If 911 Worked Like a Medical Office Phone System

Thank you for calling 911 or your local emergency response number.

Please listen carefully as our options have recently changed.

If this is a life threatening medical emergency please press “1”.

For non-life threatening medical emergencies, please press “2”.

For fire, press “3” but for a fire with life threatening burn or smoke inhalation victims, please press “31”.

For fire with non-life threatening injuries, please press “32”.

For Police, press “4” if you wish to reach State Police.

For your local police department, please press “5“.

If you don’t know which police authority to call, please press “6” for traffic related complaints, “7” for domestic assault that has happened in the past, but “71” for ongoing, life threatening assault and “72” for ongoing, non-life threatening assaults.

Press “8” for burglaries that have happened in the past.

For burglaries in progress, please press “9”.

For all other inquiries, please press 0.

To repeat these options, press the “#” key.

Today’s Medicine has no Credibility

This week’s issue of The New England Journal of Medicine once again questions two practices that used to be almost the backbone of primary care.

One article is about the low likelihood that prostate cancer detected through PSA screening will shorten a man’s life, even if he chooses just to keep an eye on it.

The other article is about how repeated mammography screening mostly leads to the diagnosis of small and not very aggressive tumors, just like PSA screening.

These two common health screening issues, along with the disappearance of all scientific rationale for cholesterol targets, baseline EKGs, digital rectal exams, testicle exams and “routine” lab work, not to mention routine physical exams, have essentially forced primary care doctors to rethink how they spend their days.

CMS has plenty of other things for us to do, although they still want us to do some of the things the evidence has debunked, and much of their vision for doctors falls within the Public Health domain.

As a result of these changes, physicians today face a serious credibility problem. The more dogmatic we have been before about following the guidelines that are now relegated to the history books, the more ridiculous we look to our patients as we more or less enthusiastically make our required 180 degree course corrections.

Thank goodness I always spoke of the guidelines as just that, current expert opinion, not something carved on stone tablets, handed down to us from Mount Sinai. As my father used to say, “view everything a little von Oben”. That’s the German expression for “from above”. The full phrase is von Oben heraus”, which rings of superiority and can even mean snooty.

As a physician, I am not putting myself above the expert opinion of the day, but I see myself as a humble servant and disciple, not of the current guidelines but of the principles of my forbears, from Hippocrates to Osler. If I take them seriously, and always speak of today’s guidelines as something likely to be temporary, I don’t seem to have to feel embarrassed when the guidelines change, which they inevitably do.

I think this attitude requires knowing your caft and its science well enough to be able to tell why the guideline looks the way it looks. Without the proper depth of knowledge you can’t be “above it all”.

Seriously, whether we are making guideline related u-turns without explaining why suddenly our practice is changing, or reciting all the possible side effects of a medication we are about to prescribe, we are making ourselves look bad compared to other practitioners, whose research isn’t double blinded and who aren’t mandated to badmouth their own treatments the way we are.

With guidelines coming and going, promising new drugs suddenly disappearing from the market, and with so many of our favorite prescriptions barely more effective than placebos, we need to go back to the source for the physicians of yesterday and those of the future:

Know your science, view today’s guidelines from a historical perspective and don’t be completely immersed in today. Because the present is just the razor sharp boundary between the past and the future.

Double-Booking the Doctor is Half-Booking the Patient

Not only have we shortened medical appointments to 15 minutes. We also sometimes double book them.

I get the feeling that non-providers think of this as something fairly ordinary, and even reasonable. But it is often a very difficult and destructive thing to do.

The term “double booking” and the way it looks in an ordinary doctor’s scheduling grid suggest that the physician might possibly be expected to be in two places at the same time. That is hardly ever the case for those of us who are mere mortals.

Sometimes a patient does need a lot of non-provider time, for example to get undressed and ready for a Pap smear. In such a case the doctor could take a quick look at another patient’s sutures or something simple like that in another exam room while the first patient is getting ready.

There is a tendency to squeeze in simple things almost anywhere, but, depending on who is losing half of their fifteen minute appointment, that might be a very unkind thing to do. In today’s reality, with Meaningful Use, ACOs and Patient Centered Medical Homes, we have to screen for various conditions and risk factors, update medication lists, immunizations and family and social history in every single visit. There really are no in-and-out quick visits anymore, thanks to our well meaning(?) Government.

