Categories

Category: Physicians

Cultivating Charisma in the Clinical Encounter (and emulating Marcus Welby, M.D.)

By HANS DUVEFELT, MD

If medical journals are the religious texts that guide me as a physician, the New York Times has become the secular source of illumination for my relationship to my country and the world I live in.

That doesn’t exactly mean that I feel like a citizen of the world. Quite the opposite, particularly now, with just me and my horses sharing our existence on a peaceful plot of land within walking distance of the Canadian border; my physical world seems quite small even though I am aware, sometimes painfully but with an obvious distance, of the calamity of our planet.

Early Sunday morning, drinking coffee in bed as the gray morning light revealed the outline of the trees and pasture outside my window, I read the Times on my iPad as usual and came across an article titled “What makes people charismatic and how you can be too”.

The article claims that charisma can be learned and cultivated, and that thought resonated with me as I think often about how we as physicians have roles to fill in the stories of diseases and transitions in our patients lives. I try to be the kind of doctor each patient needs as I walk into each exam room.

The article mentions three pillars of charisma: Presence, Power and Warmth.

As I think of my current third guiding light in addition to my medical journals and the New York Times, my DVD collection of the Marcus Welby, M.D. shows, which is shorthand for his character and all the other role models I carry mental images and video clips of, Charisma is definitely something we need to consider and cultivate in our careers.

Continue reading…

Are Radiologists Prepared for The Future?

By ALEX LOGSDON, MD

Leave your bias aside and take a look into the healthcare future with me. No, artificial intelligence, augmented intelligence and machine learning will not replace the radiologist. It will allow clinicians to.

The year is 2035 (plus or minus 5 years), the world is waking up after a few years of economic hardship and maybe even some dreaded stagflation. This is an important accelerant to where we are going, economic hardship, because it will destroy most radiology AI startups that have thrived on quantitative easing polices and excessive liquidity of the last decade creating a bubble in this space. When the bubble pops, few small to midsize AI companies will survive but the ones who remain will consolidate and reap the rewards. This will almost certainly be big tech who can purchase assets/algorithms across a wide breadth of radiology and integrate/standardize them better than anyone. When the burst happens some of the best algorithms for pulmonary embolism, stroke, knee MRI, intracranial hemorrhage etc. etc. will become available to consolidate, on the “cheap”.

Hospitals can now purchase AI equipment that is highly effective both in cost and function, and its only getting better for them. It doesn’t make sense to do so now but soon it will. Consolidation in healthcare has led to greater purchasing power from groups and hospitals. The “roads and bridges” that would be needed to connect such systems are being built and deals will soon be struck with GE, Google, IBM etc., powerhouse hundred-billion-dollar companies, that will provide AI cloud-based services. RadPartners is already starting to provide natural language processing and imaging data to partners; that’s right, you speak into the Dictaphone and it is recorded, synced with the image you dictated, processed with everyone else to find all the commonalities in descriptors to eventually replace you. It is like the transcriptionists ghost of the past has come back to haunt us and no one cried for them. Prices will be competitive, and adoption will be fast, much faster than most believe.

Now we have some patients who arrive for imaging, as outpatients, ER visits, inpatients; it does not matter the premise is the same. Ms. Jones has chest pain, elevated d-dimer, history of Lupus anti-coagulant and left femoral DVT. Likely her chart has already been analyzed by a cloud-based AI (merlonintelligence.com/intelligent-screening/) and the probability of her having a PE is high, this is relayed to the clinician (PA, NP, MD, DO) and the study is ordered. She’s sent for a CT angiogram PE protocol imaging study. This is important to understand because there will be no role for the radiologist at this level. The recommendation for imaging will be a machine learning algorithm based off more data and papers than any one radiologist could ever read; and it will be instantaneous and fluid. Correct studies will be recommended and “incorrectly” ordered studies will need justifications without radiologist validation.

Continue reading…

“Thanks for Your Time”: Einstein’s Relativity in the Clinical Encounter

By HANS DUVEFELT, MD

In business literature I have seen the phrase “getting paid for who you are instead of what you do”. This implies that some people bring value because of the depth of their knowledge and their appreciation of all the nuances in their field, the authority with which they render their opinion or because of their ability to influence others.

