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Tag: practice of medicine

A Modest Proposal: Replace the Med School Interview With fMRI

A fashion faux pas almost prevented me from getting into my dream medical school. Midway through the interview there, the interviewer pointed to my left earlobe and said, “Do you really think we accept men who wear … those things?”

I had no idea what he was talking about at first, but then remembered the gold post I’d forgotten to remove. In a disdainful southern drawl the interviewer let me know how dark a shadow this stylistic error cast on my otherwise favorable application.

I left his office fairly sure I would not be admitted. I also doubted whether I wanted to be admitted to a school that selected physicians on the basis of their jewelry. Really?

Twenty years later, medical schools around the country still struggle to find the right way to decide who should be the physicians of the future, and who should not. Most have evolved past caring about male earrings, but what are the right criteria for admission – what makes a good proto-doctor?

Over forty thousand students apply to medical school each year. Each applicant spends thousand of dollars in fees and plane tickets, and institutions spend still more to screen, host, interview and pick among the hordes of black-suited applicants. Increasingly, medical schools are considering innovative and creative ways to distinguish the most promising applicants from the rest.

New approaches include:

1. Using a more holistic review rubric that de-emphasizes grades and MCAT scores, such as at Boston University;

2.  Suspending traditional pre-med requirements for humanities students, such as at the Icahn School of Medicine at Mt Sinai; and,

3. Creative admissions interviews that include problem solving, multiple mini-interviews and even observed standardized patient interactions.

Each of these innovative methods sounds great. Used in combination I suspect they will identify applicants with the necessary academic chops plus a great bedside manner.

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Criminal Charges for Providers Won’t Fix the NHS, Dr. Berwick

One of US President Barack Obama’s key health advisers has just published a review in the aftermath of the Mid Staffordshire hospital scandal. Don Berwick’s review is both thoughtful and reflective but one of his key recommendations – to create criminal sanctions against health staff – will not make the NHS safer for patients.

Many patients, particularly elderly ones, suffered unnecessary indignities and avoidable harm at Mid Staffordshire.

The Francis report into the crisis concluded that patients were routinely neglected by a health trust more preoccupied with cutting costs and meeting targets rather than its responsibility to provide safe care. Patients’ calls for help to use the bathroom were ignored and some were left lying in soiled sheeting or sitting on commodes for hours. Events and failings there will probably go down in history as the blackest and bleakest moment for the NHS.

When the report was published in February, the government committed to appointing a advisory group of patients to consider the various accounts of what happened and the recommendations made by Robert Francis and others. The idea was that they would distill for the government and the NHS what lessons should be learned and what changes needed to be made.

Don Berwick, who worked on the long fought for Obamacare provisions in the US, is director and co-founder of the Institute for Healthcare Improvement in Boston. He was called in by the government to reflect on the Francis report and on patient safety.

Berwick’s review makes ten recommendations including that sufficient staff are available to meet the NHS’s needs now and in the future – staff should be well-supported and able to ensure safe care at all times; quality and safety sciences and practices should be a part of the initial preparation and lifelong education of all health care professionals, including managers and executives; and leaders should create and support learning and subsequently change, at scale, within the NHS.

But most controversial is his final recommendation:

We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.

Berwick proposes the government creates a new general offence of “willful or reckless neglect”, applicable both to organisations and individuals. Organizational sanctions might involve removing leaders and disqualifying them from future leadership roles, public reprimand of the organization and, in extreme cases, financial sanctions – but only where that will not compromise patient care.

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The Rise of the Hospitalists

Good for Healthcare?

Sarah Jones was an anomaly in contemporary healthcare.  Despite shifting alliances between physicians, hospitals, and insurance companies, she had been under the care of the same physician for over 20 years.  Over this time, patient and physician had gotten to know each other well and had developed a fine relationship.  Mrs. Jones had always assumed that, should she ever need to be admitted to the hospital, this relationship would pay big dividends, ensuring that her medical decision making would be based on long acquaintance and strong mutual understanding.

When the dreaded day came that she finally needed inpatient care, however, her hopes were dashed.  Her physician explained to her that he no longer sees hospitalized patients.  Instead she would be under the care of a team of physicians known as hospitalists.  When she arrived, the hospitalist on duty introduced herself and told her that she would be the physician responsible for her care, while colleagues would be responsible during off hours.  Unlike her regular physician, who would have been on hand only once or perhaps twice per day, the hospitalists would always be in house and ready to address her needs.

