This July will mark the 16th anniversary of the installation of our electronic medical record.
Yup. I am that weird.
Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care. I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red. I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue. I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care. I heard people say primary care doctors couldn’t afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time. To me, it was just a matter of time before everyone finally saw that I was right.
The passage of the EHR incentive program (aka “meaningful use” criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it. I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.
But something funny happened on the way to meaningful use: I changed my mind. No, I didn’t stop thinking that EHR was a very powerful tool that could transform care. I didn’t pine for the days of paper charts (whatever they are). I certainly didn’t mind it when I got the check from the government for doing something I had already done without any incentive. What changed was my belief that government incentives could make things better. They haven’t. In fact, they’ve made things much worse.
My in-laws are in town for my daughter’s graduation.
When I came home yesterday I was greeted with a big smile and vigorous handshake from my father-in-law. ”I just want to thank you,” he said, standing up from his chair, “for finding us a good doctor. The one you found for us is wonderful.”
My wife smiled at me warmly. I just earned myself big points. Yay!
Her parents and mine are both in their 80′s and are overall in remarkably good health. When I called my father after he had a minor surgery over the summer, my mother told me he had a ladder and was “on a bee hunt.” It’s a blessing to have them around, especially having them healthy.
My parents have a wonderful primary care physician, which takes a whole lot of pressure off of me to do family doctoring, and puts my mind at ease. I’ve only personally contacted him once when my dad had a prolonged time of vague fatigue and body aches. I try not to use the “I’m a doctor, so I am second-guessing you” card that I’ve had some patients’ children pull. I called his doctor more as a son who wanted a clear story about what was going on than as a physician with thoughts on the situation.
“I first want to say that I am very grateful my parents have gotten such good care from you,” I said at the start of the conversation. ”It’s nice to not have to wonder if they are getting good care.”Continue reading…
It was during my residency that the first indication of heart toxicity of antibiotics affected me personally. The threat was related to the use of the first of the non-drowsy antihistamines – Seldane – in combination with macrolide antibiotics, such as Erythromycin causing a potentially fatal heart arrhythmia. I remember the expressions fear from other residents, as we had used this combination of medications often. Were we killing people when we treated their bronchitis? We had no idea, but we were consoled by the fact that the people who had gotten our arrhythmia-provoking combo were largely anonymous to us (ER patients).
Fast forward to 2012 and the study (published in the holy writings of the New England Journal of Medicine) that Zithromax is associated with more dead people than no Zithromax. Here’s the headline-provoking conclusion:
During 5 days of therapy, patients taking azithromycin, as compared with those who took no antibiotics, had an increased risk of cardiovascular death (hazard ratio, 2.88; 95% confidence interval [CI], 1.79 to 4.63; P<0.001) and death from any cause (hazard ratio, 1.85; 95% CI, 1.25 to 2.75; P=0.002). Patients who took amoxicillin had no increase in the risk of death during this period. Relative to amoxicillin, azithromycin was associated with an increased risk of cardiovascular death (hazard ratio, 2.49; 95% CI, 1.38 to 4.50; P=0.002) and death from any cause (hazard ratio, 2.02; 95% CI, 1.24 to 3.30; P=0.005), with an estimated 47 additional cardiovascular deaths per 1 million courses; patients in the highest decile of risk for cardiovascular disease had an estimated 245 additional cardiovascular deaths per 1 million courses. (Emphasis Mine).
I saw a gentleman in my office recently. He was having severe pain radiating from his lower back, down to his calf.
I was about to describe my plan to him when he interrupted me saying, “I know, Doc, I am overweight. I know that this would just get better if I lost the weight.” He hung his head down as he spoke and fought off tears.
He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds. On the other hand, I don’t know of any studies that say obesity is a risk factor to ruptured vertebral discs. Besides, he was in significant pain, and a lecture about his weight was not in my agenda. I wanted to make sure he did not need surgery, and make him stop hurting.
This whole episode really bothered me. He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him. He was living in shame. Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character. After all, losing weight is as simple as exercise and dietary restraint, right?
Perhaps I am too easy on people, but I don’t like to lecture people on things they already know. I don’t like to say the obvious: “You need to lose weight.” Obese people are rarely under the impression that it is perfectly fine that they are overweight. They rarely are surprised to hear a person saying that their weight is at the root of many of their problems. Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.
Yes, I am going to talk about…autism. The last time I did so I was inundated with people trying to convince me of the dangers of immunizations and their causal link to autism. I really, really, really don’t want to go anywhere near that one.
No, I am not going to talk about the cause of autism; I am going to talk about my observation of the rise of the diagnosis of autism, and a plausible explanation for part, if not most of this fact. The thing that spurs me to write this post is a study by the CDC which was quoted in the NY Times:
The new report estimates that in 2008 one child in 88 received one of these diagnoses, known as autism spectrum disorders, by age 8, compared with about one in 110 two years earlier. The estimated rate in 2002 was about one in 155.
