Four Things I Don’t Plan To Change

Here’s another great post from Waco family physician and friend Tim Martindale:

I hear constantly we are in a new world of medicine, and things cannot stay the same. We must make some adjustments, they say, to survive and cope in this new environment. Well I don’t want to be an ostrich with my head in the sand, and I am very involved with reading articles, attending meetings, and wrestling constantly with this new, changing world. I am active in my county medical society, my local specialty society, and my hospital staff. But there are some things the conventional wisdom says have to, or already have, changed, and I don’t agree.

1. I want to focus on listening to, looking at, and examining the patient. This affects decisions on how many patients I see, how to use my electronic medical record, and how I prioritize my time in the exam room. There is no substitute for the gestalt I get when I see, listen to, review history, examine the patient, then talk it over with them. So I see less numbers, find ways to not be boxed in or directed by my EMR, and make the patient my partner in their care.

2. I want to remain a patient advocate. Insurance, government, employers, drug companies, etc. all want me to consider their agendas, and put obstacles, checklists, prior authorizations, peer to peer reviews, endless paperwork, and threats of lower reimbursement or being branded as a lesser quality doc in my way. But my first priority is the health interests of my patient, and I’ll wade through all that nonsense tirelessly to meet that goal. My staff has the same vision and the perseverance of a bulldog.

3. I want to do complete, continuous, comprehensive, efficient care for my patient. I still do all my own hospital work, as well as nursing home and home visits. By doing this, I maintain the commitment to comprehensive and continuous care, the desire to be there for my patients at their most difficult times, the need for someone who knows the patient best to serve as the coordinator of care, the goal to keep my skills at maximum and not narrow my scope of practice, the pleasure and challenge of complicated hospital acute illness management, the camaraderie with the specialists as we work together, the desire to be a leader in hospital and community medical issues, and the widening of my knowledge base as I work with challenging cases alongside specialists. Yes, I do work harder, but I’m more happy and fulfilled. I should note that I respect physicians who have chosen otherwise, and hospitalists today are excellent.

4. I will continue to make my physical, emotional and spiritual health and wholeness a priority, as well as that of my physician partner and clinic staff. That means I think about it, plan for it, make sacrifices for it, and talk about it regularly with those alongside me. We can’t be victims of this relentless pressure and paperwork so that we push ourselves to the point of disqualification where we can no longer serve our communities in such a powerful way because we have forgotten about ourselves.

So Simple A Child Could Do It: Slide Rules vs. iPads

Checking in at the dentist’s office

 

When we walked into the dentist’s office, my kids ran straight up to the computer to check in for their appointments.  This was my first time to take them to the dentist as my wife usually drives them.  My son and daughter quickly entered their names on the touch screen, grabbed books, and took their seats.  Freed from manually registering patients, the front desk clerk monitored patient flow and welcomed everyone to the clinic with freshly baked chocolate chip cookies.

Later that day, I went to my doctor’s office where I signed my name on a clipboard and patiently waiting in the lobby as patients have done for decades.  His office has the same electronic medical record as mine, but his clipboard system has not changed in decades.  My clinic has an EMR with a web portal and secure patient email, but our patients still queue at the front desk to give  their information to a clerk.  At the gas station, I swipe my credit card and fill my gas tank without talking to another human being.  At the airport, I walk up to the kiosk, insert a credit card, and print the boarding pass for the flight I checked in to the night before.  We expect businesses to adopt the latest customer service technology and embrace their use while we keep our clinics in the technological dark ages, suspiciously questioning each new innovation.  We complain about the inefficiencies of our electronic medical records but are slow to adopt innovations to improve the efficiency and ease of our patients’ visits to our offices.  Are we so focused on our frustrations that we forget our patients?

