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Pledge to the Participatory Medicine Manifesto!

By THE SOCIETY FOR PARTICIPATORY MEDICINE

We are excited to announce that the campaign to pledge to the Participatory Medicine Manifesto is launching today — and we need your support!

Our Participatory Medicine Manifesto is a call to action for patients, caregivers and health care professionals to equally share decision-making and respect one another. 

We want you and your organization to help us fix a broken healthcare system from the ground up. We want to put democracy back into the culture of healthcare by enabling patients, healthcare professionals and caregivers to all have an equal voice. We need your influence to inspire people. We will list individuals and organizations that support the Manifesto.

Please view and sign the SPM Manifesto Pledge today 

We have designed a promotional campaign encouraging people to pledge to the Participatory Medicine Manifesto. As part of this campaign, we created a pledge form and social media toolkit for people and organizations to use in spreading the work about Participatory Medicine.

And spread the word to your colleagues and friends to help us reach our goal. After you pledge you will find the easy to use social media toolkit.

We greatly appreciate your help and support!

Eric Bersh, Judy Danielson, Kevin Freiert, Matthew Holt, Dr. Danny Sands, Amber Soucyall board members of SPM

Pledge Today! 

PS – Please share with your friends & followers!

The Art of Asking: What’s Your Biggest Fear?

By HANS DUVEFELT

When a patient presents with a new symptom, we quickly and almost subconsciously create a hierarchy of diagnostic possibilities. I pride myself in my ability to effectively share my process of working through these types of clinical algorithms.

But sometimes I seem to get nonverbal clues of dissatisfaction or simply no reaction at all to my eloquent reasoning. And only then do I remember to ask the important questions, “do you have any thoughts on what’s causing this” and, most importantly, “what’s your biggest fear that this could be”.

It doesn’t matter how brilliant a diagnostician you are if a patient with less medical knowledge than you has a thought, fear or hunch that diseases and symptoms work in ways that don’t make sense to you.

An uncle may have had a burning sensation in his nose minutes before a stroke, so this symptom may seem like a much more obvious harbinger of disaster to your patient than it does to you. How would you know, if you didn’t ask, what the number one question is that your patient wants the answer to?

We are often so focused on our own thinking process, especially with our time pressures and the bureaucratic requirements of medical encounters these days, that we risk forgetting our patients may not think the way we do.

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The Art of Prescribing (Or Not)

By HANS DUVEFELT

I have learned a few things about prescribing medications during my 42 years as a physician. Some are old lessons, and some are more recent. I thought I’d share some random examples.

First: I don’t like to have to use medications, but when they seem necessary, I choose, present and prescribe them with great care.

CHOOSING MEDICATIONS

Medications are like people. They have personalities. With so many choices for any given diagnosis or symptom, I consider their mechanism of action, possible beneficial additional effects and their risk of unwanted side effects when selecting which one to prescribe. To some degree that goes against today’s dogma.

Blood pressure medications, for example, have what I call an A-list and a B-list. The A-list contains drugs with a proven track record of not only reducing blood pressure, but also actual heart attack and stroke risk. Why we choose from the B-list, the drugs that don’t decrease cardiovascular risk or actually increase it, is a little beyond this simple country doctor’s ability to understand.

ACE inhibitors like lisinopril and diuretics like hydrochlorothiazide are the two recommended first choices in this country. But the A-list also contains amlodipine, a calcium channel blocker and, further down, metoprolol, a beta blocker. I make those less favored A-listers my initial choice in two scenarios:

Amlodipine is my choice when I see a hypertensive patient who prefers a set-it-and-forget-it treatment plan. No bloodwork is required after starting it to monitor for kidney or electrolyte problems, so even if the patient doesn’t come back for a year or more, there is no real risk involved.

Metoprolol, which blocks the effect of the stress hormone adrenaline on the cardiovascular system, is what I talked my own doctor into prescribing for me. That was back in the day, when I was a hard working, somewhat Type A personality with high blood pressure. With the passage of time, life experience, weight loss and my transformative relationship with my Arabian horses, my blood pressure normalized and I didn’t need medication anymore.

Years ago, we all selected blood pressure medications according to the “phenotype” (appearance or general impression) of the patient: metoprolol if intense, hydrochlorothiazide if swollen, nifedipine if cold-handed, lisinopril If naturally hypokalemic (low potassium).

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The Art of Explaining: Starting With the Big Idea

By HANS DUVEFELT

We live in a time of thirty second sound bytes, 280 character tweets and general information overload. Our society seems to have ADHD. There is fierce competition for people’s attention.

As doctors, we have so many messages we want to get across to our patients. How many seconds do we have before we lose their attention in our severely time curtailed and content regulated office visits?

