Thoughts on Turning 60–What’s with that?

Sixty is a formidable number. Different from 30, 40, 50. One of those “decade” numbers that stops you in your tracks. Fifty was a bit intimidating but ultimately the approach and the finish of 50 turned out not to be a big deal. However, I’ve been thinking about 60 for a year now and I suspect I’m going to continue to ponder it for a while throughout the next several months. It is the top of some distant hill that I’ve reached, huffing and puffing along. Turning to look behind there are so many great memories but looking forward seems mirkier than other hills climbed in the past. Darker and a little frightening.

Why is that? Mortality is closer. Fears of morbidity arise. I’m a little stiffer and a little heavier than I’ve ever been. Getting pounds off is so much harder than it used to be and I’m less willing to put in the work to do so. What’s with that? I’ve always been a very goal-directed individual and now I find myself wanting to sit quietly, enjoy the moments and draw more often than choosing the next thing to accomplish. What’s with that?

I considered getting a master’s in something—Informatics being the most likely candidate. All my peers seem to be doing that—no longer is “just” an MD satisfactory. You need a Master’s in something—an MBA or an MPH (public health) or Informatics. So I did some research on pursuing that. I enjoy learning, why not? Well primarily because I wouldn’t have time to do any of the other things I am enjoying—traveling, drawing, spending time with friends and family. And what would a master’s get me—another frame on the wall and an opportunity to work harder? What’s with that?

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The drive to become something else is gone. Been there, done that–mother, doctor, wife, blogger, geek–check, check, check, check, check. My children are grown and successful, my marriage is happy, my career cemented. After years of ambitious productive activity it dawns on me–finally, I can do what I enjoy doing—drawing, writing, seeing patients, tinkering with Apple products–and saying no to ambition.

 

At 60, I get to choose just being better at the things I do now. I can quit dabbling.

 

And I am so OK with that.

 

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Google Glass in Primary Care

Google Glass is in its infancy, with over 8000 “explorers” who are eager to find compelling uses for it. The concept is cool: A hands-free cell phone that is voice activated. A month ago my healthcare social media friend Kathi Browne, who is a Glass Explorer, proposed driving to Louisville from Knoxville to allow me to play with Glass for two days.

Kathi Browne‘s Google+ site

I was excited to accept her generous offer. She was equally accommodating about spending two days in my home which is presently a construction area with two cats, to which she is allergic. She seemed to tolerate the experience admirably.

As expected with a beta product, we had a few setbacks. We couldn’t tether Glass to my iPhone unless I gave up my grandfathered unlimited data plan. That wasn’t happening. Next we tried using the local network in my office. When that didn’t work we thought we’d found an answer jumping on my MiFi. That was great until Glass went into sleep mode (which is frequent due to a short battery life) which disrupted the MiFi connection and I couldn’t get it back online until the battery was taken out of the unit. It isn’t easy to remove. Finally Kathi just handed me her phone and I stayed live on her account.

The main advantage over a regular smartphone is how surprisingly unobtrusive the device is, both to you and the patients. It’s easy for the wearer to ignore it except when in use. Patients were of three varieties–too polite to ask what was on my head until I brought it up and then not caring, knowing immediately what it was and wanting to play with it, and being unaware of the product but excited to learn about it. No one appeared worried and the first thing I told them on entering the room was that it was not recording.

While it’s easy to understand how surgeons, teaching physicians or ER personnel might use Glass, its implications in the primary care office are less clear. A few thoughts:

