By HANS DUVEFELT, MD
“By the way, Doc, why am I tired, what’s this lump and how do I get rid of my headaches?”
Every patient encounter is a potential deadly disease, disastrous outcome, or even a malpractice suit. As clinicians, we need to have our wits about us as we continually are asked to sort the wheat from the chaff when patients unload their concerns, big and small, on us during our fifteen minute visits.
But something is keeping us from listening to our patients with our full attention, and that something, in my opinion, is not doctor work but nurse work or even tasks for unlicensed staff: Our Public Health to-do list is choking us.
You don’t need a medical degree to encourage people to get flu and tetanus shots, Pap smears, breast, colon and lung cancer screening, to quit smoking, see their eye doctor or get some more blood pressure readings before your next appointment. But those are the pillars of individual medical providers’ performance ratings these days. We must admit that the only way you can get all that health maintenance done is through a team effort. Medical providers neither hire nor supervise their support staff, so where did the idea ever come from that this was an appropriate individual clinician performance measure?
By CHADI NABHAN, MD, MBA, FACP
thought about your own mortality?
given the frequency of seeing death and grief depicted in the media or through
real life encounters with friends, relatives, neighbors, or patients? These
incidents trigger uncomfortable and sometimes uneasy thoughts of how we might
personally deal with potential illness and disease. The same thoughts are soon
displaced by the busyness of living.
dealing with the death of his mother from a brain tumor, we learn David
Fajgenbaum was healthy, living life to its fullest, and a future doctor in the
making. He may have thought about his own mortality as he grieved the death of
his mother, but likely never imagined anything dire would happen to him.
Fajgenbaum was pushing forward on several fronts, including leading a
non-for-profit organization for grieving college students, symbolically named
“Actively Moving Forward” or “AMF” after his mother’s initials, all while first
playing college football and then attending medical school. By all accounts,
this was a vigorous young man, meticulous about his diet and physicality. When he became ill, it was a blunt reminder
that life is unpredictable.
In his book “Chasing my Cure”, Dr. Fajgenbaum takes us back to the time when he first got ill. He vividly describes his physical symptoms and various scans which detected his enlarged nodes. Interestingly, we learn how long he was in denial of these symptoms, thereby delaying medical attention in favor of studying. This neglect of self-care highlights part of his personality, but also represents the pressure and expectations placed upon a majority of medical students.
By ANISH KOKA, MD
It took some doing, but I had finally
made it to Bobby’s home.
It was a rowhome tucked into one of those
little side streets in the city that non-city folks wouldn’t dream of driving
down. As I step in, I’m met by the usual set up – wooden steps that hug the
right side of the wall leading up to the second floor. Bobby certainly hasn’t made it up to the
second floor in some time. At the moment she is sitting in her hospital bed in
the living room. The bed is the focal point to a room stuffed to the gills with
all manners of stuff. At least three quarters of the stuff seems to be food.
Cinnamon buns, Doritos, donut holes, chocolate frosted Donuts, crackers,
Twinkies. The junk food aisle at Wawa would be embarrassed by the riches on
Bobby weighs in at four hundred pounds, 5
foot 5 inches. She has a tracheostomy from multiple prior episodes of
respiratory failure that have required ventilatory support. I’m here at the
request of a devoted primary care physician that still makes home calls. I’ve
looked through the last number of hospital stays. The last few discharge
summaries are carbon copies of each other. Hypoxemic respiratory failure
related to pulmonary edema complicated further by morbid obesity. Time on the
vent. Antibiotics. Diuretics. Home. Return to the hospital 2 weeks later. The
last echocardiogram done was 3 admissions ago. A poor study. Not much could be
seen due to ‘body habitus’.
I sit on the side of the bed trying to acquire my own images of her heart. I talk to her as I struggle. Bobby is 58, the youngest of three sisters, and the only surviving member of the family. Her elder sisters died of respiratory complications as well. They both died with tracheostomies. The conversation is circular. The problem according to Bobby is the tracheostomy. Everything was fine before that. I explain that a prolonged period of time on the ventilator on a prior admission prompted the tracheostomy, and that the multiple recent admissions to the hospital that required a ventilator seemed to validate that decision. She doesn’t waver. Both her sisters died shortly after they got tracheostomies. Bobby thinks the physicians taking care of her sisters had a hand in their demise. “They didn’t care.” “We told them they were sick.”
By HANS DUVEFELT, MD
As a family doctor I receive a lot of reports from emergency room visits, consultations and hospitalizations. Many such reports include a dozen or more blood tests, several x-rays and several prescriptions.
