matter what, the doctor-patient encounter is a human thing.  Love is human, war is human, murder is human, and so is childbirth.  You can’t put humanity into a bottle, you can’t throw a single label on it.  The highest calling is to enter into another’s life, to see things from their perspective, and to add good to it.

That goes for all of us, regardless of letters behind our names.

Thanks for listening.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

The Paradox of Evidence-based Medicine

5

Img2

While many doctors remain enamored with the promise of Big Data or hold their breath in anticipation of the next mega clinical trial, Koka skillfully puts the vagaries of medical progress in their right perspective. More often than not, Koka notes, big changes come from astute observations by little guys with small data sets.

In times past, an alert clinician would make advances using her powers of observation, her five senses (as well as the common one) and, most importantly, her clinical judgment. He would produce a case series of his experiences, and others could try to replicate the findings and judge for themselves.

Verb-alizing

7

One of my interns was “running the list” with me last week (giving me a thumbnail update on the plans for each of our inpatients). It was standard stuff until he got to Ms. X, a 80ish-year-old woman admitted with urosepsis who was now ready for discharge. “I stopped her antibiotics, advanced her diet, called her daughter, and YoJo’ed her.”

Say whaa?

I’m pretty sure that the most valuable thing I’ve done in my 15 years running UCSF’s inpatient service has been to convince the hospital to hire a discharge scheduler, Yolanda Jones, a delightful woman with a big smile and the world’s most thankless job. When a patient is ready for discharge, the interns send Yolanda a note with a list of follow-up appointments, radiology studies, and other outpatient tests that need to be scheduled. She makes all the appointments, then calls the patient and intern with the info. Our hospital would cease to function if not for Yolanda; she is the unsung hero of the medical service.

And now, the process of asking Yolanda Jones to schedule discharge appointments had become a verb.

The Best Part Of The Health 2.0 Fall Conference Agenda

0
There’s still time to secure your ticket before prices increase to this year’s Health 2.0 11th Annual Fall Conference. Whether you’re a Health Provider, Entrepreneur or Investor; the Fall Conference is the place to see the latest health technology, to hear from some of the influential innovators impacting the landscape, and to network with hundreds of health care decision makers. Click here for the full agenda.

Health Providers Agenda Highlights 
Entrepreneurs Agenda Highlights 
  • MarketConnect: A live matchmaking event designed to accelerate the health tech buying and selling process by curating meetings between pre-qualified healthcare executives and innovators.
  • Exhibit Hall: Gain access to 90+ exhibitors, including Startup Alley, is the premier gathering of innovative companies and individuals. The exhibit floor is also home to MarketConnect Live.
  • Developer Day: Expect your day to be filled with strong technical sessions in relation to interoperability and user testing as well as opportunities to network from others in the industry.
  • 2 CEOs and a President Session: Three top health tech executives sit down for separate intimate interviews with a journalist. They will be dishing on both their personal and company journeys.
Investors Agenda Highlights 
  • Investor Breakfast: Bringing together leaders in the Health 2.0 investment community and our innovative startup network for an exclusive breakfast meeting.
  • Investing in Health 2.0 Technologies: Panel experts will address what’s in store for the rest of the year and predict the next big bets in Silicon Valley and beyond.
  • Launch!: Ten brand new companies unveil their products for the very first time and the audience votes on the winner!
  • Traction!: Annual startup pitch competition that recruits companies ready for Series A in the $2-12M range. Teams will compete in two tracks, consumer-facing, and professional facing technologies.

Click here to register for the Annual Fall Conference! Prices increase after September 4th!

PHYSICIANS: Morrison on The Doctor Conundrum

0

Non-plagiarist* whatever anyone says, Ian Morrison has a great article called The Doctor Conundrum, suggesting that doctors are cranky again. Essentially Ian says it’s not that we’re paying doctors too much–it’s that they’d make more as salesmen or futurists.

*This is in reference to an appalling comment in this post

Should a Doctor Prescribe Drugs that are Unapproved by the FDA?

5

Here’s an interesting clinical dilemma brought to my attention by another physician.

She was asked to refill a prescription for a drug called domperidone to help a patient with lactation. Domperidone is not FDA approved in the United States for any indication. However, in Europe and in Canada it is approved as a promotility agent for patients with a condition called gastroparesis, which causes the stomach to empty very slowly and results in chronic nausea and vomiting. As a side effect the drug is also known to increase the production of prolactin, a hormone that stimulates milk production. In the case of this physician’s patient, she had adopted a child and found that the medication had effectively enabled her to produce milk and nurse, with seemingly no untoward effects. It’s unclear who had initially prescribed the drug, but various online lactation support forums discuss it as an option  for women who have trouble with lactation.