  • Glass is much less obtrusive than the laptop I carry or even the chart I used to carry. If I could dictate into the EHR this could enhance communication with patients.
  • Having a projection screen that would show the patient what I was looking at could be used for education, the way I sometimes use my iPad now. For instance, I had a patient with shingles on her back and I could project her rash or a reference rash for comparison. I can do that with my iPad now but that involves carrying an iPad and a laptop. I don’t use the laptop for education because the screen is awful.
  • On the down side, there is no unobtrusive way to Google a question using voice activation. My patients would know exactly how dumb I am. Wait, I already do that with them on the laptop so with Glass I could look cool and dumb.
  • In a rural setting, sending a picture or a video from the exam room to a specialist would be advantageous but no more than telemedicine could do.
  • Calling up an examination video for something I don’t do a lot of, like a specific orthopedic exam, could be helpful but I’m not sure about the patient’s reaction. They usually prefer to think their doctor is well-versed in such things. Back to cool and dumb.
  • It’s quicker to Google with Glass, an advantage over a cell phone.
  • The voice recognition is amazing. Odd names and medical terms were usually nailed on the first try. However, there didn’t seem to be a way to correct recognition mistakes.
  • I suppose patients would get used to it, but would they worry that I was secretly recording them?
  • As Clive Thompson commented in today’s New York Times[1], using Glass is uncomfortable enough that constantly looking at the little screen is not an option. That could improve communicating time instead of the way the EHR takes away from it.
  • How about an app in Glass that would identify a rash within certain parameters of likelihood? That is, a Watson for Glass. This was also suggested by Melissa McCormack of Software Advice in the Profitable Practice blog.
What I enjoyed most was the shear delight of several patients who wore it for a few moments. They were so excited by the device and its possibilities. Whether it will prove of use in the everyday practice of the primary care doctor remains to be seen.

1. Googling Yourself Takes on a Whole New Meaning http://goo.gl/WAAWki

Post was edited 9-4-2013 by request of Ms. McCormack to better describe her blog.

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A * Readable * Usable * Patient Note

It’s not just the clicks. It’s creating a Readable.Usable.Note.[1][2] It is embarrassing to look at a patient chart and read: “Your HDL (good) cholesterol is excellent but your LDL (bad) cholesterol is too high. I would recommend trying to reduce sure fact food intake.” What? Oh, yeah, reduce your fatty food intake. Or worse: “She wanted me to know that she had a laparoscopic hysterectomy and in for reck to me over the summer.” That one took a while to figure out. What I dictated was “she had a laparoscopic hysterectomy and oopherectomy over the summer.” Ouch. I read over my notes before I sign them but between the rush of seeing patients and the problem with editing your own notes within the horrible output that electronic records produce, it’s easy to miss your own mistakes.

The notes are built to maximize the billing that we do. But frankly, even though I revisit a patient’s chart and check their past medical history, update their meds, update their family history, review their social history, etc. IT DOESN’T NEED TO BE REPEATED IN THE NOTE! However, if I don’t rewrite all that, Medicare or the insurance company doesn’t believe I did it and I can’t charge for it. As a consequence everything is repetitive and finding the little gem of information one needs to care for the patient becomes more and more difficult. As anyone who has ever received the reams and reams of paper from an ER with an electronic health record (EHR) that has no discernible font changes or indentation can tell you, it is next to impossible to determine why the patient was there, what treatment they received and what followup they need.

To counteract this I dictate my medical reasoning in the discussion box at the end of the note. Next visit that’s where to look to find the important stuff. Of course this increases the amount of time documenting, taking away more precious moments I have to spend with the patient creating inelegant notes that are one step away from being worthless for subsequent treatment.

What if we could create two notes for every patient. One that went in to the billing records for auditing purposes and one culling the important stuff into a true “patient care note”. Surely there is software that could help us with that.

To quote Dr. Vartabedian: What do you think?

1. We need to reassess the patient note. http://www.kevinmd.com/blog/2013/08/reassess-patient-note.html
2. The doctor will see your medical record now. http://www.slate.com/blogs/future_tense/2013/08/05/study_reveals_doctors_are_spending_even_less_time_with_patients.html

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The Google Pre-consultation

Patients frequently preface a question with “I know doctors hate it when their patients look stuff up on the internet, but…” In typical doctor fashion I interrupt them at this point and say, “No I don’t, I like it when patients do that.” It takes a moment or two for that to take. Then they nod and ask whatever is worrying them that they’ve found on line.

