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Category: Physicians

As Physicians Today, We Must Both Represent the “System” and Disregard it

By HANS DUVEFELT, MD

Healthcare today, in the broadest sense, is not a benevolent giant that wraps its powerful arms around the sick and vulnerable. It is a world of opposing forces such as Government public health ambitions and more or less unfettered market ambitions by hospitals and downright profiteering by some of the middlemen who stand between doctors and patients, such as insurers, Pharmacy Benefits Managers, EMR vendors and other technology companies.

Within healthcare there is also a growing, more or less money-focused sector of paramedicine, promoting “alternative” belief systems, some of which may be right on and showing the future direction for us all and some of which are pure quackery.

I stand by my conviction that physicians must embrace the role of guide for their patients. If we see ourselves only as instruments or tools in the service of the Government, the insurance companies or our healthcare organizations, patients are likely to mistrust our motives when we make diagnoses or recommend treatments.

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Advanced Professionalism and Fitzhugh Mullan

By MIKE MAGEE, MD

As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His seminal piece, “A Flag In The Wind: Educating For Professionalism In Medicine”, seems written for today. 

Nearly two decades ago, Inui keyed in on words. In our modern world of “fake news”, concrete actions carry far greater weight than words ever did, and the caring environments we are exposed to in training are “formative”—that is, they shape our future capacity to express trust, compassion, understanding and partnership.

Inui reflected on the varied definitions or lists of characteristics of professionalism that had been compiled by multiple organizations and experts, commenting:

“From my own perspective, I have no reservations about accepting any, or all of the foregoing articulations of various qualities, attitudes, and activities of the physician as legitimate representations of important attributes for the trustworthy professional. In fact, I find it difficult to choose one list over others, since they each in turn seem to refer largely to the same general set of admirable qualities. While we in medicine might see these as our lists of the desirable attributes of professionalism in the physician, as the father of an Eagle Scout I know that Boy Scout leaders use a very similar list to describe the important qualities of scouts: ‘A Scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, reverent (respecting everyone’s beliefs).’ I make this observation not to descend into parody, but to make a point. These various descriptions are so similar because when we examine the field of medicine as a profession, a field of work in which the workers must be implicitly trustworthy, we end by realizing and asserting that they must pursue their work as a virtuous activity, a moral undertaking.”

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Who’s in Your Supply Chain?

By KIM BELLARD

Tesla is now, by market cap, the second largest auto manufacturer (after Toyota).  Its market cap exceeds U.S. auto makers Ford, G.M., and Fiat/Chrysler — combined.  This despite selling less than 400,000 vehicles in 2019, a figure that is more than the prior two years combined.   

Tesla has made its bet on the future of electric cars.  It didn’t invent them.  It isn’t the only auto manufacturer selling them.  But, as The Wall Street Journal recently said

Investors increasingly see the future of the car as electric—even if most car buyers haven’t yet. And lately, those investors are placing bets on Tesla Inc. to bring about that future versus auto makers with deeper pockets and generations of experience.

 A recent analysis suggested a big reason why, and its findings should give those in healthcare some pause.  Tesla’s advantage may come, in large part, from its supply chain.

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The Legacy of Forced Sterilizations

Brooke Warren
Phuoc Le

By PHUOC LE, MD and BROOKE WARREN

In the 1970s, Jean Whitehorse, a member of the Navajo Nation, went to a hospital in New Mexico for acute appendicitis. Years later, she found out the procedure performed was not just an appendectomy – she had been sterilized via tubal ligation. Around the same time, a Northern Cheyenne woman was told by a doctor that a hysterectomy would cure her headaches. After the procedure, her headaches persisted. Later, she found out a brain tumor was causing her pain, not a uterine problem. Like Whitehorse and the Northern Cheyenne woman, thousands of Native American women have suffered irreversible changes to their bodies and psychological trauma that continues to this day. Most medical providers are unaware of our own profession’s role in implementing these racists policies that have direct links to the Eugenics movement.

Eugenics was a “movement that is aimed at improving the genetic composition of the human race” through breeding. From its origin in 1883, eugenics became the driving rationale behind using sterilization as a tool to breed out unwanted members of society in the United States. With the 1927 Supreme Court case Buck v. Bell permitting eugenic sterilization, 32 states followed suit and passed eugenic-sterilization laws. Although the outward use of sterilization declined after World War II because of its association with Nazi practices, sterilization rates in poor communities of color remained high throughout the United States.

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Mindful Daily Practice Offers an Antidote to Healthcare Burnout

By GREG HAMMER, MD

Burnout among healthcare professionals is at an all-time high. Its drivers include longer work hours, the push to see more patients, more scrutiny by administrators, and loss of control over our practice. We seem to spend more time with the electronic medical record and less time face-to-face with our patients.

I have faced burnout personally. My son passed away at the age of 29, which was beyond painful. At the same time, I felt burdened by the growing number and complexity of metrics by which I was judged at work. Days in the operating room and intensive care unit seemed more and more exhausting, and my patience was becoming shorter and shorter. I was fortunate to have had a long-standing meditation practice as well as sabbatical time that I used to decompress and re-evaluate my career. Many of us are not so lucky. More than half of physicians have serious signs of burnout, and more than one physician commits suicide every day.

So many of us feel burned out these days because in our rapidly changing profession we are asked to do more for less and with inadequate resources. We suffer from exhaustion, self-criticism, and worry about what will happen next to our practice, our families, and ourselves. If we want to save our practices, patients, marriages- even our lives, we must acquire personal resilience.

