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Category: Physicians

Low Value Testing and Unmet Cascades

By ANISH KOKA, MD

Mr. Smith has a problem. 

He can’t see. 

Even this cardiologist knows why.  The not so subtle evidence lies in the cloudy lens in front of his pupils.  He is afflicted with cataracts that obstruct his vision to the point he can’t really do his job refurbishing antique furniture safely.  His other problem is that he hates doctors. He hasn’t had reason to see one for more than a decade.  He’s 68, takes no medications, smokes a pack of cigarettes a day, and is a master of one word answers. He’s in my office because he needs a medical evaluation prior to his cataract procedure. Someone needs to attest to medical safety. I’m it.

He just wants to get out of here.

His annoyance of being in the office is justified.  Cataract surgery is very low risk.  Unless he’s having an acute medical problem, there is little to do.  The problem is that in an age of high volume, super specialized care, the eye doctor can’t attest to this, and the anesthesiologists have little interest in finding out the morning of his procedure that Mr. Smith has been having more frequent episodes of chest pain over the last two weeks.  Perhaps the chest pain is just acid reflux, or maybe it’s because of a pulmonary embolism related to the tobacco induced lung malignancy no one knows about. It’s possible, and highly likely, Mr. Smith will survive his cataract surgery even if he has a pulmonary embolism.  Cataract surgery really is pretty low risk.

But the doctor’s ethos has never been to ‘clear a patient for a cataract’, it is to commit to the health of the patient.  Mr. Smith deserves the opportunity to receive good medical care that isn’t made threadbare just because of the cataract surgery on the horizon.

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Why Do We Have Residency Training?

By BRYAN CARMODY, MD

Surely every resident has had the experience of trying to explain to a patient or family what, exactly, a resident is. “Yes, I’m a real doctor… I just can’t do real doctor things by myself.”

In many ways, it’s a strange system we have. How come you can call yourself a doctor after medical school, but you can’t actually work as a physician until after residency? How – and why – did this system get started?

These are fundamental questions – and as we answer them, it will become apparent why some problems in the medical school-to-residency transition have been so difficult to fix.

In the beginning…

Go back to the 18th or 19th century, and medical training in the United States looked very different. Medical school graduates were not required to complete a residency – and in fact, most didn’t. The average doctor just picked up his diploma one day, and started his practice the next.

But that’s because the average doctor was a generalist. He made house calls and took care of patients in the community. In the parlance of the day, the average doctor was undistinguished. A physician who wanted to distinguish himself as being elite typically obtained some postdoctoral education abroad in Paris, Edinburgh, Vienna, or Germany.

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“I Want Complete Labs Ordered Before My Physical”

By HANS DUVEFELT, MD

Many patients make this or similar requests, especially in January it seems.

This phenomenon has its roots in two things. The first is the common misconception that random blood test abnormalities are more likely early warning signs of disease than statistical or biochemical aberrances and false alarms. The other is the perverse policy of many insurance companies to cover physicals and screening tests with zero copay but to apply deductibles and copays for people who need tests or services because they are sick.

It is crazy to financially penalize a person with chest pain for going to the emergency room and having it end up being acid reflux and not a heart attack while at the same time providing free blood counts, chemistry profiles and lipid tests every year for people without health problems or previous laboratory abnormalities.

A lot of people don’t know or remember that what we call normal is the range that 95% of healthy people fall within, and that goes for thyroid or blood sugar values, white blood cell counts, height and weight – anything you can measure. If a number falls outside the “normal” range you need to see if other parameters hint at the same possible diagnosis, because 5% of perfectly healthy people will have an abnormal result for any given test we order. So on a 20 item blood panel, you can pretty much expect to have one abnormal result even if you are perfectly healthy.

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Healthcare Needs Some IHOPs

By KIM BELLARD

The New York Times had an article that surprised me: Current Job: Award Winning Chef.  Education: IHOP.   The article, by food writer Priya Krishnaprofiled how many high-end chefs credit their training in — gasp! — chain restaurants, such as IHOP, as being invaluable for their success. 

