PookieMD's Blog: Where Physicians Learn About the Business of Medicine

I received a request to sign the following Letter to the Editor that will appear in the Denver Post on Saturday, March 14 edition.

“Doctors feel the consequences of unavailable or unaffordable health insurance every day. Uninsured and under insured patients forgo needed care, turning treatable conditions into complex and expensive health care events. Many can’t get insurance due to pre-existing conditions or over-priced individual plans. Our fragmented health insurance system creates administrative burden for patients and doctors alike, but does little toward improving quality, communications, or overall health in America. Our patients are seeing double-digit insurance premium increases and sky-rocketing deductibles.  More and more they cannot afford to come to the doctor.

Delaying health insurance reform would unnecessarily perpetuate lack of access to health care, financial hardship, and suffering. We urge passage of federal health care reform legislation immediately and call for continued executive evaluation and creative legislation until all Americans have access to affordable quality health care.”

Would you sign this? If you want to sign, go to http://bit.ly/aY9IuW.

I went to a noon lunch and learn given by my medical malpractice carrier, and the speaker reminded us that most patients have a 5th grade understanding of medical jargon. He told us to tailor our conversations and handouts to this level of understanding. I had heard this before and have tried to use this as a guide in my conversations with patients.

I was paging through the Annals of Internal Medicine, and there at the back are summaries of articles that can be given to patients.  (I’m not sure why you would want to give a patient a summary of a double blind placebo controlled randomized study, but just in case you do, Annals has it for you!) Anyway, there was a sheet you could tear out and give to patients summarizing “Cost-Effectiveness of Different Types of Evaluations Before Sports Participation in Young Adults.” I quote the paragraph entitled, “What is the problem and what is known about it so far?”

In the United States, sudden death in young people participating in competitive sports occurs at a low rate. Previously unknown heart disease is the leading cause of these deaths. Major medical organizations recommend that young athletes be evaluated for heart disease before they participate in organized sports. The American College of Cardiology and the American Heart Association recommend a medical history and physical examination, with further testing if history or examination is abnormal.  The European Society of Cardiology and the International Olympic Committee recommend including electrocardiography (ECG); this test records the electrical impulses of the heart and provides information about abnormal heart rhythms and other heart conditions.”

Wow. You’d have to be some fifth grader to make heads or tails of that paragraph! If I was a fifth grader, I could care less about the American College of Cardiology and the American Heart Association, as well as the European Society of Cardiology. I might care about the Internal Olympic Committee, if I envisioned myself as the next Lindsey Vonn, but other than that, the entire paragraph would mean nothing to me.

Should I send Annals the hand out from my malpractice insurer to help them make hand out sheets that are actually readable?

It was a busy night at my local hospital.  I spent a lot of time in the ED, and the pager was in status.  The hospital I was at is a large tertiary hospital, and receives transfers from small mountain clinics that send us stuff like chest pain (easy) and hypertensive urgency/renal failure/barfing patients (hard.)  We get patched in to the Tiny Mountain Clinic Doctor, who gives us the skinny, and then we banter a bit about treatments etc, and then the helpful “connect” ombudsman arranges transport.

All good, so far. Except when the mountain doc wants to talk to me right as I am transferring a crashing patient to the ICU.  The helpful connect ombudsman calls me, and tells me that the Tiny Mountain Clinic Doctor needs to talk to me.  “I’m really busy,” I say, “I’m moving a patient to the ICU.  Can I call you back in 10 minutes?”  The helpful ombudsman agrees.  (BTW, our conversation is recorded, and we have all been warned to be polite as the powers that be will slap our hands if we are not.)

I’m busily assessing my patient, trying to get the transfer orders done, when the pager goes off again, not 5 minutes later.  It’s the helpful connect ombudsman.  “Tiny Mountain Clinic Doctor needs to talk to you,” she says.  Needless to say, Tiny Mountain Clinic Doctor takes first priority, even though I already said I would call back after the fire I’m putting out is taken care of.  (After all, we are being tape recorded!)

Oh how impatient we are.  But sadly, oh how impatient I am as well!  Could I just have a minute to think?

I don’t know how you feel about pain management, both acute and chronic, but articles like the recent one in Annals of Internal Medicine(“Opioid Prescriptions for Chronic Pain and Overdose” 1/19/2010, vol 152, #2, pp88) don’t make it even easer.

Basically the article said that 3% of adults are on long term opioids, and that the older the patient and the higher the dose, the higher the risk of overdose.  Add benzos in to the mix, and the risk goes up even higher.  Additionally, the highest chance of accidental over dose is upon initiation of the drug.  The situations that I think are potentially dangerous are the times you have a Little Old Lady right out of surgery, on her valium for sleep (“I’ve been on it for years, Sweetie!”) who now needs narcotics for her hip replacement. And yup,  the orthopods want you, trusty hospitalist, to manage her pain!