The questions: Is it legal, ethical or good medical practice for a physician in the United States to write a prescription for domperidone for a patient who has been using it for lactation with good results? How about for gastroparesis? Where does one get the drug? Is it even legal to sell the drug in the United States?

I’ve cared for at least two patients who have used domperidone. In both instances it was ordered by prescription from an overseas source by a local gastroenterologist. In these two cases my patients had tried just about everything on the market in the United States for gastroparesis and were still struggling with debilitating symptoms. In one case, my patient had required hospitalizations and ultimately a feeding tube because of intractable vomiting. The drug was ineffective in both patients and it was eventually discontinued.

Will the “Instagram for Clinicians” Be a Game-Changing Educational Resource?

2

Working with clinicians to set up forums where care teams would discuss their patients daily, I was privy to the excited eyes and cheshire cat smiles that accompanied the talk of “woah” patients – the medically rare, gross, or otherwise notable cases which made the day a bit more interesting. The patient with Anton-Babinski Syndrome. The child whose amputated hand was proof he shouldn’t have been playing with an axe. The all-too-common gunshot wounds of every type, notable for their stories more than the wounds.

With the release of Figure 1, a photo-sharing app for health care professionals, those conversations can leave the hospital and enter the cloud; physicians can upload a picture to their feed, and it’ll be instantly available to the world. It’s Instagram for health care workers, except instead of filtered “selfies” and pictures of brunch, it has pictures of rare medical conditions and x-rays of things inserted where they shouldn’t be. It’s a new, neat idea that could change the face of medical education or serve as stress-relieving entertainment. Or both.

Dr. Joshua Landy, co-founder at Movable Sciences, said in an email interview that he created Figure 1 to fill a gap he identified in clinician-to-clinician communication. Currently, “many physicians collect images of interesting or representative cases on their smartphones,” and share with colleagues. Sensing an opportunity, and “recognizing the educational benefit of these images,” Landy created an app that would “harness thousands of educational assets being collected by individuals each day.”

The app opened to the public three weeks ago, and has a user base “well into the thousands,” Landy said. Anyone can download it, but only health care professionals can upload images; once vetted, physicians will have a “Verified Physician” badge on their profiles. Users can search for images of specific conditions and have conversations with others through a commenting feature – which Landy said has already been used as a virtual classroom, with “experienced healthcare professionals answering questions for medical students.”

Into America: The Odds Against a Foreign Trained Doctor

1

By SAURABH JHA MD SAURABH JHA

In this episode of Firing Line, Saurabh Jha (aka @RogueRad), has a conversation with Chadi Nabhan, MD MBA FACP, who is a preeminent oncologist, speaker and the Chief Medical Officer of Cardinal Health Specialty Solutions.

At the great heights of his career, and a secure American citizen, Chadi recalls the struggle and effort it took to get from Syria to Boston. He credits his journey to good luck and a tenacious drive and uncompromising desire to work in the U.S. Chadi speaks for thousands of international medical graduates to fight odds to get here.

Listen to our conversation at Radiology Firing Line Podcast.

Saurabh Jha is a contributing editor to THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.

Academic Medicine Survival Guide

13

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.

QUALITY/PHYSICIANS: Just what we need now, another grandstanding politician on end of life issues

6

I’ve been having a backchat email with the people from the Tenet Shareholders Committee. They are enjoying the legal  attack on the Louisiana physician who is supposed to have performed a mercy killing or provided ample pain medication at Tenet’s Memorial Hospital a little too much for my taste. Admittedly they are so opposed to Tenet that this one is too easy for them. But I doubt this one has anything to do with Tenet, which frankly didn’t do much to help its patients (HCA was a little more honorable).

But where the hell was the Louisiana or New Orleans AG (or for that matter any other level of government) when desperate physicians, nurses and patients needed help? Absolutely effing nowhere. A humane person wouldn’t leave a dog to slowly die or drown in the 105 degree heat, let alone another human. And it seems to me that in absolutely desperate circumstances, Dr Anna Pou did what she felt was best for those patients.Yet six months later a grandstanding DA gets his jollies off by sending physicians and nurses on trial for homicide.

This is total bullshit. A series of studies in the 1990s showed that physicians routinely ignored DNR orders. I don’t recall any of them being prosecuted, but they probably caused more harm and inflicted way more distress on patients than Dr. Pou would have done under any normal circumstances…..and let us not forget—those were anything but normal circumstances. If I was a patient there suffering with no water, no power,and no hope other than suffering a long agonizing death—I’d have been very grateful for the relief Dr. Pou’s care would have given me in my final hours.

And now we’re going to send her to jail?!