I immediately thought of Atul Gawande’s 2012 article in The New YorkerWhat Big Medicine Can Learn From the Cheesecake Factory.

Ms. Krishna mentions several well-known chefs “who prize the lessons they learned — many as teenagers — in the scaled-up, streamlined world of chain restaurants.”  In addition to IHOP, chefs mentioned experiences at chains such as Applebee’s, California Pizza Kitchen, Chipotle, Hillstone, Houston’s, Howard Johnson’s, Olive Garden, Panda Express, Pappas, Red Lobster, Waffle House, and Wendy’s.  

Some of the lessons learned are instructive.  “It was pretty much that the customer is always right,” one chef mentioned.  Another said she learned “how to be quick, have a good memory, and know the timing of everything.”  A third spoke to the focus that was drilled into all employees: “Hot food hot. Cold food cold. Money to the bank. Clean restrooms,” 

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Doctoring in 2020: Why is the Patient Here? Whose Visit is it Anyway?

By HANS DUVEFELT, MD

A new decade and a new EMR are making me think about what the best use of my time and medical knowledge really is. The thing that stands out more and more for me is the tension between what my patients are asking me for and what the medical bureaucracy is mandating me to do. This is, to be blunt, an untenable, crazy-making situation to be in.

Many of my patients with chronic diseases don’t, deep down, want better blood sugars, BMIs or blood pressures – nor do they want better diets or exercise habits. People often hope they can feel better without fundamentally changing their comfortable, familiar and ingrained habits – that’s just human nature.

I went to medical school to learn how to heal, treat and guide patients through illness, away from un-health and toward health. I didn’t go to school to become a babysitter or code enforcement officer.

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Chronic Disease Drugs are Big Business, Antibiotics are Not

By HANS DUVEFELT, MD

I have noticed several articles describing how antibiotic development has bankrupted some pharmaceutical companies because there isn’t enough potential profit in a ten day course to treat multi-resistant superbug infections.

Chronic disease treatments, on the other hand, appear to be extremely profitable. A single month’s treatment with the newer diabetes drugs, COPD inhalers or blood thinners costs over $500, which means well over $50,000 over an effective ten year patent for each one of an ever increasing number of chronically ill patients.

Imagine if the same bureaucratic processes insurance companies have created for chronic disease drug coverage existed (I don’t know if they do) for acute prescriptions of superbug antibiotics: It’s Friday afternoon and a septic patient’s culture comes back indicating that the only drug that would work is an expensive one that requires a Prior Authorization. Patients would die and the insurance companies would be better off if time ran out in such bureaucratic battles for survival.

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Doctors Lack Knowledge about Medical Cannabis Use. Their Patients Can Help.

By DOUGLAS BRUCE, PhD

On January 1, 2020, recreational cannabis use became legal in Illinois. More than 80,000 people in Illinois are registered in the state’s medical cannabis program. Surprisingly, many of their doctors don’t know how to talk with them about their medical cannabis use. 

As a health sciences researcher, I have a recommendation that is both practical and profound: Physicians can learn first-hand from their own patients how and why they use medical cannabis, and the legalization of recreational cannabis may make them more comfortable discussing its usage overall.

Nationwide, physicians too rarely discuss cannabis use with their patients living with chronic conditions, such as chronic pain, cancer, multiple sclerosis, epilepsy, fibromyalgia, and Crohn’s disease—all conditions with symptoms that evidence shows cannabis may effectively treat. Why don’t physicians talk with their patients about cannabis use? Research from states with longer histories of legalized medical cannabis shows that many physicians do not communicate with patients regarding their medical cannabis use for a variety of reasons. 

First, physicians aren’t well trained in cannabis’ medical applications. Unlike the endocrine or cardiovascular systemsthe endocannabinoid system—comprised of receptors which bond with the compounds THC and CBD found in cannabis—is not taught in medical school.

