Time Thieves

man-95720_640As I look to the end of my sixth decade, time is more precious than ever. Having a mother, maternal uncle and maternal grandmother with late onset dementias forces the realization that not only is my time limited on this earth, but my intellect as well. How can I squeeze the most out of the moments? Like most physicians, in addition to my career in medicine there are life enhancing avocations I enjoy such as perfecting my French language skills and improving my sketch art that has joyfully crept into my journals. To those ends I listen to Johan, the creator of Français Authentique and began an online course with Sketchbook Skool. Understanding that exercise is the single most important way to ward off memory loss, time must be found to keep moving. Important relationships are built and remain strong with convivial meals and moments together.

My home

My home

Age forces the recognition that time is the true currency of our lives. When people waste it for you, it is frustrating and angst producing. One of the underlying tragedies of physicians’ daily lives, especially in primary care, is the theft of our time, stolen away by the health care system. We entered medicine expecting to spend our lives caring for patients by spending time with them and researching best practices, not being glorified data-entry clerks and insurance company proxies. The amount of time that governmental regulations, employers, compliance directed mandates, insurance company prior authorizations and administrator volume expectations take from us is demoralizing. I want that time back to spend with my patients, my family, and myself.

After more than two years of listening to the innovative suggestions of individuals who care about creative disruption in medicine, I firmly believe that this time theft can only be stopped when our patients come first–before profits, shareholders, meetings, EHRs, or any other thing on the long list of healthcare “needs” that may serve but should not be served. When patient needs are met, so will my own.

 

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A New Form of Insurance Denial of Coverage

Doctors hate the first of the year. Besides the cold weather, there are a myriad of reasons for that. In private practice one typically goes without a paycheck for two months. That’s a bit of a stressor. Increasingly more frustrating every year is all the changes from pharmacy benefit managers. Finally the physician finds the right combination of antihypertensive drugs, blood pressure is well controlled, life is good! Then the dreaded letter from the pharmacy benefits company arrives, stating that Exforge (or Metoprolol ER or…) is not covered under the patient’s insurance plan. For some reason this year it is extended release medications on seniors’  plans that are not covered, generic no less. The elderly patient, who may be challenged in regard to compliance, now must take his or her medicine two or three times a day instead of just once. No problem, I’m sure the insurance company will send out a nurse to make certain that the patient takes all medications properly. No wait, the nurse is busy sending the patient to the emergency room for a hangnail because she’s worried that pain in the left arm is cardiac. But I digress.

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Copy from denial letter

This week a new level of denial has been breached. Now medications are deemed “experimental”. Somehow pharmacy benefit managers have confused off-label with experimental. Why would they do that? Simple: off-label use isn’t excluded on a patient’s insurance but experimental is. In one particular case my patient has a progressive debilitating neurologic disease that is causing pain. The patient already has issues with constipation due to an inability to be mobile so narcotics are not a good option, not to mention that he does not want to be dependent on narcotics for this pain. Amazingly this “experimental” medication was doing a  good job of managing the pain for the last year or so.

Not only is the denial of this medication arbitrary and cruel, it is unethical. Off label use of medications is an accepted and necessary treatment choice, particularly with pain, where avoiding narcotics is important for patient quality-of-life and many off-label use of medications is well-studied but not in the drug’s package insert since the medication has long been generic. In the meantime the patient asks ME how to deal with the issue. I recommended that they call their insurance company to begin an appeal process. Frankly a good lawyer might be a good idea as well.

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Wellbeing Starts in the C-Suite

Recently an employee from a nationally known firm based in my city came in for his wellness “physical”. He works 16-hour days from home, rarely leaving his computer. He is a poster-child of poor lifestyle decisions in regard to wellness and wellbeing; in vernacular terms “a heart attack waiting to happen”. Wellness programs are quite the rage these days. I fill out forms on a daily basis documenting patients’ blood pressures, cholesterol values, waist measurement, etc. Employers are hoping to motivate their employees to be healthier.

Rand and Pepsi Company recently published their report of how well this program worked for Pepsico. It contains interesting data. While disease management assistance for employees was successful, the return on investment for the lifestyle management, which includes those yearly physicals and lab draws, was less so. The report created a bit of a stir. I suggest following Khanna On Health Blog regarding wellness vendors and the lack of data to support much of the recommendations that seem to be taken as facts judging by the forms I fill out routinely.