Ideally I would read all these reports in some detail and be more than casually familiar with what happens to my patients.
But how possible is it really to do a good job with that task?
How much time would I need to spend on this to do it well?
Is there any time at all set aside in the typical primary care provider’s schedule for this task?
I think the answers to these questions are obvious and discouraging, if not at least a little bit frightening.
10 years ago I wrote a post titled “If You Find It, You Own It” and that phrase constantly echoes in my mind. You would hope that an emergency room doctor who sees an incidental abnormal finding during a physical exam or in a lab or imaging report would either deal with it or reach out to someone else, like the primary care provider, to pass the baton – making sure the patient doesn’t get lost to followup.
By AMITA NATHWANI, MA
This week’s impeachment hearings show what a crisis of trust we live in today. 69% of Americans believe the government withholds information from the public, according to recent findings by Pew Research Center. Just 41 % of Americans trust news organizations. We even distrust our own health care providers: Only 34% of Americans say they deeply trust their doctor.
One important way doctors can regrow that trust is to become educated about the types of medicine their patients want, including alternative therapies.
People are seeking new ways to care for their health. For instance, the percentage of U.S. adults doing yoga and mediating—while still a minority– rose dramatically between 2012 and 2017, according to the CDC’s National Center for Health Statistics. Likewise, the number of Americans taking dietary supplements including vitamins, minerals and natural therapies like turmeric, increased ten percentage points, to 75% in the past decade, according to the Council for Responsible Nutrition. As Americans increasingly seek out non-pharmaceutical ways to address wellness, they need doctors who can talk to them about such alternatives.
Unfortunately, this is rare. As a provider of an holistic approach to health called Ayurvedic Medicine, I often see people who tell me their physician dismissed them when they asked about treatments they’d read about on the internet. In many cases, clients tell me their doctor has actually chastised them for entertaining an alternative approach to their existing illness. This leaves them disempowered. They wanted to make choices to improve their own health, but found they were not acknowledged, supported or even understood by the doctor.
By YOLONDA Y. WILSON, PhD
Last week a nurse posted a video of
herself on Twitter mocking patients with the caption “We know when y’all are
faking” followed by laughing emojis. Twitter responded with the hashtag #patientsarenotfaking,
created by Imani Barbarin, and
a slew of testimonials of negligent medical care. While the nurse’s video was
not explicitly racialized, plenty in the black community felt a particular
sting: there is clear evidence that this attitude contributes to the problem of
black patients receiving substandard care, and that negative behavioral traits like faking or exaggerating symptoms are more likely
to be attributed to black patients. The problem is so bad that it turns
out racial bias is built right into an algorithm widely used by
hospitals to determine patient need.
Since we can’t rely on the system or
algorithms, many health organizations and the popular media encourage patients to
themselves and their loved ones by, for example, asking questions, asking for second (or more) opinions, “trusting [their] guts,”
and not being afraid to speak up for themselves or their loved ones. But this
ubiquitous advice to “be your own advocate” doesn’t take into account that not
all “advocacy” is interpreted in the same way—especially when the advocacy
comes from a black person. Sometimes a patient’s self-advocacy is dismissed as
“faking;” sometimes it is regarded as anger or hostility.
Black male faces showing neutral expressions are more likely than white faces to be interpreted as angry, violent, or hostile, while black women are often perceived as ill-tempered and angry. These stereotypes can have a chilling effect on a person’s decision to advocate for themselves, or it can prompt violent reaction.
By AMEYA KULKARNI, MD
When Samuel Morse left his New Haven home to paint a portrait of the
Maquis du Lafayette in Washington DC, it was the last time he would see his
pregnant wife. Shortly after his arrival in Washington, his wife developed
complications during childbirth. A messenger took several days on horseback to
relay the message to Mr Morse. Because the trip back to New Haven took several
more, his wife had died by the time he arrived at their home. So moved was he by the tragedy of lost time
that he dedicated the majority of the rest of his life to make sure that this
would never happen to anyone again. His subsequent work on the telegraph and in
particular the mechanism of communication for the telegraph resulted in Morse
code – the first instantaneous messaging system in the world.
Mr Morse’s pain is not foreign to us in the 21st century. We feel the loss of new mothers so deeply that, when earlier this year new statistics on the rate of maternal death were released and suggested that American women died at three times the rate of other developed countries during child birth, doctors, patient advocates, and even Congress seemed willing to move heaven and earth to fix the problem. As someone who cares for expectant mothers at high risk for cardiovascular complications, I too was moved. But beyond the certainty of the headlines lay the nuance of the data, which seemed to tell a murkier story.
