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medical work horses

How To Be More Efficient As A Primary Care Doctor

As an overextended physician in my 40’s, with a family life and a daily sense of exhaustion, I have given up the quixotic dream of helping to change healthcare in this country. I’m just trying to survive each day, along with my patients, and to be an efficient and helpful primary care doctor.

If you too have accepted that our healthcare system is a bloated, unfixable, disappointing mess, and that you are just a squirrel trying to get a nut each day, then read on for small tips on how to survive, nay thrive, within the sad drama that has become the modern office visit.

Resolve that someday, when perhaps you are better rested, better informed, and the industrial-capitalist-insurance-forprofit model has eaten itself alive, perhaps then you will return to your passionate dreams about how to be a better doctor and craft a better medical world. In the meantime, here’s an atomic bomb shelter model to survive.

1. See patients in one room
I used to carry a laptop from room to room, fumbling around and drifting from place to place to see patients. Stop that. Set up shop in one room, and plan on being there for most of the day. Get a comfortable chair. A green plant. A mug of coffee and a water bottle. One room facilitates the rest of this list as you will see. Patients can be brought back and their visits begun in an adjacent room. When you are ready for them, leave your room and ask them to kindly join you next door where you’ve been preparing for their visit. Unless they are extremely old or frail, they will get used to the shtick, and come to expect it.

2. Take 1-5 minutes to review each chart before starting the visit
I used to feel so bad about running late that after finishing with one patient, I would burst into the next room, as if punching a time card, and apologize to the patient, barely knowing whom I was seeing next. Forget that. It doesn’t serve you or the patient to be unprepared for the visit. You will make mistakes, be unfocused, and look like you don’t remember them.

Instead, sit in your little home base with the door closed. Review the last visit or two. Jot down some quick reminders on an actual piece of paper. Among the 15 complaints from last visit, which ones still need attention? I write down chief complaints and quick to do lists. (Last visit – Chest pain, ?stress test done. Elevated alk phos. Bone scan ok. ?paget’s. See rheum. DM2. HTN. Colonoscopy scheduled? Dysphagia, needs EGD. Etc)

Review imaging tests. Jot down loose ends. Review specialist letters’ conclusions. Review recent labs.

Scan vital signs. Did they lose 20 pounds since last visit, unintentionally? Is the BP 180/100? Bad to miss that.

3. Set up the assessment and plan
Yes, do this before the visit. I know you haven’t even seen the patient yet, but unless she is here for a quick same day visit, she’s going to have her own agenda and priorities as soon as you open the door. If you don’t crystalize your own agenda before you are juggling hers, the visit is going to be even more of a struggle.

List 5-15 chronic or recent problems on the chart’s assessment and plan before even seeing the patient. If there are major tasks you know the patient needs, or has failed to complete, order them before seeing the patient. Chest pain, didn’t get stress test, you’ve already ordered it. You can always delete it.

Once the visit has begun, you can add new complaints and diagnoses. Sometimes the visit can become unruly, and finishing with a problem list 10-20 issues deep is exhausting. But 99214’s and 99215’s result, diligent care is achieved, and everyone is happy-ish.

4. Small talk is good, for a small time
This hurts the most. I love knowing my patients as human beings, appreciating their stories, legends, quirks, bravery, and fears. But this is survival mode, and if you are in a saturated situation with kids to pick up by 6 PM at school after-care, then you must stay on point after a brief detour into humanism.

This really sucks.

5. Let the patient’s agenda come first
You may or may not see the patient holding a tangible list of problems in hand, but what you don’t want to do is take over from the beginning, force your way through your pre-planned list of 5-15 items, and then find out they have 6 more. “I know you are here for a check up today, and I have a lot of questions to review with you from recent visits, but I want to give you the floor first. How are you? What can we help with today?” It sounds like family medicine softness. Kind of deadly. But it is actually eastern Zen philosophy combined with German engineering – letting the visit pass through you without resisting its true motivations, yet holding onto an invisible scaffolding beneath.

Once you’ve handled the patient’s biggest concerns, your preplanned list may already overlap with theirs, making the additional dump of your diligent reminders easier. Don’t drag this part out. You’ve already done the work from prior visits. Lung nodule, due for CT Chest, reminder and script given.

6. Demand enough time
Modern primary care visits cannot be reasonably accomplished in less than 20 minutes. Demand 20 minute visits for chronic care, and 30-40 for the most complex patients, hospital follow ups, new patients, and most “preventative physicals” which end up being chronic disease management with USPTF essentials added in. 15 minutes is disrespecting you and the patient, and making money for someone else anyway. Plus, with better care 99213’s are rare, so it evens out or you come ahead in terms of RVU’s and that stuff.

7. Smile, breathe, laugh if you can
It really helps. But don’t force it. A smiling or laughing doctor at the wrong time is creepy and unnerving.