Meanwhile, back to my patient. I don’t care how much you love your job or need your job, working 16 hours a day is not a healthy way to live. As a family practice physician, I would love to make editorial comments on the forms that I’m filling out but there is no option for that. To be fair, despite encouragement by their employers to be healthier, employees may refuse to take the bait. Without knowing the specifics of his company’s wellness policies, or how well his supervisor adheres to them, it’s impossible to know how much is the fault of the company and how much is about the individual.

Being involved in my own company’s Wellness/Wellbeing Committee, what struck me is how creating a culture of wellness must start by changing any ideas of enforcement.  “Mandatory engagement” in such programs is an oxymoron but encouraging a culture of self-care makes sense. There are so many things that don’t cost a lot of money that can be the start of culture change: different food and drink options in the cafeteria, access to better choices in vending machines, posting nutritional content of all foods in the cafeteria, putting up signs that encourage stair use, self-tracking contests, employee workout sessions (at convenient times for them), a farmer’s market in the parking lot with discounts supported by the corporation. We need to start from the top—the C-suits and the doctors making wellbeing and self-care a priority. Watching both those populations work 60 hours weeks is not a way to exemplify healthy behavior.

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Thoughts on a Bad Review

IMG_1474It’s a Monday. Drinking my coffee and in my email is the weekly update from mdwebpro.com. There is a new listing on one of the MD rating sites. I groan inwardly. By working hard to maintain patient-physician partnerships it’s easy to fall into the trap of believing it’s possible to please everyone. When staying abreast of new developments in one’s profession and practicing evidence-based medicine where it is appropriate, one thinks the bases are covered. Staying on time in order to avoid wasting my patients’ time is a priority. Encouraging patients to use exercise and dietary changes to control and reduce the development of life-threatening illnesses isn’t what every patient wants to hear though. And let’s face it, I am human. Sometimes when I see patients, it’s with exhaustion. Sometimes it’s necessary for me to get to a meeting or go home in time to take care of something. None-the-less I try very hard not to allow my impatience to show in the exam room, that’s unprofessional. But this morning there is the knowledge that patients generally don’t post online reviews unless they are unhappy gnawing in my brain. Sometimes I ask patients to review us, but I haven’t done that recently. Indeed the review is terrible. I recognize the name of the individual who posted it and am somewhat surprised. They’ve  been a patient for 10 years. It is a sad commentary on our medical relationship that after knowing someone for 10 years there isn’t enough of a comfort level to yelp (1)bring concerns to me instead of writing it in public. I look at the interaction in the EHR. Nothing jumps out at me, it was not a day I was rushed, there was discussion about an unexpected medication cost. What am I missing? How did the interaction go badly and I missed it? My office manager will reach out to the patient and ask questions. Hopefully this will improve our care (the staff was rude too, according to the review, so that may have set the stage for my failure).

Intellectually I know that the great majority of my patients are satisfied with my care (we’ve done a variety of surveys that tell me that). As written above, it’s important to me to deliver competent care that includes partnering with patients to ensure that their questions and needs are addressed. I think I’m doing the best that is humanly possible and recognize that the human element ensures that I will sometimes fail—despite knowing all this my sleep will be interrupted tonight.

And I guess that’s OK. That’s how we improve our skills.

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Contemplating the Last Third of One’s Life

Sleepily perusing a blog post I read, “Think about when you’ve been happiest in your life”. The post was about finding happiness and hit close to home as I’ve struggled with how busy my life has become and wondered how satisfied I am in it.

When I am most frenetic and busy, it is not when I’m most happy.  As an introvert who has to spend time alone to recharge, I often come home spent. Because of that, I don’t exercise like I should. Intellectually I understand that if I exercised more, my energy levels would recharge better.

Between the morning coffee and my thoughts, my brain awakens and uses the moment as a stepping stone to consider: “what do you want with the last third of your life, what is it that makes you most satisfied?”

  • Connecting with a patient and feeling like we are making progress together.
  • Spending a few hours with friends or family.
  • Seeing ongoing improvements in my ability to draw.
  • Learning something new.
  • The feeling I get AFTER I exercise (not during as I dislike it).

Ultimately the question becomes, how does one craft life to increase those moments that give you real joy. After 58 years on this earth I should be able to do that, shouldn’t I?