In small practices, where the scheduler knows patients really well, it might be possible to predict better whose visit will be short and whose will take more time. But we have found as we have grown that this kind of knowledge is disappearing a little, and in some computer programs, the scheduling grid doesn’t show the names or concerns of scheduled patients, just that a slot is already filled.

This is why, the other day, somebody else got double booked with an elderly patient of mine who was given only a fifteen minute appointment for depression.

Double booking is sometimes used as a strategy to manage no-shows. That can be really bad.

In some practices, patients who have no-showed too many times are double booked with another patient, so that the expensive doctor doesn’t risk being idle for fifteen minutes. Of course, if the habitual no-show patient does make it to the appointment, the doctor is faced with managing both the catch-up of a patient who may be well overdue for whatever they came in for and the compromised visit of another unsuspecting patient. That unfortunate person ends up paying the consequences of having another patient booked in the same time slot. Two players in this triangle pay the price of the past transgressions of the third.

There is no good solution for no-shows. Dismissing such patients may seem easy for the practice, but even if you don’t believe health care is everybody’s right, some people no-show because of their economic or social situations and really need to be seen when they are finally able to keep an appointment, for example a child who is behind on immunizations.

The double booking due to being busy needs to be looked at in a humane and business-like way, and it needs the direction of the medical provider: The random double booking of unmarked squares on a computer screen is no better than throwing darts. We need to analyze our data to better predict the demand for services on a Monday morning or Friday afternoon before a long weekend.

And we need to risk a provider sometimes having fifteen unscheduled minutes. That time could be spent on patient relations or care coordination. Because doctors aren’t just faceless widget makers who produce visits. We are the ambassadors and medical leaders, or brains, if you will, of our practices.

Something Extra

The pressures of time, the complexity of our patients’ needs and today’s documentation requirements can easily make a medical provider feel less than generous these days. We must counteract that in order to carry on as healers.

All day long, I am conscious of the time as I work my way through my long list of fifteen minute encounters. But I am also conscious of the fact that the more pressure I feel, the less empathic I can become, and the less effective I am in building and maintaining the relationships that lie at the root of my ability to care for my patients.

It is only because of those relationships that I am in any way able to tell a fellow human being what to do; it is that relationship that allows me to reassure someone in just a few words with only my demeanor and the tone in my voice.

I can only cover so many issues and help solve so many problems in fifteen minutes, and I have long been aware that some of those minutes need to be time spent nurturing the relationship that allows me to be my patient’s doctor, not just any doctor.

I have made it my golden rule to always be realistic about the size of the agenda of every patient encounter, but to also always give something extra that the patient didn’t ask me for. By thinking and working like that, I have found myself less frustrated at the end of each day, more energized and, I believe, more effective in my craft.

That extra effort with each patient can take different form: Sometimes I personally bring a wheelchair bound patient back out to the reception area, sometimes I show an animal lover a picture of my horses or miniature goats, sometimes I tell a child a story of when I was their age, and sometimes I just give a more detailed explanation of a medical issue and tell the history behind the medication or treatment I am recommending.

It’s like when you give or get a humble gift that is wrapped really neatly with carefully chosen matching paper and a hand-made instead of stick-on bow.

It isn’t calculated this way, but not only does that little extra in every visit help create a more healing atmosphere in the medical encounter, it also creates an emotional bank account so that in those situations when I do have to rush or when I can’t deliver the help my patient was hoping for, they are more likely to still understand that I am only doing the best I can.

Return visit: A Samurai Physician’s Teachings

A few days ago, The New York Times had an article about the Munich academic and expert in Chinese medicine, Dr. Paul Unschuld, whose name translates as “innocence”. What struck me was that this expert apparently doesn’t believe all that much in the pharmacological effectiveness of traditional Chinese medicines, but sees the classic writings of the Yellow Emperor as an instrument that brought a certain enlightenment and pragmatism into Chinese medicine and culture.

Dr. Unschuld indicates that he believes traditional Chinese medicine can be effective in certain situations, but that it is also an expression of the Chinese way of thinking. The article states:

“For Dr. Unschuld, Chinese medicine is far more interesting as an allegory for China’s mental state. His most famous book is a history of Chinese medical ideas, in which he sees classic figures, such as the Yellow Emperor, as a reflection of the Chinese people’s deep-seated pragmatism. At a time when demons and ghosts were blamed for illness, these Chinese works from 2,000 years ago ascribed it to behavior or disease that could be corrected or cured.