I have found that it generally works better to make a stark, radical statement as an attention grabber and then qualifying it than to carefully describe a context from beginning to end.

Once a person shows interest or responds with a followup statement or question, you have a better chance for a meaningful discussion. Just starting to explain something without knowing if the person wants to hear what you have to say could just be a waste of time.

Here are some of my typical conversation starters – or stoppers, if you will:

“The purpose of a physical is to talk about stuff that could kill you, more than about symptoms that annoy.”

“Nothing makes a cold go away faster.”

“Urology is about plumbing, nephrology is about chemistry.”

“Most headaches are migraines.”

“Sinus headaches don’t exist in Europe.”

“I don’t care what your blood pressure is today if you’re scared or in pain.”

“A healthy lifestyle is at least as effective as taking Lipitor.”

“We now know that eating fat makes you lose weight.”

“Cholesterol only causes damage if there is also inflammation.”

“Fat free means high in sugar.”

“I don’t believe in vitamins.”

“Osteoporosis happens to every woman around 80, so is it really a disease?”

“You have to treat 35 men for prostate cancer to save one life.”

“You know how many cases of testicular cancer I’ve come across in 40 years? Three!”

“It takes 45 minutes of walking to burn 100 calories, but only 10 seconds to drink them.”

My brief experience as a substitute teacher for junior high school students as well as my many years as a scout leader taught me that you can’t assume you have people’s attention just because you’re standing in front of them. They will give it to you if they believe you have something interesting to say. You often have less than thirty seconds to prove that you do.

Is our medical knowledge alive enough in our minds that we can share it in a quick, easy and captivating way with our distracted patients?

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

There Are Three Kinds of Primary Care, Not to Be Confused With Each Other

By HANS DUVEFELT

Primary care doctors, the way things are organized in this country, perform three kinds of services. If we don’t recognize very clearly just how fundamentally different they are, we risk becoming overwhelmed, burned out, inefficient and ineffective. And, if we think about it, should we really be the ones doing all three?

SICK CARE

Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.

Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.

In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.

Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?

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This is Not Health Care

By HANS DUVEFELT

We use the word health rather loosely in America today. Especially the expression health care, whether you spell that as one word or two, is almost an oxymoron.

Health is not simply the absence of disease, even less the pharmaceutical management of disease. The healthcare “industry” is not the major portion of our GNP that it is because there is a lot of health out there, but the opposite. What consumes so much money and generates so much profit is, of course, sick care. The sicker people are, the more money is spent and earned in this market segment. It is a spiral, and a vicious one.

Health is a naturally occurring phenomenon, a state of perfection. Modern life has corrupted many natural, self-healing biological mechanisms and upended the natural order of things in our bodies – just the way it has altered our environment.

Our bodies are pretty ingenious in their ability to heal. When I crushed my finger in my garage door a few years ago, my disfigured fingertip, bisected nail and contused nail bed slowly regained their original shape, almost like a lizard grows a new tail. Yet in an opposite scenario, a person with scleroderma can lose their fingertip to gangrene without physical injury because of what we call autoimmunity – instead of self healing, our bodies can engage in self destruction. My fingertip could heal perfectly but some people’s skin or stomach ulcers fail to do so.

We intuitively seem to have accepted that, most of the time, nature takes care of itself if we don’t mess with it. And when temperatures rise, forests burn or species go extinct, we are quick to assume our industrial or agricultural processes are the cause.

Yet, we have this head-in-the-sand view of disease that it is a random occurrence, the sudden manifestation of ancient and rare genetic glitches or I don’t know what. The real answer is that much of it is a consequence of what we eat and otherwise expose our bodies to – how we produce and refine food, how we alter its natural properties and how we over- or under-consume basic nutrients.

Functional Medicine asks and answers many of these questions and promises to be the future of medicine. I believe in this, but I also believe that the sick-care industrial complex is powerful enough to severely slow down this revolution. I also believe the food industry will double down its efforts to continue misleading the public.

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Quality in Healthcare: Cultural Competence, Diagnostic Accuracy or Patronizing Insensitivity?

By HANS DUVEFELT

I sometimes tell patients “I work for the government”, but sometimes I say the opposite, “I work for you”.

Herein lies a dichotomy that is eating away at primary care in this country, like a slow growing cancer. I suspect everybody is aware of it, but it seems nobody has the inclination to deal with it.

2020 exposed how differently Americans view and prioritize things like personal freedom and public safety. We have also seen how vastly different perceptions of reality suddenly exist about what constitutes medical facts. Alternative facts and fake news are suddenly household concepts.

For years, American healthcare has paid lip service to ethnic and cultural sensitivity, as long as minority opinions or practices don’t clash too badly with the holy cows of western society. We tolerate circumcision in men, but not genital mutilation in women, for example. But we don’t even pay lip service to the majority’s right to direct their own healthcare.