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Even Specialists Need to be Primary Care Doctors on Occasion

My husband received a phone call from a friend in a panic. She was in a urologist’s waiting room with her son. The son is his early 20’s and previously healthy, was seen in the emergency room the night before with severe flank pain. The ER physician originally thought the young man had a kidney stone although there was no blood in his urine (a classic sign of a kidney stone). While in the ER he develops numbness in his groin and difficulty standing on his right leg. He is also having difficulty urinating. After the family relates this change in condition and since the kidney cat scan(CT) is negative, a CT of the head is performed. It is also negative. At this point the ER doctor shrugs about the difficulty standing and the young emergencyman is given an appointment for a urologist the next day. In hearing the story my husband and I agree—the problem is in the spine, not his urinary tract but the urologist is in the best position to get him further assistance from the appropriate doctor. I reassure the mother. Fifteen minutes later there is another phone call from her. They are in the car (15 minutes later?) with a prescription for his prostate and an admonishment to call their primary care doctor to get the young man in to a neurosurgeon. It is at this point that I lose it. Maybe things have changed since I (and this urologist) went to medical school, but difficulty urinating or defecating from a neurologic problem was taught as a neurologic urgency. The specialist has now put yet another physician in the way of this young man getting an appropriate diagnosis with treatment.

I’ve already texted the patient’s symptoms to my first year medical student daughter who quickly makes the diagnosis of caudal equina syndrome. I’m amazed, not that my daughter made the diagnosis, but that the urologist couldn’t or wouldn’t. I am furious that the patient is made to see another unnecessary physician and that the urologist is unable or unwilling to call another doctor. Are we really that busy? Worried about the young man’s inability to void, I make a quick phone call to a neurosurgeon who agrees to see him within the next hour. The young man receives his MRI in the morning and a preliminary diagnosis of cauda equina syndrome is made. Within 24 hours he is getting the treatment he needs.

This is a classic example of how fragmented our healthcare system has become, when physicians can’t think beyond the silo specialties they’ve created. Sometimes I have to think like a specialist and sometimes the specialist has to think like a primary care doc. That’s why we all attended four years of medical school and studied other organ systems besides the one we might primarily treat. And at all times, we need to think of the patient and the best care for him, not the care most convenient for the physician.

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Patient Advocacy

(This post was originally posted on the Baptist Health Kentucky Blog)

In online healthcare forums, community boardrooms and hospital C-suites these days the conversation is centered on “patient engagement”. The problem is, our medical system is not set up for engaging patients and if you have the misfortune of needing treatment, ofttimes it is all about disease management as opposed to maintenance of health. There is even a Patient Advocate medical career, someone who helps patients with insurance billing, explaining difficult and complicated medical options for treatment, tracking medical records,etc. Fact is, the best patient advocate is the patient (or their immediate caregiver) themselves. But how does one approach a system with no cost transparency, poor internet accessibility of providers and medical records, hospitals more concerned about provider convenience or facility appearance than the effect their care has on patients. Frankly, it’s a mess. Things are changing for the better but it is a long time coming.

Screenshot 2014-02-02 12.42.34The redesign of care will occur as more patients push the system for it. Becoming your own advocate (or your family member’s advocate) is paramount to excellent care. There are many patient advocacy websites assisting individuals in this new roll–The Society for Participatory Medicine*, Inspire.com* and Healthunlocked.com* to name just a few. However, to start, you have to accept the idea that YOU are in charge of your health.

Personal patient advocacy begins by PUTTing yourself first:

  • Partner
  • Understand
  • Try
  • Track

Partnership begins the process of advocacy. It is foremost that the individuals you trust your health with are willing to be partners with you in the journey. You should never feel threatened or dismissed by a physician when you present your research during an office visit. You should expect to be questioned about where you found any medical information. There is much rumor and poorly researched, non-evidenced based poppycock in the media. In my practice I expect patients to understand as much about their disease states or their health as they are capable of. I expect them to bring questions from reputable sites like MayoClinic.com  Cleveland Clinic or specialty sites like Inspire.com. People who passively accept my recommendations without understanding are not engaged and are less likely to live healthy lives.

