Scrolling through my morning feed I happened upon this article about a physician’s suicide: Doctor’s Death an “inconvenience”for patients. Suicide has become an epidemic among physicians. Blog posts are rampant regarding this fact and most suspect that the loss of respect and control physicians have experienced in their careers over the last thirty years contributes mightily to the despair of practice.[1,2,3,4]
The callousness apparent in the article reminded me of less horrendous, but similar instances in my own practice and stories from other doctors who have taken vacation or had to reschedule patients due to unforeseen circumstances. I have been upbraided by patients who wanted to know why I had the audacity to spend time with my family or take a personal day when they needed to see me. This is amplified by my new contract which features “allowed time off” instead of “paid time off”. Not only do patients not value the time I need to replenish, but my system punishes me for doing so. If I never take time off, then I make more money for them and me. The importance of play in innovative thinking and better patient care is forgotten in the greed of corporate money-making.
As my daughter enters the arena of healthcare as a third year medical student, I hope the joy in patient care outweighs the sometimes callousness of corporate and patient expectations.
Yesterday my feed sent me an interesting article on the iMed Apps website. The Slideshare below by David Sobel, Director of Patient Education and Health Promotion for The Permanente Medical Group and Kaiser Permanente Northern California, is intriguing. Looking through the slides, they resonated in me. Burnout has crept back into my daily existence and some days it’s as if I’m fighting it tooth and nail, yet not making much headway. The slides are worthwhile to see for patients and doctors alike, both searching for the motivation to make lives better–our own and the patients that we care for.
My LinkedIn update this week referenced a term I recently became acquainted with when it was used by an administrator in my system. It seemed vaguely offensive at the time but I couldn’t quite get my head around it to understand why. It’s called leakage. When this article, “How to reduce patient referral leakage” popped into my inbox, it hit me–is this going to be one more set of numbers administrators can threaten me with? I understand this is a term used in other industries to refer to the consumers they are losing to competitors and I’m fine with that. However, what does leakage mean to a doctor? It’s what aging bladders do. It’s what comes out of an infected wound sometimes, or an imperforate anus. When doctors use the term leakage it is not a pleasant visual. Maybe a tube is blocked. An organ is swollen. The idea that my patients are being referred to in this way is offensive. I’d like to do a study with my patients. “Tell me, how do you like being referred to as leakage if you go to another healthcare system or an independent imaging facility for your healthcare needs?” Somehow, I suspect I already know the answer to that question.
The way we use words is important. Leakage is simply not an appropriate term to use in healthcare. If I didn’t have faith that my system employs some of the best doctors around and takes extraordinary care of patients both inpatient and outpatient, I wouldn’t be working for it. Unless my patients request otherwise, and they seldom do because they trust me and they trust my system, they are referred within. But how much trust would they continue to have in me if they knew I was being pressured to refer in-system? Let’s stop talking about leakage and instead attract the best doctors to take care of our patients because they deserve it. Let’s make our system one where the best doctors want to come and know their patients will be well cared for. Let’s put our patients first and they will continue to come back to us. Let’s be careful with our terminology. Just because other industries use a term that does not mean it is appropriate to use it in healthcare.
When the chair of the board brings his daughter to me and she needs to see a cardiologist do you think he’s going to want me to choose the physician she sees based on who employs her? I suspect not. And next time he or anyone else uses that term around me, be prepared for an earful. My patients are not leakage. You will not refer to them as such in my presence.
My daughter recently introduced me to a friend of hers via email. She is a newly minted fourth-year medical student who asked me the following question:
“I would love to hear your thoughts about the future of primary care and what it is like to work as a family medicine doctor in Louisville.”
To start, I’d encourage you to read this recently published New York Times review of the state of primary care. If you began in practice today you would quickly find yourself with more patients than you can adequately care for having just left residency and not expecting to see 25-30 patients daily. In Louisville, you will probably be employed by one of three healthcare systems. All of them have compensation based on patient volume and RVUs–I hope someone has showed you what RVUs are but I bet they haven’t. Relative Value Units are supposed to measure the “time, skill, training and intensity” of patient care and compensate accordingly. Unfortunately they are heavily skewed toward proceduralists. As Dr. John Mandrola, a Louisville interventional cardiologist, observes in his excellent post Thirty Dollars…Really?, a doctor is paid a lot more to do a coronary catheterization than to talk about the causes behind coronary artery disease. To understand a little more why the RVU is skewed that way, here is an excellent post on the Kevin MD blog that summarizes it nicely: The Relative Value of How Physicians are Paid Needs to Change. So in today’s environment you need to see more patients than you are comfortable with, spend less time than you deem adequate with them which will promote pill-pushing over explanations. This will mean your risk of burnout will be significant. It is estimated that 43% of Family Practice physicians are burnt out according to a Medscape survey done in 2013.
There is some good news. Value-based care, which bases compensation on how well you take care of patients rather than the number of patients that you see, is coming. In our corporation, systems are being put in place that will help primary care doctors take quality care of their patients and compensate those that do it well better than the ones that don’t. Of course how one is measured is controversial as evidenced by this NEJM article from November: Grading a Physician’s Value. And data can’t be gathered without an integrated EHR (Electronic Health Record) and those are far from prime time. Being a digital native, you’ve likely already noticed that EHR software on your rotations is not up to the gaming software standards you are used to.