The Google “pre-consultation” is a fact. According to research done by the Pew Research Center, 72% of internet users have searched the internet for health information.[1] Many doctors I know, or at least the ones on social media, will pro-actively ask their patients “what did you read about it online?” This often relieves a couple of anxieties. First, that the doctor will negatively judge the patient for checking on line and secondly, the patient can proceed to ask questions about what is worrying her or him.

So when you come in to see me, instead of the “petit papier” with all your questions, I’ll expect them to be in a list on your smart phone or tablet (the paper is OK too). And if you want to send them in ahead of time, be my guest! Go to RelayHealth.com, register and send me your questions before your appointment. We can save time and cover more ground that way.

Oh, and when you are researching on the web, be careful out there. You can find lots of wrong information, chicanery and just plain bad advice on the internet. Here are my recommended web sites for disease searches:

If you are looking for patients with similar conditions to yours, there are some great patient communities out there as well:

And always, if you think of a question you forgot to ask please contact me through RelayHealth.com.

1. http://www.pewinternet.org/Commentary/2011/November/Pew-Internet-Health.aspx

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Dying With Dignity

She is always put together perfectly and today is no exception.

She’s tells me how she’s giving away her things and I decide against complimenting the beautiful opal she wears, fearful she might hand it over. We’ve been together for six years yet I know so little about her. Her husband is also my patient and has been very ill for several years. Despite his many medical issues he seemed to take care of her so it concerned me that he would die first.

Death decided he wants her instead. He stalks her but she stays gracious, not giving in to despair. She asks me about my daughters, she is honestly curious. She talks about how much her energy has ebbed but she is no longer frustrated by it. She teases her husband a little.

As she leaves she thanks me for taking such good care of her. How can she say that? I’ve failed. Neither I nor the oncologist can stop this inexorable process that is whittling her down to nothing. She hugs me as she leaves and I feel healed. What a startling reversal of roles.

 

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What would you do?

A text lights up my phone late in the evening. It’s from someone who is a patient but we’ve been together for so many years I consider her a friend. She has my phone number from other times she’s needed medical advice. She knows me well enough that she can assume I am adept at texting though we’ve never communicated that way before. The patient is immune deficient and somehow managed to scratch her leg. It didn’t originally look all that bad but in the last hour or two it has become red and swollen around the scratch and she is concerned about cellulitis.

 

There are no Immediate Care Centers open this late on a Sunday night. It is not clear to me from the description, even after speaking with her on the phone, if it is bad enough to need hospitalization. If not, the best care would be to start an antibiotic tonight and check it in the morning. My choices: send her to the ER at the height of flu season (a terrible idea for anyone but especially an immunocompromised individual), have her wait eight hours until morning and I can see the wound, treat it empirically, or have her send me a picture. The picture can’t be in a text because that’s not HIPAA compliant. It also can’t be email because that’s not HIPAA compliant. SKYPE? Maybe but I’m not sure how good the encryption is.
So I sit on my couch and weigh options–all the while thinking, “How did we get in such a quandary, where taking the best care of the patient is not first on my list of considerations? Where common sense is delegated to the back of the bus behind government regulations and insurance rules? And where the technology to make all this simple can’t be utilized to help my patient or me?” Patient portals are great but can she figure out how to load the picture on it? And our portal only accepts up to a 50 MB file. What if it’s larger? Will she know how to reduce the size? Yes, I could do what my 1950’s MD ancestor would do, which is hop in the car and make a house call, but he only saw 12 patients in the office the next day and made relatively leisurely rounds at the hospital. Not the frantic 20+ I’ll see tomorrow, needing all the rest I can get.

What would you do?

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Saying Goodbye

It’s Friday afternoon and I check the day’s schedule. A name jumps out at me and I groan a little and worry–what am I going to say to someone I’ve treated for twenty years, who’s my age and just been admitted to hospice care? If this is goodbye, how do I as a physician, who is more than an acquaintance but not quite a friend, handle this appointment?

All kinds of things go through my head. Do I really want to charge for this? How bad will he look? Can I keep from crying? Is there anything I can do for him anyway? Will I ask the right questions? Will I say the right things?

