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A Patient in the Lobby Refuses to Leave: Medical Emergency, Unhappy Customer or Active Shooter?

By HANS DUVEFELT, MD

The receptionist interrupted me in the middle of my dictation.

“There’s a woman and her husband at the front desk. She’s already been seen by Dr. Kim for chest pain, but refuses to leave and her husband seems really agitated. They’re demanding to speak with you.”

I didn’t take the time to look up the woman’s chart. This could be a medical emergency, I figured. Something may have developed in just the last few minutes.

I hurried down the hall and unlocked the door to the lobby. I had already noticed the man and the woman standing at the glassed-in reception desk.

“I’m Dr. Duvefelt, can I help you?” I began, one hand on the still partway open door behind me.

The husband did the talking.

“My wife just saw Dr. Kim for chest pain and he thought it was nothing. He didn’t have any of her old records, so how could he know?”

While I quickly considered my response, knowing that Dr. Kim is a very thorough and conscientious physician, the man continued:

“Can we get out of here, and step inside for some privacy?”

My mind raced. This was either a medical emergency or an unhappy customer situation. We had the door locks installed not long ago on the advice of the police and many other sources of guidance for clinics like ours. It was a decision made by our Board of Directors. In this age of school, workplace and church shootings, everyone is preparing for such scenarios. We are always reminded not to bring people inside the “secure” areas of our clinics who don’t have an appointment or a true medical emergency.

I figured I had to find out more about this woman’s chest pain in order to make my decision whether to let her inside again; after all, she had just been evaluated.

“Ma’am, are you having chest pain right now?” I asked.

“A little”, she answered.

“How long have you had it?” I probed.

“A couple of years now.”

“And you just saw Dr. Kim?”

“Yes, and he said my EKG looked okay, but he didn’t bother to ask me about you heart valve operation three years ago in, Boston. He just said ’we’ll get those records’, and he told me I was okay today.”

The husband broke in, “It’s the same everywhere we go, everybody just says it’s not a heart attack, but we need more answers than that. we know what it isn’t, but we need to know what it is!” He added, again, “can’t we go inside for some privacy?”

“Have you been seen elsewhere for the same thing?” I said without answering the request.

“Yes, at the emergency room in Concord, New Hampshire when we lived there…”

“Did Dr. Kim have you sign a records release form so we can get the records from Boston and New Hampshire?” I asked.

“Yes”, the woman answered.

“Then that’s all we can do today,” I said. “I hear you telling me this is an ongoing problem, you’ve already been assessed today and Dr. Kim told you that you’re safe today and we’ve requested your old records. That’s what needs to happen.”

“You mean you’re not going to help us today?”

“You’ve seen Dr.Kim, your records will get here, I don’t know what more we can do for you today.”

“You’ll hear about this”, the husband said as they stormed out. Another man in the lobby introduced himself to them and said “I’ll be your witness.”

I closed the self-locking door and wished I had somehow been more skilled and more diplomatic, and I wished the world wasn’t the way it has become in just a few years, with more concern for bolted doors, gun violence and mass shootings than simple customer relations.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

India’s Mob Problem

By SAURABH JHA, MD

Recently, my niece gingerly confided that she was going to study engineering rather than medicine. I was certain she’d become a doctor – so deep was her love for biology and her deference to our family tradition. But she calculated, as would anyone with common sense, that with an engineering degree and an MBA, she’d be working for a multinational company making a comfortable income by twenty-eight. If she stuck with tradition and altruism, as a doctor she’d still be untrained and preparing for examinations at twenty-eight.

Despite the truism in India that doctors are the only professionals never at risk of starving, the rational case for becoming a physician never was strong. Doctors always needed a dose of the irrational, an assumption of integrity and an unbridled goodwill to keep going. Once, doctors commanded both the mystery of science and the magic of metaphysics. As medicine became for-profit, the metaphysics slowly disappeared.

Indians are becoming more prosperous. They’re also less fatalistic and expect less from their gods and more from their doctors. In the beginning they treated their doctors as gods, now they see that doctors have feet of clay, too. Doctors, who once outsourced the limitations of medicine to the will of Gods, summarized by the famous Bollywood line “inko dawa ki nahin dua ki zaroorat hai” (patient needs prayers not drugs), now must internalize medicine’s limitations. And there are many – medicine is still an imperfect science, a stubborn art, often an optimistic breeze fighting forlornly against nature’s implacable gale.

