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Talk, Think, Listen and Type

Four and a half years ago I read an editorial in JAMA, the Journal of the American Medical Association, that etched a short phrase into my memory. These five words seemed so profound and poignant that I really think they almost define primary care medicine today, perhaps with the alliterative addition of the word “teach”.

Dr. Abigail Zuger wrote of how the computer had changed the dynamic in the exam room and of the communication skills physicians now need to master:

“The physician will know the highly technical vocabulary of relevant research agendas well enough to encourage patients to get involved. The physician will also keep up with popular culture, tracking popular direct-to-patient communications and incorporating them into the clinical dialogue. In addition, and most importantly, the physician will have virtuoso data entry and retrieval skills, with an ability to talk, think, listen, and type at the same time rivaling that of court reporters, simultaneous interpreters, and journalists on deadline. The physician will do all of this efficiently and effectively through dozens of clinical encounters a day, each one couched in a slightly different vernacular.”

We’ve come a long way since Sir William Osler advised “Look wise, say nothing and grunt”. In his day, arriving at the right diagnosis was the most important task of a physician. Treatment options were usually limited. Today, even the most mundane diagnosis has myriads of treatment options. And in spite of all the advances of medicine, today’s false prophets and practitioners promote the medical equivalents of “alternative truths”. This is where the “teach” comes in. In rural medicine in particular, the village doctor may be the most learned person for miles around and we do need to promote scientific common sense to our patients and our communities.

Back to Dr Zuger’s quote:

I love the comparison of a physician’s work with court reporters, interpreters and journalists on a deadline. Our need for accuracy is obvious, and an interpreter truly needs to be familiar with both languages; even before I moved to this country I could spot the translation errors in the subtitles of American movies on Swedish television. You probably have to spend some time here to know that a six pack is a quantity of beer, and that half and half is a coffee whitener made up of half milk and half cream. Similarly, we have to be familiar with the worlds and cultures our patients live in. And the time pressures of primary care are obvious.

The ability to listen at the same time as we talk or think about what we want to say is essential if we want to be patient centered. We need to be exquisitely sensitive to our patients’ verbal and nonverbal communication if we are going to be any help to them.

And, as far as the typing goes, I actually do better on the iPad’s virtual keyboard with autocorrect than on a conventional keyboard, especially one with great “travel” of the keys and manual spellchecking (in my case type-checking; my spelling is fine). Then, of course, there is Dragon, Siri, and on my mini, the ultimate two-thumb typing.

And just like Dr. Zuger suggests in her editorial, the iPad allows me to pull up next to my patient so we can both see the reports, lab tests and the evolving office note that we, in many ways, create together.

How I Will Work Smarter in 2018

I don’t regularly make any New Year’s resolutions, but this year I am tossing around a couple of ideas. One reason is that I have so many things going on that I need to be clever about how I use my time.

I work four days a week at my regular clinic and I also work two long days at a clinic in far northern Maine. In addition, there are many farm chores, this blog and three book projects I am working on, or at least pondering.

So here is a first draft of A Country Doctor’s New Year’s Resolutions:

1) I will more systematically listen to Audio Digest and other Continuing Medical Education talks while I drive up North and back. Halfway through the Family Medicine Review, I am noticing how I have adjusted my practice in many small ways to newer information.

2) I will be more diligent about scanning The New England Journal of Medicine on my iPad every Wednesday night. I’m usually on call that night, so it will be easy to remember this resolution.

3) In my Northern clinic, where routine prescriptions are filled by the providers, I will save myself up to an hour a week by refilling routine, non-controlled medications for a whole year and relying on the other existing systems for making sure patients don’t get “lost to followup”. I learned this from Christine Sinsky’s work many years ago, but because my Southern clinic has standing orders for routine prescription renewals, I haven’t had to worry about it so much.

4) In both clinics I will invest a little more time polishing my EMR templates in order to speed up and beef up my documentation. I will also continue to ponder how I can insert a visit snapshot near the top of each progress note so I can get the gist of it without scrolling down to the bottom when rereading it at the next, follow up visit.

5) I will more consistently insert a comment for myself with each lab test I order that requires some action on my part when it comes back, like “calculate ten year cardiovascular risk” after a lipid profile, or “increase lisinopril to 20 mg if labs ok” for a creatinine or chemistry profile.