He comes with a relative. He is living alone but they have found a nursing home that he liked today and he hopes to transition there quickly. He has one sorrow and one fear. He needs to find a home for his dog of 14 years. He shows me a picture of a cute lap dog of some sort. Amazingly, during his last hospital stay he met someone who is willing to take care of the dog. His fear is how breathless he will be near the end. I reassure him that every effort will be made to make him comfortable and he should not suffer.

We talk a little about his parents, with whom he has been estranged for some time. He assures me that he has spoken with them. They are older and have had their own medical challenges. I cannot imagine how they feel. He jokes a little about his relationship with them.

Finally it is time for him to go. He looks tired, but not that ill. He asks me if he should try to eat, he doesn’t have much appetite, and I encourage him to eat whatever he wants. He stands up and gives me a hug, whispering “I love you” in my ear as he does. After reminding me that the phone is a good method of communication, he leaves.

I am lost in thought and emotion but still have two more patients to see. I take a breath, walk into the next room and apologize for my tardiness. It’s probably obvious that I’m upset but the rhythm of seeing patients takes over and somehow, reassures me.

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Physician Patient Communication

All professions need good communication skills. Obviously in healthcare the ability to communicate with patients should rank high in a physician’s list of talents. These days that interaction occurs in a number of ways: face-to-face, direct telephone contact or though a staff member, via emails, patient portals, or even texting. Because the communication is in the arena of medicine, the protection of an individual’s health information is paramount. Enter HIPAA, which is a federally mandated program to ensure patient confidentiality.

The face-to-face form of interaction is the most rewarding because multiple senses are used in the process. First, I listen to the words while hearing the tenor of a patient’s voice; a few octaves higher with anger or fear, deep and gnarly from years of smoking, “push” of speech in an anxious or grandiose individual, or an accent that might be heavy enough for me to wonder if there is a cultural or comprehension problem. Sight gives me other cues; body language–crossed arms, angry face, tearful, an open posture, a resigned facial expression, stiff limbs or back. Sometimes my sight reveals more concrete things–bizarre tattoos, picked at sores, expensive accessories, worn and torn clothing. My nose may be assailed by the scent of the smoker, too much perfume, not enough soap, musty clothing or pleasant shampoo–all of that speaks to me. Finally touch–dry and peeling skin, a mass somewhere it shouldn’t be whose texture may speak to me of reassurance or of terror.

The opposite must be true as well. We speak volumes to our patients without opening our mouths, or despite opening them. The tenor of our voices may be patronizing, authoritative or uncertain. Our faces and body language reveal our thoughts with a roll of the eye, crossed arms, or open facies. We can look professional or casual. Smell can be important–what asthmatic wants to see a physician whose aftershave or perfume is overwhelming? Perhaps touch is the most expressive. Early on I learned that even when I don’t need to, patients expect to have a “laying on of hands” in some fashion. They may trust you less if you haven’t at least looked in an ear or listened to a heart.

The hardest communication for me is remembering to finish with eye contact and a plan: “We’ll contact you with the lab results”, “I will have our referral clerk Megan call you” or just “Have a great holiday” instead of rushing out to see the next patient. But the best visits include a hand shake or on a good day, a hug.

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Nostalgia and the Local Pharmacy

Recently a patient in our practice requested his Plavix renewal from a 90-day mail order pharmacy. When the “estimated” price came to $585 he decided to stop taking his cardiac medication. In exploring his insurance website I found that the actual cost would only be $200. In addition the company had a “Do Not Substitute” order on the prescription (something his cardiologist denies writing) and the cost of the generic is $28.59. Wow–the drug he almost quit taking because of the website price estimation was, in reality, 96% cheaper than originally thought.