Mrs. Jones was surprised and disappointed to discover that her primary physician would not be involved in her hospital care.  She had always assumed that she would be able to rely on their longstanding relationship for counsel and support.  She imagined that if she were facing some really important decision, such as whether or not to proceed with a risky operation or how to manage her own end-of-life care, it would make a huge difference to know that she could count on a physician she knew well.  Instead her hospital-based physician was a complete stranger.

Mrs. Jones’ experience is far from unique.  In the past 15 years or so, medicine has seen the birth of hospitalists, a new breed of physicians who care only for hospitalized patients.  There are now over 30,000 hospitalists in the US.  From a patient’s point of view, such physicians offer a number of advantages.  In many hospitals, a specialist in hospital medicine is always on duty, day or night.  Moreover, because such physicians work only in the hospital, they are often more familiar with the hospital’s standard procedures, information systems, and personnel.

It is not difficult to see why hospital medicine might be so attractive to young physicians.  For one thing, it provides them with a high degree of control over their working hours.  They come on and off shift at regular times, and do not bear patient care responsibilities outside these hours.  In addition, they are usually employed by the hospital, which means that they do not need to attend to a host of practice management issues that self-employed physicians confront.  They can also focus on acute-care, in-hospital medicine, avoiding the challenges associated with long-term care of chronic-disease patients.

Some non-hospitalist physicians also find the rise of hospital medicine attractive. They do not need to travel to one or more hospitals each day to see patients, which takes considerable time and generates little revenue.  They do not need to work so hard at staying abreast of changes in hospital procedures and technologies, which often vary from institution to institution, as do requirements for acquiring and maintaining hospital medical staff privileges.  And finally, they can focus their energies on outpatient care, avoiding the more acutely life-threatening and complex situations associated with hospitalization.

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Flipping the Doctor’s Office

Consider the doctor’s office: the sanctum of care in American medicine, where a patient enters with a need — a question or an ailment or a concern — and leaves with an answer, a diagnosis or a treatment. That room, with its emblematic atmosphere of exam table and tiny sink and bottles of antiseptic, is in many ways the engine of our health care system, the locus of all our collective knowledge and all our collective resources. It’s where health care happens.

But in a less sentimental light, the doctor’s office doesn’t seem so exalted. Yes, it remains the essential hub for clinical care. But what occurs in that room isn’t exactly ideal, nor state-of-the-art. The doctor-patient encounter is fraught with tension, asymmetrical information, and flat-out incomprehension. It is a high-cost, high-resource encounter with surprisingly limited value and limited returns. It is too cursory to be exhaustive (the infamous fifteen-minute median office visit), too infrequent to create an honest relationship (one or two times a year visits at best), and too anonymous to be personal (the average primary care doc has more than 2,300 patients).

At best, it offers a rare personal connection between doctor and patient. At worst, it is theater. The doctor pretends she remembers the patient, and that she has actually had the time to read the patient’s chart in full; the patient pretends that he hasn’t spent hours on the Internet trying to diagnosis himsef, half-admitting what he’s really doing day to day, and pretending he won’t second- guess the doctor’s orders the moment he gets back to a computer.

As woeful as that sounds, we know that there’s real value here. This encounter can be meaningful; it should and must be meaningful. The doctor is a necessary interface to medicine, and his office is a source of care, expertise, and trust. The patient is eager and receptive to learning, primed for guidance and direction. Pragmatically, the doctor’s visit is a powerful part of modern medicine. The problem is that we, collectively, are not optimizing this resource; we have not reconsidered and re-evaluated how we might exploit the visit to its full advantage.

So how can we improve this situation? How can we fix this thing?
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The Samurai Physician’s Teachings on the Way of Health

Every now and then the title of a book influences your thinking even before you read the first page.

That was the case for me with Thomas Moore’s “Care of the Soul” and with “Shadow Syndromes” by Ratley and Johnson. The titles of those two books jolted my mind into thinking about the human condition in ways I hadn’t done before and the contents of the books only echoed the thoughts the titles had provoked the instant I saw them.

This time, it wasn’t the title, “Cultivating Chi”, but the subtitle, “A Samurai Physician’s Teachings on the Way of Health“. The book was written by Kaibara Ekiken (1630-1714) in the last year of his life, and is a new translation and review by William Scott Wilson. The original version of the book was called the Yojokun.

The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.

