The Patient and the Chocolate

Having just spent the last 10 minutes giving my patient a very hard time about his increased girth and ongoing weight gain, I sighed, stood up and indicated that the visit was over. As I walked to the door he said “Just a minute Dr. Nieder. I have something for you”. He reached in his pocket and pulled, with just a little difficulty, a tin of Godiva chocolates out of it.

“Happy Easter Dr. Nieder.”

I was startled and a little speechless. I stammered a thank you, then reminded him that he needed to come back again in three months instead of the usual six because his numbers, both blood pressure and lab work, were starting to rise. I walked back to my office, sat the gift in the middle of my desk and contemplated it. He had to have known that I’d be frustrated that not only had he made no progress on his weight loss but had picked up a few pounds. It reminded me of an apple given to a teacher. A sweet thank you for my efforts. But I don’t feel deserving–I can’t find the right words to say to motivate him.

Perhaps that was what the gift was about–appreciation of my effort. In the end, he has to make the choices and changes, and I have to accept that he’s doing the best he can in his circumstances.

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When Diet and Exercise are not enough

Mrs. Jones presented to my office approximately six months ago having been told that she had type 2 diabetes two years ago. Her HbA1c was 8.2. This is a measurement of how well glucose has been controlled for the previous three months. Normal is under 5.7 and anything over 7 is typically considered too high. Her number correlated with an average blood glucose of 186 and we know it needs to be under 120 to avoid serious diabetic complications. Since her previous primary care doctor had not been able to adequately help her,  I sent her to an endocrinologist. She returned to my office six months later and was proud to point out her HbA1C which was down to 6.2. Blood_Glucose_Testing_-_Kolkata_2011-07-25_3982She said to me, “I read my records from my previous doctor.  She told me to diet and exercise. That’s all she ever said. She never told me why it applied to my diabetes. Now I understand how increased weight and lack of exercise affects insulin. Why didn’t she tell me those things?” I thought about it. Why didn’t I tell her? I assumed that the physiology and treatment of her condition had been well explained to her and that she was just ignoring her doctor’s advice. Diet and exercise alone as words are not powerful enough for people to understand their importance. Education is more than advice. It includes understanding the significance of the recommendations.

How many times am I guilty of the same poor communication technique? Doctor comes from the latin docere, to teach. It is part of my job and I hope my patients feel comfortable enough to say, “Hey, I don’t understand that” when I am unclear.  Only by working together can we hope to improve the “outcomes of chronic disease”. And more importantly, my patients will feel better and live longer.

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Can Meditation Help?

Listening to a patient talk about her issues with food binging she told me “I had an ‘aha’ moment recently.” I nodded and she continued, “It’s OK to be uncomfortable.” Seeing that I wasn’t following her she elaborated, “I think our culture engenders a belief that whenever you are uncomfortable, that feeling must be fixed. The ‘aha’ is that simply is not true, but it took meditation for me to step back and recognize that fact.” As a consequence she is less likely to reach for food when she is uncomfortable with her life, something she has done for 45 years. Angry with her spouse? Eat a muffin. Didn’t get a promotion? Stop by McD’s on the way home. Meditation is giving her space, the ability to step back before she reaches for the chips.

While at Doctors 2.0 this summer, Ronan Kavanagh spoke with passion to me about a new app he was using: Headspace. This is an  app developed by Andy Puddicombe, a former Buddhist monk who is taking meditation to the masses. I would encourage my patients to take advantage of the Take10 series for free.Screenshot 2013-10-16 14.31.44

In this fast-paced world of a constant barrage of sensations, media hype, unrealistic expectations and overwhelming frustrations, taking 20 minutes out of the day to stop, step back and become mindful becomes paramount to surviving the everyday crises we become involved in. Ultimately, the training provides not just an oasis when you sit, but within the moments of crises themselves which can improve not only your own circumstance but those of the individuals who surround you.

If you have an Android or iPhone consider taking 10. Careful though, it may lead you to a lifetime of taking 20.

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The Irony of a Paper TOC Document in an EHR

Over one year ago my office implemented Allscripts Enterprise EHR (Electronic Health Record). I’ve not done a note on paper since. Last week, a “Transition of Care” (TOC) document was placed on my desk with a sticky note stating: “Dr. Nieder please fill out this form so we can bill a 99496 for your visit with Mrs. Jones yesterday”. I pick up two sheets of paper with multiple questions including: 