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Can we move on?

By CHADI NABHAN MD, MBA, FACP

Every so often, my cynical self emerges from the dead. Maybe it’s a byproduct of social media, or from following Saurabh Jha, who pontificates about everything from Indian elections to the Brexit fiasco. Regardless, there are times when my attempts at refraining from being opinionated are successful, but there are rare occasions when they are not. Have I earned the right to opine freely about moving on from financial toxicity, anti-vaxers, who has ‘skin in the game’ when it comes to the health care system, the patient & their data, and if we should call patients “consumers”? You’ll have to decide.

I endorse academic publications; they can be stimulating and may delve into more research and are essential if you crave academic recognition. I also enjoy listening to live debates and podcasts, as well as reading, social media rants, but some of the debates and publications are annoying me. I have tried to address some of them in my own podcast series “Outspoken Oncology” as a remedy, but my remedy was no cure. Instead, I find myself typing away these words as a last therapeutic intervention.

Here are my random thoughts on the topics that have been rehashed & restated all over social media outlets (think: Twitter feeds, LinkedIn posts, Pubmed articles, the list goes on), that you will simply find no way out. Disclaimer, these are NOT organized by level of importance but simply based on what struck me over the past week as grossly overstated issues in health care.  Forgive my blunt honesty.

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A Rose by Another Name

By SAURABH JHA, MD

Can we reduce over diagnosis by re-naming disease to less anxiety-provoking makes? For example, if we call a 4.1 cm ascending aorta “ecstasia” instead of “aneurysm” will there be less over-treatment? In this episode of Radiology Firing Line Podcast, Saurabh Jha (aka @RogueRad) discusses over diagnosis with Ian Amber, a musculoskeletal radiologist at Georgetown University, Washington.

Today’s Doctors: Colleagues or Free Agents?

By HANS DUVEFELT, MD

My first job after residency was in a small mill town in central Maine. I joined two fifty something family doctors, one of whom was the son of the former town doctor. I felt like I was Dr. Kiley on “Marcus Welby, MD.” I didn’t have a motorcycle, but I did have a snazzy SAAB 900.

Will was a John Deere man, wore a flannel shirt and listened to A Prairie Home Companion. He was kind and methodical. Joe didn’t seem quite as rural, moved quicker and wore more formal clothes. I never could read his handwriting.

They each had their own patients, but covered seamlessly for each other. They were like a pair of spouses in the sense that they answered to each other as much as to their patients. They had to make everything work for the benefit of their shared practice, their shared livelihood. Their mutual loyalty was essential and obvious, although allowing for their differences in temperament and personalities.

Invited to stay on and enter into a partnership, I hesitated. How did I fit in? Could I follow in their footsteps and become an equal partner, covering for them and doing things similarly enough to fit in for the long haul?

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The ABCs of Beginning a Clinical Encounter

By HANS DUVEFELT, MD

You’re running late and many things didn’t go right today. You knock on the door and enter the exam room with an apology. If you’re like me, you have a few papers and an iPad or a laptop in your hand. You sit down and open the patient’s chart in your device or perhaps on the big desktop, eyes not exactly locked on the patient.

Only after getting to where you need to be in the computer do you really look the patient in the eyes. Your body language has been one of hurry and distraction. Now you try to repair the damage of that, so you try to show you’re settling down now, at least for a few moments. You might sigh, move your arms in a gesture of relaxation and say something to get the history taking underway.

So far, you’re failing. I do that often, too.

Here’s what we all know we need to do, but often don’t; we should follow these ABCs:

A – Attention:

Clear your mind. It doesn’t matter what happened in the other room with the other patient, or on the phone with the insurance company or the smug specialist or ER doc who pointed out the diagnosis you missed. Open the door (I always knock first) and immediately look at the patient. Make eye contact and observe them. Pay attention to how they look, what they are signaling. The computer can wait; a few moments of focused attention will usually save you time in the end. After all, red or teary eyes, a leg cast, a big bruise or change in grooming can make the visit go in a direction you wouldn’t have expected from he listed chief complaint. How many times have we heard a patient comment about another doctor: He didn’t pay attention to me. Do we always do that ourselves if we’re rushed or preoccupied?