Social Media, regardless of what city you ultimately practice in, will be the best means of keeping up with the ever-changing landscape of medical advances, political hot potatoes and healthcare tech so if are not following healthcare thought leaders already on Twitter I’d advise you to start that today. Begin with Primary Care Progress (@PCProgress), Berci Mesko (@Berci), Mike Sevilla (@DrMikeSevilla), John Mandrola (@drjohnmd), Kevin Pho (kevinmd), the Society for Participatory Medicine (@s4pm) and me (@docnieder), of course. If you haven’t found ZDoggMD, that’s another must.
Primary Care is alive and, if not well, at least no sicker than the rest of healthcare in the world but I see better things on the horizon. If I were fresh out of residency today I would get my feet wet as an employed physician for a couple of years, making sure your non-compete clause does not include going into private practice but only prevents you from moving to a different healthcare system across the street. Then I’d look long and hard at the DPC movement (Direct Patient Care) and make that my goal. Taking care of patients in an atmosphere that values the doctor-patient relationship above all other business needs is what we go into medicine to do. Physicians in DPC are happier and so are their patients. While it remains a patient care area where it is difficult for lower income patients to access, this may change as this successful way of caring for patients brings down costs and increases quality. I believe that government entities will find ways of incorporating this model into their systems. The DPC model can be affordable for people who can’t afford health insurance but still make a modest living, giving them an option for excellent healthcare at low costs. For now, a physician can use the time generated by working in an upbeat and efficient model to volunteer at community health clinics like theFamily Community Clinic offered by St. Joe’s on East Washington St. in Louisville.
RVU BASED PHYSICIAN COMPENSATION AND PRODUCTIVITY. Merritt Hawkins. http://www.merritthawkins.com/pdf/mharvuword.pdf
Lifestyle and Burnout: A Bad Marriage. Peckham, Carol. Medscape.com. 3/27/2013. http://www.medscape.com/viewarticle/781161
No argument that EHRs began as billing platforms, though I will argue that they work just as poorly with charging as they do for communicating patients’ stories or making better decisions in patient care. After two years our EHR still isn’t used for billing and even if it were, since it has no Natural Language Processing capabilities, the doctor would have to manually enter the correct CPT code.
My rant today is a brief one about how physicians document in an ambulatory EHR. On paper, we documented the patient’s story, any pertinent medical history and/or family history, the physical exam, our assessment and the plan (better known as a SOAP note). This was a short, succinct and usable communication device (assuming you could read the doctor’s handwriting). Today’s physicians, in the hopes of better compensation, pull in every possible bit of information into the note including their great great great grandmother’s penchant for getting hangnails. OK, that’s hyperbole, but it is almost that bad. And then complain that the EHR is a terrible way to communicate and that everyone else’s notes are too long.
Having been the “champion” for the EHR in our system I have a request to make — Hide, or have your assistant hide, all that past medical history. You didn’t put it in your paper note and IT DOESN’T NEED TO BE IN YOUR ELECTRONIC NOTE EITHER. If it’s a matter of training or you don’t know how to take it out, please ask your friendly IT trainer and they will gladly help you.
As 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.
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.
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 man 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.
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,
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,
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:
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.
This 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.
The Greater Louisville Medical Society (GLMS) hosts an annual “Wear the White Coat” opportunity for leaders in the Louisville community to spend a day with a physician and get a first-hand look at what we do. When GLMS president Dr. James “Pat” Murphy put a direct plea into my inbox it seemed easy to volunteer.
The program began with a breakfast get-together to meet our shadows. Mine was London Roth, an enthusiastic Human Capital Consultant executive with Humana. It took me a while to understand what her job is but both of us are avid social media advocates so it was a match made in heaven. On a Monday morning London joined me for five hours during which most of my patients allowed her to accompany me in the exam room. She listened to their medical issues and participated, with the patient’s permission, when they had questions of her. She was observant, interested and insightful. She was indulgent as I ranted about issues with her company, as well as other payors. She asked lots of questions.
Kathy & London Selfie
She commented on the awkwardness of our EHR system. She saw first-hand that, even if it is well-intentioned by the insurance company, sending over-worked clinicians patient information of who has not had colonoscopies, mammograms, pap smears, etc. are next to useless. Who in the office has time to work the data, especially if it is not as accurate as the insurance company believes? London also listened to patient stories about how her company’s HR policies affect employees’ ability to care for themselves and their families.
We met again at a dinner organized for the group where each “shadow” related their experience. State politicians spoke about better understanding when legislature affects physicians’ ability to practice. Business leaders talked about how seeing the effects of poor health habits reenforced the need for encouraging their employees to have healthier lifestyles. Community leaders saw how patient support systems (or lack thereof) can determine the success of patient care plans.
Personally, London gave me two gifts: she ended her comments with how well I knew about the little things that were important to my patients, the human connection that makes for a better patient-doctor relationship. And she designed the best iPhone case ever, a gift to me illustrating one of my frequent questions to patients:
Programs like this give IRL* examples of how physicians and patients are affected by the decisions of community leaders and what they can do to impact change in their companies and legislative bodies. As Dr. Murphy said “when you wear the white coat, it becomes part of you forever”.
*IRL = In Real Life a frequent expression used in Social Media. http://www.urbandictionary.com/define.php?term=IRL (caution, this link contains foul language).