Some of this skepticism is well founded.  For the past four years I have used the same EMR software I helped implement in my residency fourteen years ago.  I can do work but do not save time.  It still cannot talk to the hospital system so I do not have to look up the results of lab tests drawn five miles away. Although the computer file format that allows EMRs to communicate with each other has existed for years, I just read another editorial this morning lamenting the lack of interoperability between competing software products.  While I firmly believe that such technology can improve patient care, these benefits are far from inevitable.  In the United States, we believe in the goodness of technology like an article of faith.  If you don’t think that technology will make your life better, you must be old-fashioned – or tragically unhip.  Too often, however, we fail to adequately question whether the benefits the vendor promised are as good as advertised.

In a recent discussion thread, colleagues compared the latest fitness apps for their smart phones and GPS-based devices.  I have tried similar devices but have found an “old-fashioned” running watch to be far more reliable.  While I enjoy my smart phone, tablet, and laptop, I think we must still channel our inner Luddite by asking:  Is this technology really improving our lives as much as we think?  Are there unintended consequences we will regret in years to come?

On the other hand, we shouldn’t simply disregard potential benefits based on such concerns.  If my children can check in to their own appointments, why don’t we make this available for all our patients?  If my 80-year-old can learn to use secure email to communicate with me, why can’t you?  If my 50-year-old on Coumadin can check his own INR at home, email me the results, and adjust his medicine based on my emailed response, why don’t more patients adopt this technology?

Learning to use the iPad

 

My father learned engineering with a slide rule, was one of the first to use the “revolutionary” Hewlett Packard desk top calculator, taught himself DOS and Windows a decade later, and now is mastering the iPad. While he is not sure he likes how the screen orientation changes when he turns the it, I doubt he would give up his iPad for a slide rule.  Such technological changes are inevitable, but our responsibility is to ensure they benefit our patients.

The genie is out of the bottle and it’s too late to put him back.

How Does It Feel To Treat Someone Who Repulses You?

This post about the April 15th bombings at the Boston Marathon comes from Jerry Abraham, MPH, a 3rd year medical student at UT Health Science Center San Antonio.

“The real question is…How does it feels to treat someone who repulses you? Not just someone who annoys you—anyone training or working in healthcare in an urban area treats plenty of the very annoying: drug dealers, pimps, prostitutes, thieves, and thugs, as well as embezzlers, defrauders, money launderers, and inside traders. Rather, what is it like to treat someone whose very right to exist strikes a passionate chord?

Some health care workers may come to feel infuriated or morally wrong. A sense even may arise from some staff that they are abetting an enemy and are somehow complicit in his crime.

Of course they are not. Similar to the provisions of the Third Geneva Convention, which dictate that even the most heinous war criminal must receive humane treatment, every ill person must receive proper medical care. But this approach should not arise from the fact that it is our contractual duty under the law and we want to keep our job. Rather, providing drama-free, professional care even under extreme personal duress demonstrates our one priestly quality—our humanity, the single trait that distinguishes us from the person whose inhumane actions have caused so much sorrow.

The legal dilemma facing medical staff is clear: the Emergency Room is compelled to treat everyone who enters the doors in need of emergency care.

In 1986, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) to assure that patients in need of emergency treatment receive medically proper attention.

This law prevented patient dumping—the convenient refusal to care for the indigent demonstrated by certain hospitals looking for an exclusive, cash-and-carry clientele. Doctors and nurses, as employees of the hospital, have agreed to follow the hospital’s rules as a condition of employment.

In other words, though the issue of a morally objectionable patient has not specifically addressed, the law provides no room for personal choice—hospital staff must treat everyone—equally.”

Don’t Get Mad, Get Even: Political Advocacy

Last December, after months of “planning to,” I finally got around to calling to my state senator to set up a meeting before the legislature convened.

“Hello, my name is Dr. Y, I am a constituent and I would like to set up a meeting with Senator X in the district.”

“You know the session starts in 3 weeks.”

“Yes, I do”

“You know Christmas is in 2 weeks.”

“Yes, I do.”

“You know she’s very busy.”

Yes, I do.  I will be at the Capitol on the first day of the Legislature.  Is her legislative aide for health affairs available instead?”

“Yes.  I will ask her to contact you to set up a time to meet.”