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3 Patient Lessons: What Cancer Patients Teach Me

By YASMIN ASVAT

An estimated 1.8 million people in this country may face a cancer diagnosis this year, in what has already been a bleak year of isolation and loss.  

While news of the COVID-19 vaccine rolling out across the U.S. offers hope in a year of 311,000 deaths,  11 million  people face the financial pressure of unemployment, and, approximately 43 percent of the nation reports some symptoms of anxiety or depression.  

It is understandable that a cancer diagnosis now may be too much to bear. And yet, somehow, many patients cope with the diagnosis and the associated uncertainty, fragility, and the threat of mortality with remarkable resilience.  

As a clinical psychologist in the Supportive Oncology program at a major Midwestern cancer center, I witness these quiet heroics every day. 

Since the beginning of the pandemic earlier this year, I have been striving to listen, empathize, support, and help cancer patients cope as their lives have been disrupted by both a cancer diagnosis and COVID-19. These are lessons these patients have taught me. 

Courage is being faced with doing something that utterly terrifies you, and you do it anyway. One of my patients described that leading up to the day of chemotherapy treatment, she is highly anxious, has racing thoughts and worries, and has trouble concentrating and sleeping. The morning of treatment, she vents to her partner about how she doesn’t want to go to the clinic. During the drive, she braces herself repeating, “I don’t want to do this” over and over again. 

Once in the clinic, she tells some of her nurses that she doesn’t want to be there because she worries about COVID-19 exposure, despite all the precautions the clinics have in place. She tells another set of nurses that she is scared of the side-effects of treatment – the disabling fatigue, the nausea, the suppressed immune system. 

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A Christmas Message to All Physicians From a Swedish-American Country Doctor in Maine

By HANS DUVEFELT, MD

Growing up in Sweden without a Thanksgiving holiday, Christmas has been a time for me to reflect on where I am and where I have been and New Year’s is when I look forward.

I have written different kinds of Christmas reflections before: sometimes in jest, asking Santa for a better EMR; sometimes filled with compassion for physicians or patients who struggle during the holidays. I have also borrowed original sentences from Osler’s writings to imagine how he would address physicians in the present time.

This year, with the pandemic changing both medicine and so many aspects of life in general, and with a gut wrenching political battle that threatens to erupt in anarchy or civil war within the next few weeks or months, my thoughts run deep toward the soul of medicine, the purpose of being a good doctor, even being a good human being.

We live in ideological silos, protected from dissenting opinions. News is not news if it is unpopular. Fake news and fake science are concepts that seemed marginal before but have now entered the mainstream.

As a physician, I serve whoever comes to see me to the best of my ability. But this year I have had to pay extra attention to the fact that so many people have already made up their minds about the nature and severity of the pandemic we are living with. If they don’t believe the country’s top experts, they are not likely to believe in me. Still, I try to gently state that we are still trying to figure this thing out and until we do, it’s better to be cautious.

I am starting to read about what some are now calling the Fourth Wave of the pandemic, the mental health crisis this winter may see in the wake of the physical illness we are surrounded by.

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Two Surgeons—a Veteran and a Newcomer—Talk Fighting COVID Burnout

By MICHAEL E. LIPKIN and RUSSELL S. TERRY, JR.

Burnout has always been a concern in medicine, and that concern has been amplified by the added stress of COVID-19. Many months into an unpredictable and distressing situation, we have both hung on to our mental health and professional passion by seeking out strategies that work for us. We offer them in two perspectives: veteran and relative newcomer.  

Dr. Lipkin: A Veteran’s Perspective

When lockdown began in March, we slowed down my practice for about 6 to 8 weeks, and then returned to full pre-COVID levels. It feels like the uncertainty has affected me most, since it has not been clear if and when things will get substantially better. Everyone is both experiencing and projecting persistent anxiety, stress and uncertainty. Isolation is a problem as well. I no longer have the time or ability to sit down with colleagues and vent over a beer, which was an outlet I counted on to mitigate burnout. At the same time, on a more concrete level, the pandemic has made everything we do incrementally more difficult, which is grindingly stressful. These tips are helping me cope and avoid burnout.

There are so many changes—just accept them. As COVID affects so many areas of practice, there’s a kind of low-grade stress that fluctuates with events. It seems like everything is a little bit harder. We have to shift some patient visits to telehealth and make sure they get COVID tests before surgery. We’re all looking over our shoulders, wondering who’s going to get us sick. There’s always the specter of more shutdowns and how they might affect our livelihoods. Budgets have been cut back, so hiring is frozen and there’s virtually no incremental spending. Everything will stay this way for now, so the best thing to do is accept that we’re going through a tough period and focus on the big picture, rather than the list of irritations.

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