  • Discharge Medications: (list)
  • Present Medications: (list)
  • Diagnostic tests reviewed/disposition (list)
  • Disease/illness education (discussion documentation)
  • Home health/community services discussion/referrals: (list)
  • Establishment or re-establishment of referral orders for community resources: (list)
  • Discussion with other health care providers: (list)
  • Assessment and support of treatment regimen adherence: (discussion documentation)
  • Appointments coordinated with: (list)
  • Education for self-management, independent living and activities of daily living: (discussion documentation)
Please remember, I am now on an EHR. So I am expected to document in the EHR and THEN fill out these forms. I have no discharge summary yet from the hospital. It may be ready but no one sent it to me and since our hospital is not sync’ed with our ambulatory clinics it didn’t seamlessly flow into my patient’s chart when she was discharged. When I finally do get it, there is no mention of any referrals given other than with the surgeon she saw in the hospital and me. The discharge medications state “resume pre-admission meds”. In order for me to list what tests she had and make sure they are normal I have to return to the hospital portal and look them all up. Some of them have already been scanned into the EHR. I have no idea if there were other referrals made but I doubt it. She had a very straight-forward admission for a small bowel obstruction. She declined to keep the surgeon’s appointment since they gave her instructions in her care in the hospital. I concurred about that. She could call them if she needed them. The women is a healthy 65-year-old who still works part-time as an accountant. She travels a lot. 

This TOC visit is paid at a much higher rate than other visits IF the patient does not return to the hospital in the next 30 days. Hence, we hold the billing until that time. 

My understanding of the purpose of this new code is to improve the CO-ORDINATION of care as the patient transitions from the hospital to home. Coordination would imply that there are other individuals involved in giving the patient care and thus we should have improved COMMUNICATION

between us. However, at least in my institution, my staff and I bear the brunt of gathering information (which is what we normally do anyway, so I guess it’s nice because now we get paid for it). 


At what point will it become incumbent upon the hospital, who I work for, to send me the necessary information for treating the patient now that he/she is home again? How does it follow that improving care means the primary care doctor fills out even MORE FORMS ultimately reducing the time spent with the patient? At what point does the operability of two disparate systems (office EHR and hospital EHR) talk to each other and the information I need is already in the EHR? Why isn’t all the information the patient needs sent home with her and she is told to bring that with her to her primary care doctor’s visit which, oh by the way, should be done within two weeks? Why aren’t all appointment made before she walks out the door? 

The form will not keep the patient out of the hospital. Communication will keep the patient out of the hospital. True coordination of care might keep the patient out of the hospital. More busy work for the patient’s primary care doctor will not. Since the order of the day is using hospitalists (a discussion on that is a post for another day) it is imperative that we improve our communication systems at the time of discharge and before the patient is seen again in the primary care office. Systems must stop thinking that one more form is going to save the patient. Especially another form on my back.


This post’s ending was rewritten on 10-10-2013 to take into account the multi-faceted reasons for the form.

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Thoughts on MedX

This morning I sit in my daughter’s San Francisco apartment pondering the barrage of information that I was exposed to during the previous three days at the Stanford MedX conference. My mind is full of images that begin with Regina Holliday‘s beautiful pre-conference canvas

Representation of a part of the canvas

and end with my friends Lisa Fields and Ruth Ann Crystal; relationships made over the internet through Social Media and cemented by meeting IRL (in real life).

Ruth Ann Crystal, myself, Lisa Fields

The conference was a showcase of healthcare innovation and opportunities to network with empowered patients from the Society for Participatory Medicine and other like-minded health professionals. The epatients’ stories along with Regina Holliday’s exhortations to “change the world NOW” were the most compelling part of the program. Over the next few weeks I hope my mind processes what was learned and results in more ideas for changes that improve patient experience in my practice and, who knows, even in my healthcare system.

Flash mob on stage with Regina Holliday (in red)

At first, when asked by other participants why I came to Stanford, I wasn’t immediately sure. I made the reservation out of a gut reaction but by day two my motivation was obvious: MedX provides the energy and focus necessary to change our broken healthcare system. Tim Autrey of the Practicing Perfection Institute commented in his workshop that change must start with the individual. This individual began over a year ago but the MedX conference provided a powerful infusion of energy to improve my personal relationships with patients and exhort my system to do the same. Thank you Dr. Larry Chu, Nick Dawson and the staff who worked so hard to make the conference the success it has become.

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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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A Personal Moment

Rarely do I take two week vacations, but my adult daughters have begun their own lives, very separate from mine. This was the last chance to take one together so my husband and I indulged. Tickets were bought last September. My mother, at 84, was doing well enough though she showed signs of some memory loss.

As her memory loss became more apparent, we decided it was time for a retirement community. I began the process and as luck would have it, my vacation fell smack in the middle of planning her move, trying to sell her condo and all the attendant details involved in that. She fell apart.

Weeks before I left she began calling me five to twelve times a day. She couldn’t remember decisions we’d already made. She changed her mind a million times. Finally, I flew away for the first week of my break leaving my husband in charge of dealing with her for the first week. He did well but there was no one to help during the next week when all four members of the family were in another country.