6) I will work with the EMR coordinators on making the “lab letter” work better in both clinics, and I will make more consistent use of the web portal and smartphone messaging functionality down South in order to communicate results better to patients and also free up my medical assistants’ time (now calling many patients back with normal results) as well as my own.

7) I will firm up my morning huddle up North, where it is designed to do so many things, like catching unsuspecting patients for overdue immunizations, that the basic purpose of the visit could get lost, like “do we have the MRI and consultant report yet?”

8) I will more consistently do all action items with the patient in the room, even if some aspect of the documentation needs to happen later because of time constraints. I’m already at 90% here, but if I tell a patient, “let’s get an MRI of your shoulder”, I will always order it right then and there, so the care can keep moving along, even if I need to polish my note that night or the next day.

9) I need to think more about how I can change the insane EMR convention of making me the first one to lay eyes on incoming results and reports. In every other type of organization, information is sorted, prioritized and sometimes even condensed before it gets to the decision makers. But in medicine, providers see patients all day long without hardly even a bathroom break, while all kinds of important information piles up in their electronic inboxes. Then, when everybody else has gone home, we finally get to the abnormal results that would have taken thirty seconds to handle if someone had interrupted us with them, but often now can turn into a logistical nightmare.

10) This may not sound like a resolution to work smarter, but I will be more cognizant of the influence I have over the people I work with. As my wife once pointed out to me (see my New Year’s post 2012), I sometimes treat family and coworkers less well than I treat my patients. I can and should spread good will and consolation outside the exam room, too.

The Other Opioid Epidemic

“I made myself a hypodermic injection of a triple dose of morphia and sank down on the couch in my consulting-room….I told her I was all right, all I wanted was twenty-four hours’ sleep, she was not to disturb me unless the house was on fire.”
– Axel Munthe, MD, The Story of San Michele (1929)

When people in this country mention the opioid epidemic, most of the time it is in the context of addiction with its ensuing criminality and social deprivation, and the focus is on opioids’ medical complications like withdrawal, overdose and death.

But that is only one of the opioid epidemics we have. Far greater is the epidemic of largely compliant patients who take their modest three or four daily doses of opiates for pain that was originally described as physical, but which in many cases is at least as much psychological – not imagined, in fact often quite severe, but nevertheless without a physical explanation or available cure.

Stimulation of opioid mu-receptors in the central nervous system induces euphoria more reliably than it reduces pain. In fact low dose opiates have been shown to sometimes lower pain thresholds but at the same time allowing dissociation from the pain experience.

People who smoked opium in antiquity didn’t all have intractable pain to begin with; many had miserable lives, just like many of my countrymen today with health problems, low income, poor education, lacking social supports and limited prospects for even a sustainable future in a job market they cannot even begin to qualify for.

Most physicians have or know of patients who have remained on the same moderate or low doses of opioids for many years and never failed a pill count or a urine test. They show no addictive behaviors, but without their prescriptions they function less well. We are still tapering most of them down or off their pain medications because that is what we do these days in response to the more famous opioid epidemic and in an effort to have fewer opioids, legal ones, that is, in circulation.

Ronald is a 57 year old patient of mine with a bad back, diabetic neuropathy and generalized anxiety disorder. He has been off his 5 mg oxycodone-acetaminophen (paracetamol) pills for two years now, takes pregabalin for his neuropathy and escitalopram for his anxiety with a low dose diazepam as needed. Since he came off his pain pills, his anxiety has been almost paralyzing. Social stressors, like a move to a different neighborhood, sent him into a frenzy. Then he fractured several ribs moving his washer and dryer up the icy front steps of his new home. The emergency room gave him just a couple of days worth of his old pain pills.

“It was amazing”, he explained to me, “I felt a warm wave travel through my body and it was like I was being hugged and everything felt all right, like I didn’t have a single thing to worry about in the whole world, even my nerve pain seemed like it didn’t bother me even though it was still there.”

Next, he asked if he could stay on them, “just three a day”.

I shook my head no.

He has his three other pills that don’t work as well. But at least they’re not opiates.

Routine Physicals, Routine Labs

I still sometimes get messages from patients without known chronic illnesses who want “routine blood work” and “routine physicals”. This terrible set of medical myths just won’t go away. It is even getting promoted by well-meaning but misinformed employee wellness programs.