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Brief is Good

By HANS DUVEFELT, MD

How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain?

So why is the typical “cycle time”, the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour?

Answer: Mandated screening activities that could actually be done in different ways and not even necessarily in person or in real time!

Guess how many emergency room or urgent care center visits could be avoided and handled in the primary care office if we were able to provide only the services patients thought they needed? Well over 50% and probably more like 75%.

Primary Care clinics like mine are penalized if a patient with an ankle sprain comes in late in the year and has a high blood pressure because they are in pain and that becomes the final blood pressure recording for the year. (One more uncontrolled hypertensive patient.)

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Coaching and Leadership Training Can Help Med Students Avoid Burnout

Jack Penner
JP Mikhaie
Margaret Cary

By MARGARET CARY, JACK PENNER, and JP MIKHAIE

Burnout is one of the biggest problems physicians face today. We believe that addressing it early — in medical school — through coaching gives physicians the tools they need to maintain balance and meaning in their personal and professional lives.

We say that after reading comments from participants in our coaching program, “A Whole New Doctor,” developed at Georgetown University School of Medicine. This program, born almost by chance, provides executive coaching and leadership training to medical students, who are exactly the right audience for it.

Medical students tend to begin their education as optimistic 20-somethings, eager to learn and eager to see patients. After spending one or two years on the academic study of medicine, they move to the wards where they observe the hidden curriculum — a set of norms, values, and behaviors conveyed in implicit and explicit ways in the clinical learning environment.

In the hospital, convenience and expediency, deference to specialists, and factual knowledge tend to replace the holistic and patient-centered care that is lauded during the preclinical years. This new culture nudges some students to the brink of burnout and depression. Some consider suicide.

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The Folly of Self Referral

By HANS DUVEFELT, MD

A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.

This “system” often doesn’t work, because of the way medical specialties are divided up.

If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does ERCPs, and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from an ovarian cancer, best treated by a GYN-oncology surgeon, which anywhere in Maine means a drive down to Portland.

The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and another unrelated operation for a fracture in Bangor a few years ago. Then, after a non surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for EMG testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.

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Last Month in Oncology with Dr. Bishal Gyawali: April 2019

By BISHAL GYAWALI, MD

Keynote speech on the JAVELIN not going far enough to improve survival

The treatment landscape for metastatic renal-cell carcinoma has changed dramatically with the introduction of immunotherapies. Unfortunately though, we are promoting combinations over single agents without having much idea of added benefit of each drug. This is an important issue because when we combine two drugs, the only thing we are certain of are the added toxicities. PD-1 inhibitor nivolumab had improved OS when given in second line, however nivolumab was tested in combination with ipilimumab (not as a nivolumab monotherapy) in the first line trial. Now, pembrolizumab and avelumab have followed suit, although their combination partner was axitinib – a VEGF inhibitor. The control arm was sunitinib for both of the trials of pembrolizumab plus axitinib (KEYNOTE 426) and avelumab plus axitinib (Javelin 101). This is a little surprising because we are testing A B versus C, where both A and B haven’t been approved for the given setting – axitinib was approved for RCC in second line. Both these combinations improved PFS versus sunitinib but only the pembrolizumab combination has shown improved OS. However, I have doubts about the contribution of axitinib to these results. What would the outcome be if pembrolizumab alone is followed by sunitinib in second line? It is important to note that only one third of patients who discontinued sunitinib received PD-1 inhibitor subsequently in the KEYNOTE 426 trial. The important question for patients and clinicians would be to consider a survival difference had most of these patients received a PD-1 inhibitor subsequently. As for avelumab, the JAVELIN trial hasn’t reached as far as pembrolizumab and nivolumab have reached: The OS benchmark – so let’s reserve this combination until we see that benefit.

Have we successfully landed on the COMET?

We should remember that this combo-mania with PD-1/PD-L1 inhibitors may also backfire. Previously, the RCTs of nivolumab and pembrolizumab combos were halted in multiple myeloma for higher deaths in the combo arms. Another RCT IMblaze 370 also reports that atezolizumab, alone or in combination with cobimetinib, failed to improve survival versus regorafenib in patients with metastatic colorectal cancer.  This time again A B failed versus C although C in itself is a drug with very marginal benefits in this setting. Also, I don’t understand testing A plus B combo when both A and B are unapproved for the disease.

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