Understanding means taking the time to find resources necessary to grasp how to be as healthy as possible wherever you are in life. If you have diabetes you should be an expert in the disease. There should be no one more involved in your healthcare than you are. In this day and age of information access, there is no excuse for patients not to deeply understand their own health issues.
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Try to make lifestyle changes, using the understanding you have developed from research and the recommendations you have agreed upon with your partnering physician. This is not saying “OK I’ll lose weight” in the exam room then promptly forgetting about it until the next visit because you have no skin in the game. Try  involves active movement toward healthy goals, putting systems in place that drive change whether that is utilizing apps like LoseIt  or MyFitnessPal, joining a gym or putting aside time to plan meals every week. In the context of illness, it may mean monitoring your blood pressure and graphing it using online tools or paper, keeping a food diary or exercise journal. Which leads us to Tracking.
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Tracking is multilevel. There is a huge self-tracking movement today utilizing tools like the Fitbit  nd Nike’s Fuelband  Diabetics track carb intake or blood sugar levels using smartphone apps. A pen and paper work just as well. But the other tracking imperative is keeping a Personal Health Record so that YOU know when your last tetanus shot was, what surgeries you’ve had and why you had them and most importantly, what medicines and supplements you take, their doses, and what you are taking them for.

Together we can build a healthcare system that works for every patient, every time. And this will happen when patients are PUTTing themselves first and insisting that providers, physicians, hospitals, ERs, etc. do the same.

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How Will You Define Yourself?

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Dr. Murphy recently wrote this article for the GLMS President’s e-Voice. I liked it so well I requested permission to re-post it. Dr. Murphy is President of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, Assistant Clinical Professor at the University of Louisville School of Medicine, and serves on the board of the International Association for Pain and Chemical Dependency. He blogs at Confluential Truth.

How Will You Define Yourself?

I am a doctor, but a doctor is not what I am.

- penned in my spiral notebook, circa May 1985

Despite a medical career’s insatiable hunger for attention, my chosen path does not define me, but it has provided glimpses of who I am.

For example, during my internship at Balboa Naval Hospital I was occasionally assigned to draw blood for labs. One such afternoon, my blood-rounding brought me to a diminutive, bent, hairless, elderly man sitting quietly in his bed on the open bay ward. After a brief exchange of pleasantries, he offered an atrophied left upper extremity for blood acquisition. Upon completion he warmly thanked me and even complimented me on being a “good needle-sticker.”

Later, I learned that the diminutive octogenarian was a retired two-star admiral who was admitted to this ward because he had refused any special treatment in deference to his lofty rank. If a no-privacy open bay ward was good enough for his sickly comrades, it was good enough for him too.

Besides an amazing lesson in leadership, my encounter with the admiral taught me that, regardless of how powerful, wealthy, famous, weak, poor, or humble one might be, we each travel a path to the same destination.  In days past, simply rumor that he was onboard ship would have created an air of anxious hyper-attention. But in his life’s final chapter he was humbly grateful that the apprentice doctor sent to draw his blood didn’t botch the needle stick.

What defined this person: his accomplishments? his failures? his youthful conquests? his final chapter?

Are we defined by life’s moments? Perhaps the sum of life’s moments?  Is one’s present moment – or even one’s final moment – life’s truest summation?

I have my doubts.

Despite our yearnings to the contrary, our present evaporates and becomes our past – no different than a dream. And we are not defined by our dreams – nor our past.

So, if not the past, are we defined by the present?

I have more doubts.

The brain does not work at the speed of light – not even close. In fact, every conscious thought results from a chain of chemical reactions initiated by sensory stimuli. Therefore, awareness of a moment in time can only occur after the stimulating event.  Awareness of the present is really just a memory.

So does the present even exist? Yes it does; in theory (i.e. the theoretical present). But I can’t prove it.

During a deposition I gave years ago, with the lawyer’s argument hinging upon proving the medical record to be comprehensive, she asked, “Isn’t it true that if it wasn’t documented, it didn’t happen?”

My response was, “If it wasn’t documented it simply means it wasn’t documented.”

I still stand by that.

Like the medical record, your perception of the present moment is legitimate documentation that your present moment exists.  But that’s all it is – documentation. Not proof.  Again, awareness of the present is really just a memory.

I have lots of memories – especially of my patients. And being a physician to a significant number of elderly patients, I deal with loss on a regular basis. While it is never easy to say good-bye, I usually find solace in knowing that I tried to provide comfort in a patient’s latter steps along life’s journey.