I hate PCAs. I really hate PCAs and Little Old Ladies.  (I don’t however, hate Little Old Ladies!)  So whenever possible, I nix the PCAs and try to convert patients on to oxycodone (no acetaminophen–I like to dose that separately), and occasionally on to ms contin with oxycodone for breakthrough.  The only issue I have with this is that nursing staff can get really busy and not get the oral analgesic to the LOL on time, and the pain level sky rockets, and LOL ends up with a shot of morphine or dilaudid.

So what to do?  Anyone know of slick tricks around this so that the  Little Old Lady has her pain managed with oral medications delivered on time?  (By the way, is not a rap on the hands of nursing–I just want to be realistic!) Let me know how you manage pain in this vulnerable population!

Imagine, you are the pilot of a 747, getting ready to land the plane at LAX (pilot speak for Los Angeles International Airport), your ear phones are strapped on, you are talking to the tower, verifying your landing instructions, going through the check list, lowering the landing gear, adjusting the fuel mixture, and just as you throttle back–

“Excuse me, captain, but the passenger in 12B really needs to go to the bathroom even though the no smoking sign is on.  Is that okay?” 

Pilots have the sterile cockpit–a situation in which, if the plane is below 10,000 feet, only conversation directly relevant to flying is allowed.  The rule was developed because take offs and landings are the most likely time a crash will occur, and take offs and landings occur below 10,000 feet. Simple enough, and it saves lives.

Physicians need a sterile cock pit.  I speak as a hospitalist, but I imagine many specialties would benefit as well.  What are mission critical times during my day? For admissions, I would say writing (or typing!) the H&P is the most critical time, followed by order entry (or order writing.)  For discharges I would say medical reconciliation is the most critical time.  For rounding, I would again say order making followed by the “plan” part of the SOAP note.

Wouldn’t it be nice if we could have a “cone of silence” or sterile cockpit in which we could think and perform these critical functions? Wouldn’t it be nice to have all pages delayed for a set amount of time (say, 20 minutes) until we are through with our critical tasks? (Does such a pager exist?) I’d still be willing to get Code Blue pages, but can’t the other stuff wait?  (Mr. Smith’s constipation for example.)  Nurses at my institution have a “no talk zone” around the pyxis to help decrease medical errors, so why are physicians any different than pilots and nurses?

They aren’t.  It’s a cultural issue.  Page early and often needs to be replaced with “page urgently when appropriate,” and an understanding that physicians need to be able to think uninterrupted to make good decisions and give good patient care.

I’m reading a cute book–the Happiness Project.  The author has a really fun part–her “12 commandants of adult living”  (or something like that.)  I got to thinking about my 10 commandments of physicianhood–in other words, rules to doctor by.

1. Patients die.
2. Doctors can’t save everyone–refer to rule number 1.  (Surprisingly a rule that I have struggled with as it seems as if this should be something I can do–what else did I train for?)
3. Ask questions, even if you think you will look stupid.  Don’t be afraid that others know more than you–they do, but you know more on other subjects!
4. Read as much as you can.  I have been trying to outline articles on index cards and filing them. No, I don’t think I will ever refer to them, but the act of writing stuff down helps me learn.
5. Have good friends that will watch your back.  We all need someone to bounce stuff off of, and to complain to, who will tell us that we are good doctors even when the chips are down.
6. Stay calm outwardly if possible.
7. Use this ridiculous stuff we experience to write a memoir.  (Someday I will tell you about the white supremacist, the acupuncture incident and the paralyzed guy who walked to his appointments.
8. Resign yourself to spending some long days, no matter how hard you try.
9. Experience is a good teacher.
10. No one but other doctors appreciate sick doctor humor, especially at the dinner table.

Full disclosure: rules 1 and 2 came from M*A*S*H–my most favorite TV show of all time!

I have never heard a physician shout with glee, “yay, we’re getting an EMR!!!”

Physicians love to hate this latest technology, and for good reason.  Here’s why we hate ‘em:

• EMRs are comlicated.  When we had paper charts we wrote our notes on one side of the paper, and our orders on the other.  Quite simple.  If we had to read a note from a different doctor, we flipped through the pages.  (Hopefuly it was legible.)  We would open the tab to the lab results and look at them.  (Now, don’t forget that half the time you couldn’t find the chart!!!)
• EMRs are not intuitive.  EMR geeks have given us 10 different ways to do one thing.  We are simple souls– we want one way to do one thing. We wrote our orders on the paper and handed them to the ward clerk.  We don’t care about 7 different ways to order a lab test or medication, we just want to get it done.
• EMRs make us learn a whole new skill set.  We now have to “navigate”, and “cut and paste”, and use “smart phrases.”  We also have to know how to type.  This wasn’t part of our medical education, and we perceive it to take time away from what we need to do–take care of patients.
• EMRs make us feel like clerks.  When my hospital went to order entry, the clerks vanished.  ‘Nuff said.
• EMRs don’t mimic our work  flow.  When I work on paper, I take my note out, and have labs and other notes open on the table in front of me, so I can synthesize data and come up with a coherent plan.  EMRs make it difficult to mimic this work flow.
• EMRs don’t talk to each other.  There are a kazillion different EMRs out there that hospitals, offices and clinics are adopting.  Those of us that work at multiple different settings have to learn multiple different EMRs. 
• EMR  bulders forget that the EMR is a tool, not the end product!!! The end product is patient care.  The tool should be used  to enhance and deliver improved patient care.