“It is a metaphor for enlightenment,” he says.

Especially striking, Dr. Unschuld says, is that the Chinese approach puts responsibility on the individual, as reflected in the statement “wo ming zai wo, bu zai tian” — “my fate lies with me, not with heaven.” This mentality was reflected on a national level in the 19th and 20th centuries, when China was being attacked by outsiders. The Chinese largely blamed themselves and sought concrete answers by studying foreign ideas, industrializing and building a modern economy.”

I often think about how our perceptions about disease are culturally rooted and how physicians not just deliver treatments but are in a position to nudge our patients’ views of how health and disease come about.

It seems to me we are now in the middle of a big transition that echoes the Yellow Emperor. In his era, demons and ghosts were blamed for causing disease, and he pointed out how much our own lifestyle lies at the root of illness. In the last hundred years, our culture, with its tremendous scientific and technological advances, embraced the notion that our diseases come from invading bacteria, random gene mutations and other causes completely beyond our control. The promise of modern medicine has been that we can understand and counteract these forces through science, with more and more counteractive interventions. But as our treatments get more and more powerful, we have seen many of them cause ripple effects that cause other types of discomfort or disease. Now, we are instead seeing serious research into the relationships between illness and our psychological state, our harmony with our own gut bacteria, our low level exposure to dust and dirt we thought were harmful, our dietary choices and our physical activity level. We are beginning to see ourselves as no longer the hapless victims of outside forces, but products of our own day to day living choices.

I have written about the Yellow Emperor before in a 2013 piece that was also published on The Health Care Blog:

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 to archetypal 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.

People these days are not like his. They drink wine as though it were berry juice, make arbitrary what should be constant, get drunk and indulge in sex, deplete their pure essence because of desire, and thus suffer a loss of their fundamental health….Thus they fizzle out after fifty years or so.”

During the Ming dynasty, a prominent physician wrote:

“Premature death due to the hundred diseases is mostly connected to eating and drinking.”

That quote still carries relevance today.

Interestingly, Ekiken sees medications, herbs, acupuncture and all the available treatments of his time as a last resort because they are unbalanced interventions to counter the imbalance of the body. Almost a hundred years later, Samuel Hahnemann coined the word allopathy for this type of treatment.

Ekiken wrote at length about what distinguishes a mediocre physician from a good one. For example, he describes the good physician as less in a hurry to prescribe medications. One of his many aphorisms seems uncannily relevant to today’s emphasis of guidelines over individualized treatment:

“A good doctor gives medicine in response to the condition of the situation…This is not a matter of adhering to one absolute method. It is rather like a good general who fights his battles well by observing his enemies closely and responding to their changes. His methods are not determined beforehand. He observes the moment and is in accord with what is right.”

Quoting Confucius, he ends his description of a good doctor:

“A good doctor warms up the old and understands the new”.

May all of us remember and respect the wisdom of the 2500 B.C. text, now almost 5000 years old, as it speaks of “avoiding overexposure to things that can damage your body”. It reminds me of all the lectures I have attended on diabetes and heart disease where the speaker devotes exactly one sentence to this topic, and then spends the rest of the time talking about all the interesting drugs we have to counteract the effects of our exposure to harmful or excessive foodstuffs.

A little samurai discipline and restraint could help most of us…

The Art of Asking

Most people know from experience or through intuition that there is a right time and a right way to ask important or sensitive questions. You don’t usually just blurt out requests for raises or marriage proposals, for example.

In many areas of life, knowing when and how to ask difficult questions is viewed as an extremely valuable skill, for example in criminal investigations and in journalism.

In some cases this kind of skill can even make you a media star: Interviewers like Barbara Sawyer, Oprah Winfrey and Howard Stern are more famous and better paid than most of the celebrities they engage in intimate conversations in front of their national or world-wide audiences.

This year, the US presidential debates have been said to require unusual savvy from their moderators and their performance may even affect the outcome of the election.

Why is it, then, that in health care so little value is placed on when and how you ask sensitive or important questions?

In healthcare, we are constantly told that we must ask the most personal and intrusive questions of anyone who walks through our doors before we even ask what brings them to the doctor in the first place. And, unlike other interviewers, we must use “standardized” and “validated” questionnaires, because our work isn’t like other forms of fact or truth finding; our purpose is to collect data and to apply statistically proven interventions. No room for tact or finesse here.