When I met with the legislative aide several weeks later, we had a productive conversation.  She had worked on health affairs for another state senator before.  I pitched our bill to restore funding to family medicine graduate medical education and the physician loan repayment program to help place doctors in underserved areas.  We had been instructed to ask our senators to support the bill and cosponsor it if possible.  I thought, ‘What the heck, nothing to lose by asking.’  I was told that the Senator was interested in health care issues and she would get back to me with the senator’s answer.  I also forwarded a map of the senate district with all the medically underserved areas and primary care physician to population ratios labeled.

A few weeks later, she emailed me to say that the Senator had decided to support the bill.  Ok, I thought, she’ll vote for it when it is heard in committee.  A few days later I saw that she was listed as a cosponsor!  With 2 of the committee members listed as cosponsors, our chances of getting the bill out of committee looked much better.

Politics can be frustrating, but persistence pays off.  And you have nothing to lose by asking.

Enough Is Enough: Time To Reevaluate Impact of Residency Training Rules

Shocking, simply shocking. A recent article highlighted unintended consequences of the most recent changes in resident work hour rules.

Why does the ACGME impose work hour restrictions without considering unintended consequences like increased medical errors due to increased patient hand offs?

I graduated residency in the “dark ages” (1999) but rarely worked more than 80 hours a week.  While rounding post call was never pleasant, it did prepare me for “real life.” Today, I worked 12 hours in the clinic then drove 3 hours to the state capitol so I could testify in support of expanded funding for family medicine residencies.  In my first 7 years of practice doing family medicine with Ob and hospital work, I took call for 1 week at a time while covering my own Ob patients 24-7.

The ACGME seems to extrapolate from existing data without studying the impact of its past actions. As a surgeon medical  school classmate of mine says, life has no work hour rules. A rural physician colleague who still does C sections and appendectomies told me last month he no longer hires third year family medicine residents from his own alma mater because they don’t have enough experience.  He only hires grads who complete the program’s 1 year rural medicine fellowship.  When I see graduates of the program where I am now faculty say they can’t do inpatient and outpatient medicine at the same time, our training model is gravely flawed and further fragments health care at a time when more well-trained generalists are needed.

What Drew Me To Medicine Keeps Me Alive

This blog is from Tim Martindale, a friend and family physician in Waco, Texas. He is a former minister who went back to school to become a family doc.  For seven years, I drove past his office every day on the way to work.  This July, his son will start a family medicine residency.

” This is a paragraph I wrote on a physician website in response to the question of whether I am frustrated with medicine today, or at risk of burnout:

What drew me to medicine keeps me alive at 55.

Every decade there are new changes, paradigm shifts, governmental intrusions, insurance games… but none of them change the basic tenets of why I love medicine.

I get to make lives better, explore the endless universes that are people, be privy to the most challenging times of human experience.

I get to keep learning, keep changing and adapting, use and train my brain for ever-evolving understandings and circumstances.

I get an income through hard work that feeds and cares for my family, all while being given honor and respect and leadership in my community.

So are there hard times of change, shifting rules of success, moments of exasperation and exhaustion? Absolutely. But that’s everywhere in life, and we’re overcomers.”

-Tim Martindale, MD.

Waco, Texas

We Do View Gun Control Differently Here: A Red State Perspective Part II

The Texas State Capitol has three lines at each entrance. One for legislators, one for the general public, and one for concealed carry permit holders. I understand legislators and state officials getting to use the express line, but only in Texas would we let people carrying a concealed weapon avoid the metal detectors. The metal detectors were placed after a Capitol visitor followed a female staffer, then fired his weapon into the air on the steps outside the main entrance.

When I stood in the long general visitor’s line this past January on the first day of the session watching permit holders breeze through the concealed carry line, I wondered: Do you have to have a weapon, or just a permit?