Obituaries, written to summarize these journeys, usually pique my curiosity.  Some are just a few lines. Some are novellas. Some offer comparison photos of the youthful and the elderly visage.  Regardless of length, obituaries cannot define a life.

For example, by the time you read my article, the iconic Nelson Mandela will have been laid to rest – after perhaps the most extensive obituary in the history of the media – and still the world will have only gotten an infinitesimal account of his life.  At the end of it all, will we have defined the man?

Not a chance.

About a year ago, I read the obituary of a local doctor, P. Patrick Hess, M.D. He was eloquently described as: “A dedicated pediatrician, gifted artist, collector of oddities, beloved husband, father, grandfather, voracious reader, with a quick wit – Patrick Hess had an obsessive curiosity and a driving desire to unravel the mysteries of the world.”  It went on to mention his family, accomplishments, education, and professional endeavors – all lovely. But I felt there was more to this man’s life. Then I read his poem and felt something had indeed been defined.

 All physicians are artists, 

not always in disguise. 

Our way of looking at a patient, 

allowing our minds to roam all over those perceptions of our previous life,

often forgotten, 

to scan these memories and pull something from our unconscious mind – all with the purpose of creating something.  

Something to help the patient.

This creation is, 

itself, 

a work of art.

Every imperceptible moment that passes is not only a new reality; it is rebirth, renewal, and redefinition.  Therefore, like the theoretical present, we can only be theoretically defined.

How will I define myself? I guess this will have to do:

 I am a doctor, but a doctor is not what I am.

- circa January 2014

How will you define yourself?

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Physician Productivity

Maybe it’s my German ancestry that makes me enjoy reading productivity blogs. My favorite is Asian Efficiency but there are others that cross my blogging path. Today I came across this article: Why Your Brain Can’t Handle an All-Day Schedule.

ScheduleThis is not the first time that I’ve read about loss of productivity in environments where people sit in front of a computer all day. But it lead me to thinking about physicians who practice in present day medical office environments where the pressure of productivity is all-encompassing. Even though my schedule is not nearly as demanding as many doctors, on those days where I see more than 18 patients I realize that it is not only my intellectual capacity that plummets, but more importantly, my empathy quotient takes a nose dive. Somewhere around 4 pm, or #17, I am pushing away the weight of all the unfinished tasks, unfilled prescriptions and forms sitting on my desk as I try to listen to a patient problem. Couple this with the continual interruptions while trying to finish notes and it becomes obvious why physicians lack creativity if they remain in the typical constraints of a normal medical office.

Over the last several years primary care physicians have been pushed to see more patients, adopt new skills, like EHR, with steep learning curves while keeping up productivity-an oxymoron if one ever existed. This while we accept less pay, keep up with continuing educational needs and remain supportive to spouses, children and often elderly parents. If you add up the hours involved in just doing the above there is little space for exercise, reading, mediation or any other “leisure” activities that give life deeper meaning.

It is little wonder the creative element is lost on doctors.

Let’s hope new models of reimbursement, EHR’s that truly help us take care of our patients, Medical Social Media, improving patient advocacy and better models of care give physicians back some time–and with it, the creative art of medicine.

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New Year Thoughts

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Today, as my desk was moved to a new location more conducive to working, I reflected on 2013. It was one of the busiest, most productive years of my life. There were engaging, talented, passionate people in medicine both on-line and IRL (in real life) that entered my life. Traveling to new places, new friends were made. I worked hard to help my system implement and improve a new EHR (Electronic Health Record). There were about 40 new blog posts written, though not nearly as many as I intended. This new website was created by a talented webmaster. Returning to meditation after a many years absence was fruitful. Omnifocus and Evernote became indispensable productivity tools in my life. I also gained ten pounds, reduced my exercise schedule, finished only a handful of books and struggled to deal with my aging mother.

As I look to 2014 with the wisdom of this past year, I resolve to be more mindful and less busy, putting people and relationships before the rush of goal-setting.  Last year often consisted of feeling pressured and incapable; a “biting of more than you can chew” mindset. There were a tremendous number of things learned and accomplished but at a loss. The best news? I’m still young enough to learn. Hopefully that won’t change. But the pace was uncomfortable and took away from the joy of the experience.

Here’s to a slower, more healthful 2014.

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