The translator, in his foreword, points out the ancient sources of Ekiken’s inspiration during his long life as a physician. Perhaps the most notable of them was “The Yellow Emperor’s Classic on Medicine”, from around 2500 B.C., which Ekiken himself lamented people weren’t reading in the original Chinese in the early 1700′s, but in Japanese translation. One of his favorite quotes was:

“Listen, treating a disease that has already developed, or trying to bring order to disruptions that have already begun, is like digging a well after you’ve become thirsty, or making weapons after the battle is over. Wouldn’t it already be too late?”

Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:

“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.

Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference toarchetypal or somatic medicine.)

The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.

If you restrain the inner desires, they will diminish.

If you are aware of the negative external influences and their effects, you can keep them at bay.

Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”

On the topic of Restraint, the Yellow Emperor text states:

In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more.
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What Doctors Do When They Don’t Know What to Do

Medical care in the U.S. over-promises and under delivers. It costs about twice as much as in most other developed countries, but compared to them manages to produce only mediocre health outcomes. The profit motive has resulted in badly misallocated resources — too much testing and treatment for people who don’t need it and lousy access for many who do.

The impact of advances in medical science on the delivery of clinical care has also been over sold. The basic science revolution in medicine has indeed been brilliant, with powerful new tools yielding remarkable insights into how our bodies work. But translating this into better tests and treatments has been slow work and the practical benefits derived from all the brilliant science have been surprisingly disappointing.

There is a big disconnect between the daily enthusiastic reports of great new research results and the fact that treatment outcomes have improved only slowly and selectively. Clearest example — we have done a lot more to defeat cancer by dramatically reducing smoking than through the entire expensive forty year research war we have waged against it.

Certainly, we need to aggressively pursue medical research, but we also need to be realistic about the limits of our current understanding of disease processes and their treatment.

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Is Obesity a Disease? I Vote No

There is a certain irony in the nearly immediate juxtaposition of the rare introduction of a new FDA-approved drug for weight loss (Belviq) to the marketplace and the recognition of obesity as a “disease” by the AMA. A line from the movie Jerry Maguire comes to mind: “You complete me!” Drugs need diseases; diseases need drugs.

And that’s part of what has me completely worried. The notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery to fix what is best addressed through improvements in the use of our feet and forks, and in our Farm Bill.

Why is the medicalization of obesity concerning? Cost is an obvious factor. If obesity is a disease, some 80 percent of adults in the U.S. have it or its precursor: overweight. Legions of kids have it as well. Do we all need pharmacotherapy, and if so, for life? We might be inclined to say no, but wouldn’t we then be leaving a “disease” untreated? Is that even ethical?

On the other hand, if we are thinking lifelong pharmacotherapy for all, is that really the solution to such problems as food deserts? We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy? Instead of helping people on SNAP find and afford broccoli, do we just pay for their Belviq and bariatric surgery?

If so, this, presumably, requires that everyone also have access to someone qualified to write a prescription or wield a scalpel in the first place, and insurance coverage to pay for it. We can’t expect people who can’t afford broccoli to buy their own Belviq, clearly.

There is, of course, some potential upside to the recognition of obesity as a disease. Diseases get respect in our society, unlike syndromes, which are all too readily blamed on the quirks of any given patient and other conditions attributed to aspects of character. Historically, obesity has been in that latter character, inviting castigation of willpower and personal responsibility and invocation of gluttony, sloth, or the combination. Respecting obesity as a disease is much better.

And, as a disease, obesity will warrant more consistent attention by health professionals, including doctors. This, in turn, may motivate more doctors to learn how to address this challenge constructively and compassionately.

But overall, I see more liabilities than benefits in designating obesity a disease. For starters, there is the simple fact that obesity, per se, isn’t a disease. Some people are healthy at almost any given BMI. BMI correlates with disease, certainly, but far from perfectly.

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The Doctor is Viral

A post I wrote nearly three years ago has recently gone viral, bringing tens of thousands of readers and a huge number of comments.  It’s a letter I wrote to my patients who do something that all but guarantees a bad relationship with many (if not most) physicians: they don’t get better. There are basically two responses I get to this post: either readers are grateful to have a doctor admit to our flawed humanity, or they are furious that I would suggest that patients, the ones with the disease, should see physicians as needy and flawed humans and therefore watch how they act around them.  If you haven’t done so, read the comments to this post and hear the deep frustration and anger brought out by a letter that sympathizes with their pain and (apologetically) tries to help.