First at issue was the presentation of the data. Certainly, as a rate
per live births, it would seem that the United States lagged behind other OECD
countries – our maternal mortality rate was between 17.2 and 26.4 deaths per
100,000 live births, compared to 6.6 in the UK or 3.7 in Spain. But this
translated to approximately 700 maternal deaths per year across the United
States (among approximately 2.7 million annual births). While we would all agree
that one avoidable maternal death is one too many, the low incidence means that
small rates of error could have weighty implications on the reported results.
For instance, an error rate of 0.01% would put the United States in line with
other developed countries.
Surely, the error rate could not account for half the reported
deaths, right? Unfortunately, it is difficult to estimate how close to reality
the CDC reported data is, primarily because the main source data for maternal
mortality is a single question asked on the application for death certificates.
The question asks whether the deceased was pregnant at the time of death,
within 42 days of death, or in the 43 to 365 days prior to death. While
pregnancy at the time of death may be easy to assess, the latter two categories
are subject to significantly more error.
By HANS DUVEFELT, MD
At the end of the year my patients and I will start over. That is what changing EMRs does to us. I have mixed feelings about data migration, if it even happens.
I will move into a new virtual environment and my patients will take on slightly different appearances, maybe even alter their medical histories. Some will perhaps be asking me to edit diagnoses that have haunted them since we went from paper to computer records almost a decade ago.
With our first EMR, we scanned in a few things from patients’ paper records – sometimes only a few pages from years or decades of first handwritten and later typed notes. Much got lost, because we were doing something we never really had thought through, and we had to do it with a clock ticking: “Hurry, before the Federal incentives go away”. The Feds wanted EMRs because the vision was that more data would help research and population health and also reduce medical errors.
This time, another factor is pushing us forward: The EMR we have will no longer be supported after a certain date, and for an EMR that requires continuous tinkering in order to do basic tasks consistently, that is an untenable scenario. Only yesterday, I was suddenly unable to send prescriptions electronically and it took the national headquarter’s involvement to get me up and running again.
By ANISH KOKA, MD
No one likes getting bills. But there is something that stinks particularly spectacularly about bills for healthcare that arrive despite carrying health insurance. Patients pay frequently expensive monthly premiums with the expectation that their insurance company will be there for them when illness befalls them.
But the problem being experienced by an
increasing number of patients is going to a covered (in-network) facility for
medical care, and being seen by an out-of-network physician. This happens because
not all physicians working in hospitals serve the same master, and thus may not
all have agreed to the in-network rate offered by an insurance company.
This is a common occurrence in medicine. At any given time, your local tax-exempt non-profit hospital is out of network of some low paying Medicaid plan or the other.
In this complex dance involving patients, insurers and doctors, Patients want their medical bills paid through premiums that they hope to be as low as possible, Insurers seek to pay out as little of the premium dollars collected as possible, and Doctors want to be paid a wage they feel is commensurate to their training and accumulated debt.
Insurers act as proxies for patients when
negotiating with the people that actually deliver healthcare – doctors.
Largely, the system works to funnel patients to ‘covered’ doctors and
hospitals. Patients that walk into an uncovered facility are quickly
redirected. But breakdowns happen during emergencies.
There are no choices to make for patients arriving unconscious or in distress to an emergency room. It suddenly becomes very possible to be seen by an out of network physician, and depending on the fine print of the insurance plans selected, some or none of these charges may be covered.
By HANS DUVEFELT, MD
It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word.
This has been the bread and butter of counselors for years. People will faithfully attend and pay for weeks, months and even years of therapy visits just to have an attentive and active listener and to feel like they have an ally.
We also have data that shows that adherence to treatment plans is dependent on how patients feel about their provider. One problem solved can build an ally for life
Primary care medicine is a relationship based business. I don’t know how often that basic fact is overlooked or denied. Whether you are trying to get another person to alter their lifestyle, take expensive medicines according to inconvenient schedules or even just trust and accept your diagnosis, you have to “earn” the right to do those things. Our titles and medical accoutrements give us a foot in the door, but they don’t usually get us all the way into peoples inner circles of trusted advisers.
In this age of corporate medicine, there is a belief that patients attach themselves to institutions and networks because of their trust in the organizations, and that therefore the connection with their individual providers is secondary.