In spite of all the talk about evidence based medicine, patients and colleagues all around me are clinging to the antiquated misperception that disproven rituals like digital rectal and testicular exams, clinical and self administered breast exams, annual lipid profiles, PSA tests, EKGs and 20-item chemistry profiles have anything to do with good health and longevity.

A dozen years ago I started offering instead an “Annual Health Review”, a brief opportunity to talk about each patient’s individual risk factors, based on family history, personal metrics and lifestyle. I also did a symptom inventory or review of systems. But I did not check their sodium or vitamin D levels, their back molars or the lint between their toes.

That sounds a little like the new Medicare Annual Wellness Visit, but that one rigidly demands that every patient gets screened for exactly the same items (risking non-payment if a single thing is missed). The AWV is cluttered by more or less mandated silly, medically unproven items like baseline EKGs and visual acuity by means of the Norman Rockwell style eye chart (seniors need their intraocular pressures measured; even the DMV checks their acuity, at no extra cost).

The canned Routine Physical, no longer recommended by the US Public Health Service Taskforce on Prevention, is a relic from a bygone era. These days, when people can send out for their own personalized genetic profiles, their family doctors are stubbornly treating everyone according to the same yardsticks and protocols.

This costly ritual consumes more than half of the working hours of some doctors: Thirty minutes per patient times the “ideal” panel size of 1,500-2,000 patients amounts to 750-1,000 hours of a normal 2,000 hour year. Consequently we see our patients go to walk-in care or, worse, the emergency room when they get a cut, a headache, bronchitis or the flu, so we can keep doing all those physicals.

A Christmas Wish

It’s just after six o’clock on a Sunday morning in December. The barn animals have fresh hay and warm water. My wife and the dogs are asleep. The cats are gathered around me as I sit down to write. One of them has jumped up in my lap and is pawing and clawing my jeans.

The fire is roaring in the wood stove but the 1790 room is still cold. I have read the morning news on my iPad. Our house is quiet, always; we don’t have a television or a radio. We have more time to think that way.

I do a lot of thinking these days, even though I put in long hours at work. During my commute to and from the clinic and during the long winter evenings I have plenty of time to think about my role as a doctor at this age, in this place and in these times.

I never wanted to do anything else, and I never want it to end. I cringe when I hear things like the commenter on my blog who wrote “I am sick of it and intend to retire as soon as I am able”. What a shame, what a waste. Kings, Presidents, Supreme Court Justices, Popes and Archbishops don’t usually retire “as soon as they are able”.

In some fields, age and wisdom are valued, especially the combination of the two. In many areas of medicine, at least in this country, doctors aren’t feeling valued at any age or skill level. Many feel like pawns or cogs in big, corporate schemes.

We have allowed ourselves to be devalued, and we as a profession have lost our clarity of vision, our sense of calling. Because of how unappreciated and squeezed we feel, we are at risk of losing our love for mankind, without which we will completely lose our professional purpose. We are thinking too much about production and quality metrics and losing sight of our apostolic and archetypal role in the lives of the patients we serve.

We are too distracted these days; we are practicing medicine with our minds, but not always with our hearts. We need to remember why we are in this profession and we need to stop feeling sorry for ourselves.

Victims of psychological domestic abuse undervalue themselves, overestimate the power of their tormentors and underestimate their own options. They stay in abusive situations sometimes because they don’t see clearly what is happening to them. They become physically isolated and feel shame, isolation and loneliness.

Professional burnout has many similarities with these facets of domestic abuse. But doctors are not really as tortured and trapped as abused spouses. Some of us just feel and act that way. We have one of the most meaningful jobs in the world. What a shame that so many of us want to get out of it while they are still able to do it.

Others have thought and written many wise words, not so often spoken today, about finding meaning in work:

“No man needs sympathy because he has to work, because he has a burden to carry. Far and away the best prize that life offers is the chance to work hard at work worth doing.”
― Theodore Roosevelt

“He who works with his hands is a laborer.
He who works with his hands and his head is a craftsman.
He who works with his hands and his head and his heart is an artist.”
― Francis of Assisi

“The purpose of life is not to be happy. It is to be useful, to be honorable, to be compassionate, to have it make some difference that you have lived and lived well.”
― Ralph Waldo Emerson

A small taste of these ideas is what I wish for those of my colleagues who are unhappy this Christmas.