The answer, according to the New York Times: just a permit. So for $500 dollars you can buy a permit and gun, or for less than $200, you can buy just a permit and use the express line for a year.

http://www.nytimes.com/2013/03/09/us/guns-get-a-pass-at-texas-capitol.html?partner=rss&emc=rss&smid=tw-thecaucus&_r=1&

The Good, The Bad, and The Ugly: Quality Improvement Part II

Recently I received my “gap” report from our employee insurance plan and my latest physician report card.  Now that I have worked through the 5 stages of grief, I’m ready to grapple with the numbers.

The Good

• I finally hit the HEDIS 75th percentile for the number of diabetic patients with a Hemoglobin A1C less than 9%.   My percentage was parked in the 50′s for months.  I knew that my diabetics were better controlled than that, but maybe I was in denial.  Once I looked at the data and talked to our IT staff, we discovered that the list was incorrect.  Rewriting the data collection rules increased my percentage by 30%.  You have to make sure the data is correct.

The Bad

• Although I have sent multiple letters for 6 months, I still cannot get several patients to come in for Pap smears and breast exams.  Do I need do call them repeatedly, drive to their homes, and beg them to come in?  Perhaps their insurer, our hospital system, could put some of the patient’s skin in the game.  Get all the preventive care you should and your premium goes down.  Don’t get the care you should and your insurance premium goes up.  Sounds fair to me.

The Ugly

• My cervical cancer screening rate is now less than 20%?!  At least one outlier on my gap report doesn’t have a cervix.  Once I find out how to do a Pap smear on a nonexistent cervix, I’ll let y’all know.   We are being held responsible for errors in the insurers’ claims data.  Expertise in data collection and interpretation is essential for a modern physician.

So Simple A Child Can Do It

Checking in at the dentist’s office

When we walked into the orthodontist’s office, my kids ran straight up to the computer to check in for their appointments. This was my first time to take them to the dentist as my wife usually drives them. Not knowing the system, I relied on them.

Later today, I’ll go to my doctor’s office, sign in on a clipboard, and patiently waiting in the lobby. At my clinic, we have an EMR with a patient portal, but our patients still check in the old-fashioned way.

In the US we believe in the inherent goodness of technology as an article of faith. If you don’t think that technology will make your life better, you must be old-fashioned and tragically unhip.

In a recent discussion thread, colleagues compared the latest fitness apps for their smart phones and GPS-based devices. I have tried similar devices but have found LCD semiconductor based wrist watches and cycling computers more reliable. While I admit to enjoying my smart phone, tablet, and laptop, we still must channel our inner Luddite by asking: is the technology really improving our lives as much as we think? Are there unintended consequences we will regret in years to come?

On the good side, if my children can check themselves in to their own appointments, why don’t we make this available for all our patients? If my 80-year-old patients can learn to use secure email to communicate with me, why can’t you? If my 50-year-old on Coumadin can check his own INR at home, email me the results, and adjust his medicine based on my emailed response, why don’t more patients adopt this technology?

May The God Of Your Choice Bless You

Christmas has many meanings for me.

Christmas is:

• Writing a thank you note in Spanish to a 89 year old cubana for the kinds gifts she gave me in honor of Cuban Doctor’s Day (Dec 3rd) and connecting her with the Catholic church near my childhood home
• Volunteering for hospital call so my colleagues who celebrate the holiday can be with their families, just as they cover for me on my religious holidays.
•  Seeing a ten year old get presents from the hospital volunteers because an asthma attack made him miss Christmas at his grandparents’ house.
• My children going out for donuts with my father
• Watching my father learn to use an iPad Mini.  I admire a man who earned his engineering degree with a slide rule, owned the first Hewlett Packard electric calculator ($450 in 1970), taught himself to use an IBM XT 30 years ago, and now burns his own CD’s.
• Taking our annual Christmas lights tour.  Who doesn’t like an inflatable Santa outhouse?
• Enjoying Chinese food and a movie with my family
• Remembering the less fortunate among us.  This year we’ll give to organizations that provide health care for homeless and help resettle refugees in our city.  It is not enough to treat them in the hospital; we must do more to help.

“Congress shall make no law respecting an establishment of religion.”

In the words of Kinky Friedman:  ”May the God of your choice bless you.”