When Autumn, my nurse, checks in a new patient, each one has already answered questions about gender identity and gender at birth. Autumn, along with doing the usual vital signs, has to administer a depression screening, inquire about alcohol habits and smoking, along with readiness to quit. For people with a BMI over 30, she has to ask what they are planning to do about it.

In many practices, the patient’s “History of Present Illness” and “Review of Systems” are asked and documented into obtrusive computers by freshly graduated medical assistants with limited medical and psychological training or experience. But that’s okay, because we use validated instruments and people always open right up and tell us the truth, and they always present their most important symptoms to us on a silver platter, the thinking goes. So, therefore, professional skill and experience may be valuable in rare cases, but there is just too much variability in that.

So, let’s imagine that our mandates applied in other areas of life:

What if criminal investigations were conducted by administration of nationally established “Criminology Assessment Protocols”?

What if lawyers could only use validated questionnaires and weren’t allowed to cross examine witnesses?

What if all celebrity interviewers could only ask the same set of questions?

What if the presidential election was determined by having our citizens vote for candidates based on their answers to a standardized and validated “Presidential Fitness Inventory”?

No, that would seem ridiculous, most people would say. So why is that the way we have to ask questions in medicine?

Unlike detectives, journalists, lawyers, bureaucrats and politicians, doctors just don’t know how to ask the right questions to figure things out.

Three Dutchmen Walked Into an Eye Clinic


Three Dutchmen Walked Into an Eye Clinic and the Rest is History.

As a severe myopic, it is no wonder I have always had a certain interest in ophthalmology. And just the other day I had reason to ponder the peculiar Dutch dominance in the history of optics and ophthalmology.

When I was a nearsighted young school boy in Sweden, my mother brought me on the bus into town every fall to see the eye doctor. He must have been in his eighties, a tall man with a bow tie and a long white lab coat. His office was adjacent to his apartment in a white stucco building from the early 1900’s. It was a dimly lit space with dark, angular furniture. The doctor said very little as he made me read the letters on the Snellen eye chart while placing varying lenses in front of each of my eyes in an antique looking device, and while he peered into my eyes while holding a thick magnifying lens that focused a piercing light into my tearing eyes one by one. I could smell his skin and his hair as he leaned into me.

After each of my annual exams, he always sighed and wrote out a stronger eyeglass prescription with a old black fountain pen. He carefully blotted the prescription paper and always said to my mother “don’t let him read too much in bed”.

As my glasses got stronger, I became aware that if I looked at road signs or traffic lights out of the corner of my eye, the colors didn’t line up. The red outer circle of the Swedish no-parking signs would overlap one end of the inner blue circle and there would be a space between the two colors on the opposite side. In the same way, the red, yellow and green traffic lights wouldn’t be straight on top of each other, but at an angle. I learned in school that red light passes straighter than blue or green light through a prism, like the outer edges of my old-fashioned glass lenses.

As I approached my teens, working with an old viewfinder camera and black and white darkroom equipment, I understood why it was harder to read in dim light: a dilated pupil, just like a wide aperture, creates a shallower depth of field than a smaller one, and the ultimate small aperture, a pinhole, can replace the lens in a simple camera or even your high powered eyeglasses in a pinch.

In medical school I learned to do a neurologic exam, and the bedside test for visual fields – Donders’ confrontation, as we called it. I figured Donders was a Dutch name, but never gave it much thought.

The other night, wondering why my EMR incorrectly defines visual acuity by “Snelling” rather than Snellen, it struck me that Snellen was probably a Dutch name, just like Donders. A few minutes with my iPad and Dr. Google made me rediscover how much I enjoy medical history.

It turns out Donders built an eye clinic and hired Snellen to run it. They invited their friend Einthoven, who would later invent the EKG, to help in their research. Einthoven studied chromosteropsis, the phenomenon whereby red objects seem closer than blue objects. Donders, Snellen and their wives were the subjects, and Einthoven’s paper became his doctoral thesis. It seems that chromosteropsis has something to do with the fact that red light travels straighter and that our eyeballs are angled inward when we look at objects up close, which makes blue objects seem ever so slightly blurry.

So, anyway, my little exploration reaffirmed that if I ever cut back my clinic hours, I’ll read more about the history of medicine.

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