Fortunately, we can increase our resilience and happiness and reverse burnout by embracing a few simple principles—Gratitude, Acceptance, Intention, and Nonjudgment (GAIN)—that we can put into motion in our everyday lives at the hospital, at home, or wherever we are.

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The Step 1 Score Reporting Change – A Step in the Right Direction for IMGs?

By TALAL HILAL, MD

The United States Medical Licensing Examination (USMLE) Step 1, a test co-sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), has been the exam that people love to hate. For many years, blogs, Twitter feeds, and opinion pieces have been accumulating urging the presidents of the FSMB/NBME to stop reporting a 3-digit score and instead report a pass/fail score. This animosity towards the Step 1 exam originates from the reality that medical schools have increasingly focused their curriculum on teaching what the Step 1 wants you to learn – medical trivia that almost always has no bearing on how to approach a clinical problem.

This “Step 1 Madness” is unhealthy. The reasons for its existence are many: residency and fellowship programs allow it to exist by idolizing higher scores, some believe it is a metric that can predict future quality of care, board pass rates, etc. And some are naïve enough to think that what is tested on the Step 1 is actually useful medical knowledge! It may be due to a combination of the above that the Step 1 has found itself in such a peculiar spot. However, the emphasis on the Step 1 score means that medical students’ fate is being determined by a single test. Nobody wants their fate to be so unmalleable.

Those who were writing vehemently against a 3-digit score rejoiced when the FSMB/NBME announced on February 12 that the Step 1 will finally become a pass/fail test as early as January 2022!

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#USMLEPassFail: A Brave New Day

By BRYAN CARMODY, MD

Well, it happened.

Beginning as soon as 2022, USMLE Step 1 scores will be reported pass/fail.

I’m shocked. Starting around two weeks ago, I began hearing rumors from some well-connected people that this might happen… but I still didn’t believe it.

I was wrong.

The response thus far has been enormous – I haven’t been able to clear my Twitter mentions since the news broke. And unsurprisingly, the reaction has been mixed.

In the future, I’ll post more detailed responses on where we go from here – but for now, I’d like to emphasize these five things.

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Healthcare Has a Moral Injury

By KIM BELLARD

The term “moral injury” is a term originally applied to soldiers as a way to help explain PTSD and, more recently, to physicians as a way to help explain physician burnout.  The concept is that moral injury is what can happen to people when “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”  

I think healthcare generally has a bad case of moral injury.  

How else can we explain physicians practicing surprise billinghospitals suing patientshealth plans refusing to pay for pre-authorized treatments, or pharmaceutical companies charging “skyrocketing” costs even for common, essential prescription drugs?  There are people involved in each of these, and countless more examples.  If those people haven’t suffered a moral injury as a result, it’s hard to understand why.  

Melissa Bailey, writing for Kaiser Health News, looked at moral injury from the standpoint of emergency room physicians.  One physician decried how “the real priority is speed and money and not our patients’ care.”  Another made a broader charge: “The health system is not set up to help patients. It’s set up to make money.”  He urged that physicians seek to understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”

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Burned out on Burnout?

By SANJ KATYAL, MD

If you are like most doctors, you are sick of hearing about burnout. I know I am. There is a big debate on whether burnout is real or whether physicians are suffering from something more sinister like moral injury or human rights violations. That doesn’t matter. In the end, no matter what name we give the problem, the real issue is that physicians are in fact suffering. We are suffering a lot. Some of us—around one physician per day—are forced to alleviate their suffering by taking their own life. Each year, a million patients lose their physicians to suicide. Many more physicians suffer in silence and self-medicate with drugs or alcohol in order to function.

We are losing more physicians each year to early retirement or alternate careers. There are an increasing number of coaches and businesses whose single purpose is to help doctors find their side gigs and transition out of medicine. This loss comes at a time of an already depleted workforce that will contribute to massive physician shortages in the future. Perhaps even more troubling is that those physicians who remain in medicine are often desperate to get out. It is the rare physician these days that recommends a career in medicine to their own children. We now have a brain drain of the brightest students who would rather work on Wall Street than in a hospital. 

As a physician trained in positive psychology, I have been committed to helping other physicians and students improve their well-being. The focus on well-being is a welcome change in medicine.  But is it enough?

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Medical Records in Primary Care: Keeping the Story of Phone Calls and Medication Changes with Less than Perfect Tools

By HANS DUVEFELT, MD

I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.

Here’s another Metamedicine story:

In learning my third EMR, I am again a little disappointed. I am again, still, finding it hard to document and retrieve the thread of my patient’s life and disease story. I think many EMRs were created for episodic, rather than continued medical care.

One thing that can make working with an EMR difficult is finding the chronology in office visits (seen for sore throat and started on an antibiotic), phone calls (starting to feel itchy, is it an allergic reaction?and outside reports (emergency room visit for anaphylactic reaction).

I have never understood the logic of storing phone calls in a separate portion of the EMR, the way some systems do. In one of my systems, calls were listed separately by date without “headlines” like “?allergic reaction” in the case above.

In my new system, which I’m still learning, they seem to be stored in a bigger bucket for all kinds of “tasks” (refills, phone calls, orders and referrals made during office visits etc.)

Both these systems seem to give me the option of creating, in a more or less cumbersome way, “non-billable encounters” to document things like phone calls and ER visits, in chronological order, in the same part of the record as the office notes. That may be what IT people disparagingly call “workarounds”, but listen, I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.

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