Amidst the dichotomy of reactions, both of which I understand, is the obvious question: why has a relationship that exists for the purpose of healing and helping become one of frustration and anger?  The corollary to this question is perhaps more important: what can be done to heal this broken relationship? A reader of my last post (about viewing patients from a different perspective) asked me point blank:  ”Dr. Rob, for the 99.999% of us who do not have a primary care doctor who is thinking as progressively as you, what advice can you give so that we can get our doctors to be treating us in the manner in which you are treating your own patients?”

I must admit, I get a bit uncomfortable with this, as it sounds like I am putting myself above my colleagues morally. Ironically, it is my deep understanding of my own huge flaws, coupled with an upbringing that scorned conformity, that rips me away from the survival self-centeredness most docs eventually adopt.  Putting myself on any moral high ground only invites a very public (and deserved) fall back to the low ground I usually inhabit.  No, I’m also not putting myself down out of false-modesty; I’ve made peace with my flaws, embracing them for what they are: a lens with which I can understand my fellow human scum-bags.  Of course, as my best friend (and best man) used to remind me: “remember, I am doctor scum bag to you.”

Now, I don’t lay the whole problem at the feet of the fallen nature of mankind.  I believe that our system of “health care” doesn’t just fail to counter the flaws of our nature, it actively promotes bad relationships.  It does this by:

  1. Reducing patients to “problems.” The payment system requires we use “problem codes” to classify patients and justify visits.  The problem-oriented approach is not just a byproduct of the payment system, though, it is at the very core of medical education.  Despite a 100% ultimate failure rate, we are still taught that death and disease are the opponents we need to outsmart or out-procedure.  Perhaps its analogous to the public infatuation with the tawdry and grotesque (the more gruesome the murder, the more news shows cover it), but we physicians love “interesting cases.”  But nobody ever wants to be an “interesting case.” Ask any of the people who commented on the blog post.  Boring is better.
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Why Is the Doctor Angry?

I had a patient this week that really screwed up his medical care when he experienced a predicted side effect of curative chemotherapy.  Despite clear instructions and access to every number my partners, my staff and I have, including office, triage, cell, and answering service, he did not reach out.  Day-by-day he lay in bed, as he grew weaker and multiple systems failed.  No one contacted me.  Finally, he sent an email to a doctor 3000 miles away, in California.  That doc forwarded the email to me.  I sent the patient to the hospital.

Did we rush to the emergency room, to salvage his life?  Of course.  Were there innumerable tests, complex treatments, multiple consults and an ICU admission?  You bet.  Did I patiently explain to him what was happening?  Yes.  Did I look him in the eye and tell him that I was upset, that he had neglected his own care by not reaching out and in doing so he violated the basic tenants of a relationship which said that he was the patient and I was the doctor?  Did I remind him what I expect from him and what he can expect from me?  You better believe it, I was really pissed!

The practice of medicine for most doctors is fueled by a passion to help our fellowman.  This is not a vague, misty, group hug sort of passion.  This is a tear-down-the-walls and go-to-war passion.  We do not do this for money, fame, power or babes; we do this because we care.  Without an overwhelming desire to treat, cure and alleviate suffering, it would not be possible to walk into an oncology practice each morning.  Therefore, just as we expect a lot of ourselves, we darn well expect a lot out of our patients.

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The Good Doctor’s Mind Map

This, apparently, is a map of my mind.  It’s a little shocking to find out that my mind looks like a sea creature, a bug, or perhaps a vegetable.  Actually, “Rob’s mind” and “vegetable” are often used in the same sentence.

Someone suggested to me that I may benefit from mind mapping.  I don’t know how to describe it, but I think spatially; I see things abstractly as if I am pulling up from the ground and getting an aerial view of things.  I write that way, I solve problems that way, I even play music that way.  Maybe it’s tapping on the right side of the brain that is about nuances or about how things relate to other things in proximity or direction.  Like I said: it’s hard to describe.

Anyhow, I was thinking about task-management with my patients, wondering what’s the best way to think about it and what is the best design for a system helping with this.  Task management is perhaps the most important thing in health care that’s never talked about.  Maybe that’s because it makes doctors feel less special, reducing our “magical” knowledge and “miracle” cures to algorithms and checklists.  Personally, I take great comfort in systems because they assure me I am not going to forget important things (like setting a reminder to take the trash out on Sunday and Wednesday nights).

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