Contrast this with a phone call I received recently from Wish’s Drugs, a local pharmacy here in Louisville. The pharmacist paged me on a Saturday morning regarding a patient’s medication. I called the pharmacy and the pharmacist answered the phone(!). He suggested that my patient get a similar drug for half the cost of what I prescribed and asked if that would be OK. When I hung up the phone it struck me how pleasant that had been. Not just that the pharmacist was looking out for the interest of our mutual patient, but the call from start to finish–a real person answered the phone and it was the person I needed to speak to. Not only did I not push three different buttons and listen to three different voice messages along with a sales pitch for flu shots, but I immediately spoke to a person knowledgable and caring about my patient and her medical condition. Contrast THAT with the 90 day site where the patient, unknowing, was supposed to go back to his insurance web site, check the price of his medication and THEN go back to the pharmacy web site and decide that he could actually afford the medication because the real price to him would (only) be $200. No friendly pharmacist in that other state willing to make a phone call and get his patient a better deal on his medicine.

It’s not that I think mail order pharmacies are inherently evil, it’s just that the service component is reduced to the patient. However, interestingly enough, the two studies I read regarding mail-order vs. local pharmacies [1,2] found patients are more compliant when they use mail order. Perhaps this is because when medicines are delivered right to the patient’s door it reduces extra steps, making it easier for patients to remember and obtain their drugs?

In my experience patients enjoy the convenience and economy of getting 90 days worth of medication delivered to their mailbox but when there is a problem they are quickly frustrated by the difficulty of explaining to someone in another state what their needs are. As a physician, I am annoyed with the same difficulties, plus the frequent faxes asking about changing patients to a “cost-savings” alternative, something the patient is usually unaware of so we have to call him/her, ask their permission, explain what the change entails, etc. Just one more thing in my over-extended day that I don’t have time for.

Mail order pharmacies are not going away and local pharmacies where the pharmacist knows the patient and cares for him/her in a more intimate way are disappearing into distant, nostalgic memories. Given the studies quoted here, maybe that’s a good thing. Does my desire for it to be different, for every patient to have the individual attention of the good pharmacist at Wish’s make me out-dated?
1. Schmittdiel JA. The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users.J Gen Intern Med. 2011 Dec;26(12):1396-402. Epub 2011 Jul 20
2. Duru OK. Mail-order pharmacy use and adherence to diabetes-related medications. Am J Manag Care. 2010 Jan;16(1):33-40

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Continuous Partial Attention

Continuous Partial Attention–while reading a blog post this morning that term jumped out at me. The last few weeks of juggling a laptop while talking with patients have made it obvious how easily distraction can take away from the doctor-patient interaction. Right now the computer interferes with my ability to give complete attention to my patients’ stories. Did I have the same problem way back in third year medical school when my first ? I don’t recall taking pen and paper in patient rooms back then, but do remember trying to juggle all the things I needed to ask–chief complaint, history of the present illness, past medical history, family history, medications. Then there were things that needed to be looked at–vital signs, physical exam, nurses notes, ER notes–followed by the assessment and plan. These were all foreign terms and workflows to me. Was I intensely listening to the patient then or more likely, worrying about what I’d forgotten to ask, or do, or write down or study? My earliest instance of Continuous Partial Attention (let’s call it CPA so I don’t have to keep writing that term) with patient care must have begun then.

Early in practice I found ways to control the CPA triggers–a snack of nuts or fruit around 10 am to keep my sugar from dropping out; keeping the phone on silent (there are medical programs on it that I use routinely so I can’t leave it on my desk); using meditation techniques to bring me back to the patient if I find my brain wondering off; exercising and sleeping routinely so I have enough energy for my day.

It’s not just doctors who have the CPA issue. Many times I recognize the same thing going on with the patient–the gentleman this morning who needed to be at work and was only half-listening to my advice regarding his medication and exercise compliance, the woman who thought bringing three kids to her physical was a good idea, the patient who was recently diagnosed with cancer and nearly oblivious to any other health concerns, or the husband with a terminally-ill wife paying little attention to his own health (or me).

Surely the CPA will fade away as I find a path to making the electronic record become as unobtrusive as the paper one once was (hint to IT dept–smaller tablets would help with this…just sayin’). In the meantime, one of the more important lessons on the EHR learning curve is finding a way to move the laptop out of the center of the conversation–figuratively and literally.

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