So two weeks later, I return to find this horribly diminished individual. She looked like she had lost weight and she repeated herself over and over and over until it was all one can do to keep from screaming “STOP”. I seriously thought that we needed to change from a retirement home to an assisted living facility. Then the oddest thing happened. Thursday night the real estate agent called. She had a buyer for my mom’s condo. I gave a verbal OK, then cringed at the reality of convincing my mother. The next morning my husband and daughter went to oversee my mother’s signing of the papers. She did it, then my husband spent the day with her, feeding her twice. On Saturday I spent the evening with her and she accompanied me while I helped my daughter unload boxes into her apartment. While my mom couldn’t do that, she sat next to the car while three of us shlepped the boxes which really helped get the unloading done faster. Then she came into the kitchen and unwrapped dishes. When she returned home my daughter called to thank her for helping. I fed her again. On Sunday I returned to help her with some financial questions regarding the move. This time she looked at me and said “You know I’m starting to think this move is a good idea. I’m even looking forward to it a little. By the way, I called people multiple times while you were gone, didn’t I? I have no memory of that. It’s like I’ve been in a fog. I think I went a little kooky. Could I have had a stroke? You’ve been working very hard for me, come on and I’ll buy you dinner.” 

I was amazed. Suddenly she was remembering stuff she did five and ten minutes before. She had insight. What happened?? How was it that I had my mother back? She still has trouble remembering but she’s not the diminished lost woman I came home to. Was it just eating properly? I know she hasn’t been eating during these stressful weeks and we had fed her well for an entire weekend. Was it the socialization? She’d been interacting with people all weekend. Was it honestly being helpful to someone? I have no idea. What I do know is that pseudodementia is complicating an underlying mild dementia that she refuses to take medication to treat.  

At any rate, my belief it that moving her to an environment with exercise and social stimulation will improve her mentation. Maybe she’ll have quite a few years in her new home where socialization, activities and getting to know your neighbor is the norm. 

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Doctors 2.0 – First Blog Post

It’s a few days early but why not get a leap on my conference blogging? My daughter and I arrived in Paris in preparation for the Doctors 2.0 conference:

“THE” INTERNATIONAL EVENT OF 2013 IN HEALTHCARE SOCIAL MEDIA & WEB 2.0


After not sleeping on the flight over (I never sleep on airplanes) we arrived at our very pleasant apartment in the Marais, set up through “A La Carte Paris“. Kelly walked in the door, checked out the very high tech amenities as well as the bathroom hidden in the bank of cabinets on the wall: 

Oh MY — there it is!





















She then announced “We’re staying in an Inspector Gadget’s apartment!”






We spent the afternoon on a walk through Montmartre given by Chris through City Free Tours. After a beer in the Place de Tertre we made our way home and decided to eat in and then crash. 

Not too much Social Media in Medicine was accomplished today, but everyone deserves a day or two off. I’ll be tweeting from the meeting and looking forward to learning more on that topic starting Wednesday night when I’ll have the pleasure of dining with some of the best on #hcsm, @HealthHashtags, @clearmd, and #doctor20 IRL.*

In the meantime, Bon Appetit.



*In Real Life. 

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OUCH I must be a horrible doctor

Recently I began reading Dr. Kevin Pho’s book, Establishing, Managing and Protecting Your OnLine Reputation. Last year I had encouraged patients to go to the Healthgrades to rate our office. It was helpful. My staff’s friendliness needs some improving. My ratings were good but not fabulous. That got me to thinking about how to improve. Maybe it’s because I am too straightforward? Am I not kind enough? Does my face show disappointment or frustration? 


The worst was looking at the Drscore.com site. There were only three ratings and the last one was abysmal, left in March of this year. I can’t help but wonder what I did to anger  someone that badly. Was it the patient who left in a huff because a medical student came in first? (Yes, we warned him but apparently he expected me to accompany the student so we didn’t properly explain it). Or the patient who was furious because I wouldn’t give her a handicap sticker when her cardiologist refused to? Or the patient that I discharged from my practice when I found out he lied to me about his past drug history? The site itself is poorly monitored. It lists my internal medicine associate as a gerontologist with no address, my family practice associate as practicing at an address that she left five years ago, and my address is listed from four years ago. When I sent an email no one answered it. 

Most of the other sites listed were without reviews. It makes me wonder, with so many rating sites, how helpful can they be? Additionally our patients are asked to fill out a survey on Survey Monkey but the doctors aren’t given the results. What good is that? 

Pondering my ratings I wonder, would using Motivational Interviewing improve how patients perceive my suggestions and bring something more tolerable and more workable for them? It’s my hope to motivate, not lecture patients. If I see them as partners in their care, how best do I encourage their participation and help them?
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