This is the antithesis of commoditization. Many industries have become less commoditized in this postindustrial era, but not medicine. Who in our culture would say that a car is a car is a car, or that a meal is a meal is a meal?

The differences between services with the same CPT code for the same ICD-10 code aren’t, hopefully, quite that vast. But they’re also not always the same or of the same value. There is a huge difference between “I don’t know what that spot is, but it looks harmless” and “It’s a dermatofibroma, a harmless clump of scar tissue that, even though it’s not cancerous, sometimes grows back if you remove it, so we leave them alone if they don’t get in your way”.

I always feel a twinge of dissatisfaction when, after a visit, a patient says “Thanks for your time”. It always makes me wonder, on some level, “did my patient not get anything out of this other than the passage of time, did we not accomplish anything”?

Continue reading…

Healthcare IT Has Failed Providers, but It’s Not Too Late to Redeem Ourselves

By GUS MALEZIS

It’s no secret that healthcare providers are among the hardest working of all professionals – their skill and intelligence are matched only by their creativity and commitment to their patients. But the healthcare IT sector, while it has made an effort to assist, has failed to support our providers – doctors, nurses and caregivers – with technology solutions that meet the increasing demands for better, faster, more efficient patient healthcare delivery. Instead, we have cast these providers in the dark, forcing them to function blindly, devoid of necessary information, pushing many of them to the brink of what they can withstand as professionals, pushing them to burnout.

The thing about providers is that, in addition to being hardworking, dedicated, and outstanding professionals, they are incredibly creative and innovative, willing to embrace new technologies and workflows – as long as they can add value to their patients. So how about we – the broader healthcare IT solutions vendor community – focus on delivering technologies that don’t force them to compromise care and efficiency for the sake of security, or compliance and access to data?

We need to do so to address an industry crisis. Physician burnout is on the rise, and it’s increasingly clear that overworked providers have reached the breaking point. They spend valuable minutes battling technology on virtual desktops, mobile devices, biomedical equipment, and clinical SaaS applications – typing in usernames and passwords, loading various apps, and more. All the while, standing beside a patient that is desperately seeking their assistance.

Right now, nearly one-half of all physicians (44 percent) report having feelings of burnout (according to Medscape‘s 2019 National Physicians Burnout & Depression Report). While these numbers should alarm everyone, what the healthcare IT industry should be especially concerned about is that a leading cause of this physician burnout are tools that hinder provider productivity. Instead of simplifying work for doctors and nurses, technology tools are having the opposite effect. Isn’t technology supposed to make things easier?

Continue reading…

Zeev Neuwirth Reframes Primary Care…Brilliantly

By AL LEWIS

I would urge THCB-ers to read Reframing Healthcare by Dr. Zeev Neuwirth. While much of the territory he covers will be familiar to those of us with an interest in healthcare reform (meaning just about everyone reading this blog), Chapter 5 breaks new ground in the field of primary care.

Primary care is perhaps the sorest spot in healthcare, the sorest of industries. Primary care providers (PCPs) are underpaid, dissatisfied, and in short supply. (The supply issue could be solved in part if employers didn’t pay employees bonuses to get useless annual checkups or fine them if they don’t, of course.) 

They are also expected to stay up to date on a myriad of topics, but lack the time in which to do that and typically don’t get compensated for it. Plus, there are a million other “asks” that have nothing to do with seeing actual patients.

For instance, I’ve gone back and forth three times with my PCP as she tries to get Optum to cover 60 5-milligram zolpidems (Ambien) instead of 30 10-milligram pills. (I already cut the 5 mg. pills in half. Not fair or good medicine to ask patients to try to slice those tiny 10 mg pills into quarters. And not sure why Optum would incentivize patients to take more of this habit-forming medicine instead of less.)

This can’t be fun for her. No wonder PCPs burn out and leave the practice faster than other specialties. What some of my physician colleagues call the “joy of practice” is simply not there.

Continue reading…

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?

Continue reading…

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?

Continue reading…

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.)

Continue reading…

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.

Continue reading…

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.

Continue reading…

Registration

Forgotten Password?