The rise in numbers is cited as one of the main evidences for some external source – a new thing in our environment – that is causing this rise. The article, however, gives another clue:
The frequency of autism spectrum diagnoses has been increasing for decades, but researchers cannot agree on whether the trend is a result of heightened awareness, an expanding definition of the spectrum, an actual increase in incidence or some combination of those factors. Diagnosing the condition is not an exact science. Children “on the spectrum” vary widely in their abilities and symptoms, from mute and intellectually limited at one extreme to socially awkward at the other.
Children with such diagnoses often receive extensive state-financed support services — which some experts believe may have contributed to an increase in numbers.
That last sentence holds the golden ticket. What would make me think this? My experience.
I was talking to a patient a few days ago who was raving about a local grocery store.
”They get it,” she said. ”They understand how to take care of their customers.”
It made me think about how far medicine has drifted away from the same idea. Ironically, despite the fact that our “customers” (people who pay us for our services) are seeking us so we can “take care of” them, we do a lousy job of taking care of our customers. It has been an obsession of mine since I started practice, but it has been something that has been increasingly difficult to accomplish. I now have to fight against the need to meet “meaningful use” criteria so that I can have time to make the record meaningful and useful to my patients. I have to fight against the need to conform to “medical home,” criteria so that I can make my practice the place my patients see as their ultimate medical haven.
The more the government and insurance industries push me toward focusing on my patients, the less time I have for my patients because of the need to meet criteria proving that I am caring for my patients. It’s a mess.
So I went back to my roots. What do I really think should be the rights of my patients? Here is a list that I made:
Patients have the following rights:
The right to have access to care when it’s needed
This does not mean the care is done in the office either. It can be done over the phone or via computer.
The schedule of the office should accommodate the patients’ needs as much as is reasonable to expect.
The right to have care that is convenient
They should not have to wait to be seen or wait on the phone to be heard
a. Using something in a way that gives life purpose and leads to carefree days of glee.
b. It depends on your definition of the word “term.”
c. It is not mean. It is really nice.
d. A large number of rules created by the government to assess a practice’s use of electronic medical records so that they can spur adoption, give criteria for incentive rewards, and have physicians in a place where care can be measured.
e. Job security for those making money off of health IT.
The answer, of course is d and e.
Meaningful Use, in the eyes of many is seen as curse words, especially doctors.Continue reading…
I walk into the exam room and the patient looks up at me with a surprised expression. ”Wow! I didn’t expect to see you so quickly!”
I smile and turn around to walk out of the door, saying: “Sorry! I’ll leave then and come back later.”
“No, no!” They respond, smiling. ”I’m happy to see you so soon. It’s just a surprise.”
I walk back into the room with a smirk. ”I just don’t want to offend you by being on time. I’ll try to do better next time.”
I am not sure if I should be happy or sad with such an interchange. On one hand, it feels good to stay on time with my appointments, holding up my end of the bargain of the schedule. On the other hand, the patient’s surprise betrays the fact that this is not the usual state of affairs. And it isn’t. I generally don’t run on time and don’t expect to run on time.
When I first started practice, the stated objective was to get the person out of the office within an hour of their scheduled appointment. This seemed a blend of realism and responsibility. At first it was easy to stay up on things. My schedule was sparsely filled, so I could make up time. After sixteen years of practice, however, my schedule almost never has open slots; when it does have openings, they are quickly filled. I still try to get them out within an hour.Continue reading…
Thank you for your consideration of my profession for your career. I am a primary care physician and have practiced for the past 16 years in a privately-owned practice. (At some point I intend to stop practicing and start doing the real thing. It amazes me at how many patients let me practice on them.)
Anyhow, I thought I’d give you some advice as you go through what is perhaps your biggest decision regarding your career. Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices. It is the final choice that is, well, final. What are you going to do with your life? ”Being a doctor” covers so much range, that it really has little meaning. Dr. Oz is a doctor, and he has a very different life from mine (for one, he’s not the target of Oprah’s contempt like I am – but that’s a whole other story).
Here are the things to consider when thinking about primary care:
1. Do you like talking to people who are not like you?
Primary care doctors spend time with humans – normal humans. This is both good and bad, as you see all sides of people, the good, bad , crazy, annoying, funny, and vulnerable sides. If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don’t do it. The single most important thing I have with my patients that most non-pcp’s don’t have is relationship. I see people over their lifetime, and that gives me a unique perspective.
So I was walking down the hallway in my office, mildly distracted,
when I kicked something. It was a USB “thumb drive.” I picked it up
and inspected it, trying to figure out who had dropped it. The side of
the drive had a picture that I couldn’t make out, as it was all smudged
with something. I pulled out a tissue and rubbed it, thinking it may be
a clue as to whose drive it was.
There was a sudden rushing sound and a strong wind. Out of the thumb drive emerged a large blue figure wearing a turban.
“Are you a genie?” I asked
“No, I am David Blumenthal, the health IT ‘czar.’” he responded.
I hung my head down, “I guess this is about the fact that I write the word healthcare instead of health care. I was wondering how long it would be before the feds came down on me for that.
“No, that’s not my realm. That would be the job of the Department of
Language Security, and they’ll be appearing in some creative way next
week to get on your case about the whole healthcare thing. It has Matthew Holt and Maggie Mahar in a big tiff.”