Reengineering Primary Care (Again)

A few years ago primary care was all about being Patient Centered. But that turned into a bureaucratic set of superficialities that didn’t do half as much for patients’ experiences, let alone outcomes, as many of its proponents had envisioned.

Now, other forces are making us reexamine not only how we do things, but even what we are doing.

Our clinic’s Federal grant for next year will be smaller. A provider is leaving. Medicare is starting to shift from paying us a per visit fee to paying us for reaching randomly chosen quality targets. The mandates of what to fit into each visit are growing continually – very specific alcohol habits, physical activity level, sexual orientation, and on and on.

We only have so many providers, so many nurses and medical assistants and so many exam rooms. Practices around us are losing providers faster than we are, and more and more patients want to enroll with us.

The Patient Centered Medical Home recognition we achieved promised to give us some modest bonus payments, but it also cost us money in its nit-picking implementation, and now we are facing financial issues that overshadow such symbolic bonuses as PCMH incentives. It is simply time to roll up our sleeves and redefine the basics of what we do while trying to figure out how to meet the increasing demands from the community we serve.

We have previously paid lip service to the idea of having staff members work to the top of their license, because we have been stuck in the notion that only providers can enter orders and sign off reports in the electronic medical record, for example. We hold our providers to productivity targets that could easily be much higher with more support staff and more effective work flows, not only in terms of units of service but also “covered lives”.

The time has come for all of us to sit down, management with providers, nurses, medical assistants and clerical staff to look at our unique situation, our resources, our patients and start from scratch:

What can we do, here and now, and what do we envision in our own future, to better serve our patients?

If we don’t have enough providers and don’t expect to get many more – increase support staff and liberate us from unnecessary clerical tasks.

If we don’t have enough exam rooms, create check-in stations between the reception and the clinic area. Use technology to let patients check in via tablets or their own smartphones in the waiting room or even from home before they show up.

If we don’t have enough people to answer the phone to triage and make same-day appointments, open blocks of time for walk-in care, and divide providers’ time between protected time for time-consuming patients and intense stints doing urgent care.

Invest in building better EMR templates for faster documentation.

If we can’t afford or don’t want scribes to follow each provider into each visit, allow use of a paper visit form and hire one data entry person to input a stack of such forms at the end of every day if that might increase provider productivity.

In other words: Imagine local solutions for local needs.

The other day I read these encouraging words in the Harvard Business Review:

“The lesson for leadership is clear: Design your practice to maximize physician capability. Productivity, cost effectiveness, and satisfaction will follow.”

PCMH wasn’t the solution, because its recognition criteria were too rigid. Maybe the latest crises we are facing will turn into opportunities to bring some real life and passion into the next round of changes we must make in how we serve our patients and our community.

As a doctor, I solve problems all day long. As a Medical Director, I welcome the opportunity to bring my experience to the table where all of us can brainstorm in order to redefine, redesign and reengineer what is still a pretty inefficient system.

A Lousy Diagnostician

The tall, youthful seventy year old woman wore her strikingly white hair in a tight bun. She was dressed like a Donald Fagen song – in jeans and pearls (”Maxine”, 1982).

She had an intense burning, itching sensation on the left side of her neck and occiput. Looking closely at her neck and hairline, I saw a couple of small, red papules. A few of them looked like early blisters.

I suspected herpes zoster and offered her a generic antiviral. The earlier you start it, the better your chances of avoiding long lasting pain afterward, I explained.

A week later, there were some red blotches and several scratch marks. Her burning and itching were worse.

I prescribed gabapentin and told her how to titrate herself up from 100 mg at bedtime to 300 mg three times a day.

The following week she still had red blotches and scratch marks and felt no better. I frowned.

She said “My granddaughters have head lice, so I asked my daughter to check me, but she couldn’t find any. Would you check me, just to make sure?”

I leaned close and removed my -11 diopter glasses. My focal point is about one finger length from my corneas.

It took me a while, but I found half a dozen nits, enough to be sure she had the real thing.

Didn’t I feel a little sheepish. Seventy year old woman with burning and itching scalp? Must be zoster, right? Head lice is more of a pediatric problem, right?

Wrong. I narrowed my differential diagnosis too quickly.

And, I didn’t take my glasses off the first time.

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A Country Doctor Writes’ Ten Year Anniversary

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