You would think that I am a part of the anti-EMR faction.  Well, I’m not.  I’m a pragmatist.  EMRs are here to stay.  Make the best of it.   Be an influencer in a positve light–get involved to make EMRs better at your institution!

I am wearing a new hat–that of EMR consultant.  I wish I could say it has been going swimmingly, but, alas, I can’t lie.

It’s hard work, and sometimes I feel like a freshman in a graduate program.

I am in the company of a bunch of MBAs, techie types, and business wizards that use their blackberries like a third hand.  They talk the lingo, walk the walk and buy coffee together. Meanwhile, I show up, sometimes late if a patient is crashing, clutching my doctors lounge brew and a note book. I have had a big game of catch up to play as a lot of these folks have been working together for several years.

My biggest impulse is to try  to add something meaningful, such that I look like I know what I am doing. 

Wrong impulse. I called my dad, (thank god for dads!) who was an IT consultant in his time and a professor of IT. “What’s the best tactic for me to be valuable,” I asked.

“Listen much, and say little,” he responded.

Wow.  That sounds a lot like what I tell myself before I go see a patient.  Maybe I will get a hang of this yet.

I admit that I am a bit of an Egyptophile (is this a word?). It was great fun to read “Ancestry and Pathology in King  Tutankhamun’s Family”, in JAMA’s February 17 issue.  King Tut, made famous by the Steve Martin song of the same name, was portrayed in tomb art (statues/reliefs/sculptures) as androgynous and having a “bizarre form of gynecomastia.” 

The authors of the article examined several mummies thought to be related to Tutankhamun via radiological and genetic studies.  They developed a family tree, and surprise, surprise, the Tutankhamun family intermarried.  Turns out the boy king was the product of a brother sister relationship, and he in turn, likely married his sister.  Tut’s apparent grandpappy, Amenhotep had a club foot,which he passed on to Tut.  In addition, Tut’s father, the beleaguered Akhenaten, had a cleft palate, which Tut had too.  Scoliosus ran rampant as well.

In addition, King Tut had evidence of Plasmodium falciparuminfection, as well as juvenile aseptic bone necrosis, and had may have had to use a cane for much of his life.  Images of Tutankhamun frequently show him sitting during activities in which one would usually stand, like hunting. When Tut’s tomb was opened over 130 canes were found, showing signs of wear.

As for the bizarre body type seen it statuary and artistic renderings of the period? The authors found no evidence of  inherited syndromes that would cause androgynous features and “bizarre” gynecomastia.  The authors conclude that the artistic representations of Akenaten and Tutankhamun were likely stylized and idealized according to the wishes of the king.

The great thing is, the boy king is not likely to sue if the authors are wrong!

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I love that expression–fall down 7 times, get up 8. It sums up what life is like, and how to react. Lately I seemed to be mired in miscues, miscommunications, mistakes and more. What the heck, maybe writing about it will help me get up from the latest fall!

First the “toos”:

Too busy–I have been too busy working to take care of myself. Yesterday I finally got my hair down after they had to photoshop the roots out at work  when they took my picture!

Too tired–I have still been going to the gym, but have just been going through the motions. I zone out on the bike, reading gossip mags to figure out what Brad and Angelina are up to now. I feel better after a good work out, but it has seemed like so much effort.

Too stressed–our census at both hospitals where I work has been in the “red zone”, but that doesn’t mean that you don’t have to take care of patients! I have been harried by the long days, the complexities and dealing with the other doctors that are just as stressed by the high volumes. Hubby’s lack of work adds to the story too! 

Too negative–the root of much of my problem. I am trying desperately to shed this cloak of negativity I have been wearing since Hubby lost his job, but it’s been tough. For those who don’t know about the cloak of negativity, it’s like Harry Potter’s cloak of invisibility, with out the fun factor and much harder to take off.

And the most damaging –the “lacks”

The biggest: lack of faith in myself. I have constantly questioned everything I do, filling my head with “I should haves” and “why didn’t I?” which of course allows that inner voice of criticism to get louder. “You’re not smart enough/a good enough doctor/communicator/wife/human (etc.!)”

Argh.

It all seems so grim. But this time in my life, I realize, is not a permanent reality. I can’t take everything personally and let it become pervasive. So I will dust myself off, and get up again.  Thanks for listening.