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Revisiting the Concept of Burnout Skills

By HANS DUVEFELT, MD

I looked at a free book chapter from Harvard Businesses Review today and saw a striking graph illustrating what we’re up against in primary care today and I remembered a post I wrote eight years ago about burnout skills.

Some things we do, some challenges we overcome, energize us or even feed our souls because of how they resonate with our true selves. Think of mastering something like a challenging hobby. We feel how each success or step forward gives us more energy.

Other things we do are more like rescuing a situation that was starting to fall apart and making a heroic effort to set things right. That might feed our ego, but not really our soul, and it can exhaust us if we do this more than once in a very great while.

In medicine these days, we seem to do more rescuing difficult situations than mastering an art that inspires and rewards us: The very skills that make us good at our jobs can be the ones that make us burn out.

Doctors are so good at solving problems and handling emergencies that we often fall into a trap of doing more and more of that just because we are able to, even though it’s not always the right thing to do – even though it costs us energy and consumes a little bit of life force every time we do it. And it’s not always the case that we are asked to do this. We are pretty good at putting ourselves in such situations because of what we call our work ethic.

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Reference Manuals May Be Facing Obsolescence

We must ensure their relevance to contemporary patient care

By LONNY REISMAN, MD

It’s 1992 and disruptive technologies of the day are making headlines: AT&T releases the first color videophone; scientists start accessing the World Wide Web; Apple launches the PowerBook Duo.

In healthcare, with less fanfare, a Harvard physician named Dr. Burton “Bud” Rose converts his entire nephrology textbook onto a floppy disk, launching the clinical tool that would ultimately become UpToDate. Instead of flipping through voluminous medical reference texts, such as the Washington Manual, doctors could for the first time input keywords to find the clinical guidance they needed to make better treatment decisions.

The medical community embraced UpToDate’s unique ability to put knowledge at their fingertips. Today more than 1.7 million clinicians around the world use UpToDate to provide evidence-based patient care with confidence. For many, it along with other reference sources has become foundational to providing high quality medical care.

More than just an easy-to-use reference, UpToDate has gone on to improve patient outcomes, according to the Journal of Hospital Medicine.

In the new era of 21st century digital medicine, however, there are opportunities to go further in support of clinicians and patients. Reference tools must be powered by predictive and prescriptive analytics, be personalized to individual patient circumstances, and be integrated into clinician workflow. In some cases, clinicians may be unaware of which questions to ask of a computerized reference manual, or how to incorporate the nuances of an individual patient’s case into the general insights of a reference. Searching for heart failure treatment, for example, may be too broad a query and the resulting recommendations therefore may not provide optimal care for a specific patient’s unique medical circumstances. New digital health solutions that consider patients’ co-illnesses, contraindications, symptomatology, current treatment regimens, and hereditary risks are essential.

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Doctoring at Christmas

By HANS DUVEFELT, MD

I find myself thinking about how being a doctor has come to impact the Christmas Holiday for me over the years. I have written about working late and driving home in the snow and dark of Christmas Eve in northern Maine; I have shuffled Osler’s written words into something that speaks to physicians of our times; I have written about the angst around the Holidays I see in my addiction recovery patients.

This year, my thoughts go to the way Christmas is a time of reconnection for many people. We reconnect with family and friends we may not see as often as we would like, and many of us reconnect with secular traditions dating back to our childhood. Many people also reconnect more deeply with their Christian traditions, the ancient celebration of Hanukkah or the newer one of Kwanzaa.

As a doctor, I think Christmas is a time when individuals are more open toward others, more willing to extend “good will toward men” (Luke 2:14). It can be an opener for future relationships to form or grow, a time to share our humanity in the context of experiencing something larger than ourselves and our everyday existence. It allows us to get a little more personal by sharing something of what we all have in common – the need for togetherness with those we love.

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