When rechecking a blood pressure, walk the nervous patient through some calming, deep breaths, and while telling them to relax their muscles, you do the same. No laughing at this time.

8. At the end of the visit, give a narrative outline
Sometimes patients won’t let you talk as much as you need to. They are excited, nervous, or just talkative. You have to wrap this up in a tidy manner for you and them. “So I understand what you’re telling me. I’m going to tell you my impressions about what is going on, then review some diagnostic tests we may or may not want to do to figure this out, and then we’ll talk about treatment options.” That way they know to give you some space to help them. “After that, please ask any questions you have, and then we’ll run through a quick summary of your old issues with some reminders.”

Bring more structure to the visit as it progresses. Hopefully, it is satisfying for you and the patient. Making order out of chaos is what humans do, even if the laws of thermodynamics still prove everything we do ultimately creates more disorder. Alas…

9. Get up and escort patient out at the end of the visit
This is good manners. It is also a ceremonial display that this dramatic interaction has reached its natural conclusion. It stretches your legs, helps your back, and alleviates pressure on your hemorrhoids. Just kidding. Maybe not.

10. Return to your room, close the door
With peace and quiet, finish your note, organize your thoughts into coherent, thoughtful, narrative documentation. I insist on speech-to-text dictation (Dragon medical dictation software). I refuse to click on boxes or try to cram the patient’s complex story, overlapping ideas, and fluid assessment and plan into templates provided by most electronic medical records. It’s not human, and it’s bad. Enough said.

If I’m running more than 30 minutes late, I will stop finishing each note. Instead I will then move on to the next patient’s chart and start the whole pre-gaming process all over again. Leaving the full documentation of the visit for the end of the day, or “lunchbreak” whatever that is, is a total bummer. But it happens.

In between patients, take a deep breath or 5. Close and rub your eyes. Do some tai chi poses, or practice a minute of mindfulness stuff. It really helps, and maybe your first heart attack will delayed.

11. Noble sacrifices will be made
This part is optional, depending on how badly you need to get out on time and pick up your kids, or walk your dog. Consider sacrificing small talk with colleagues. Eat your lunch in that bunker of a room while reviewing the 25 phone calls that have come in for you while you were seeing patients. Put on some music. Stretch. This is a sad departure from those you work with. Optional.

12. Delegate
You can’t do it all. Don’t feel bad. Your mission is to be the doctor. Medical assistants and front desk personnel should be there to support the whole enterprise.

Good luck. Hopefully this will make you a more efficient, more diligent, better doctor within the horrible confines of a typical, busy primary care practice. There is no one-size-fits all. But this approach works for me. I bring significantly less work home, and achieve greater productivity than my colleagues.

I’m soldiering on, muddling through, being a workhorse. These are not visionary pointers, and there is little inspiration in them. But until the larger struggle is won against our broken healthcare system, some of us choose to survive within the system, while others set up systems of care that are off the grid with concierge practices, ideal micro practices, or some other funky model for cash.

It also helps to have a photo depicting a rustic, mossy cabin in the woods posted somewhere.

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specialized facilities africa

We Should Construct Specialized Ebola Facilities in the US. Now.

The US should be ready to build facilities, akin to what the military has been setting up in West Africa – specialized Ebola hospitals with moon suits, free-flowing bleach solutions, and brave healthcare workers who have been properly trained, and will be properly compensated for their risk.

Conventional hospitals have failed to protect at least two healthcare workers from contracting Ebola, despite what sounds like fairly diligent safety precautions. The nurse in Spain, and the nurse in Dallas just diagnosed today, both practiced stringent precautions and wore protective gear. It has been postulated that a single Ebola virus is enough to transmit the infection between close contacts.

And, while the CDC director assumes there was “a breach in protocol” to explain the nurse’s infection, this is not reassuring to any healthcare worker who knows how impossible it is to achieve perfection in the care of sick patients. Doctors, nurses, medical workers – we are not trained, prepared, or equipped to deal with something like Ebola.

And even with buddy systems and moon suits, any human being lacks perfect motor execution when disrobing. And the disrobing protocol in this country does not even include being sprayed/bathed in a disinfection solution prior to disrobing – something done in Africa for years. This is outrageous.

Even with regional Ebola treatments centers, the diagnosis and triage of potential infections will likely continue to be through the conventional health system, as false scares will certainly outnumber true diagnoses. But once a diagnosis is made, that patient needs better care, and workers need better protection than all the reassurances thus provided by the CDC and WHO and hospital protocols.

The four hospitals in the country commonly cited by the news as having high containment units do not have sufficient beds to handle Ebola if it picks up speed and numbers. The death toll among healthcare providers in West Africa is much, much higher than the average population. It would be here, too.

The Ebola epidemic continues to grow exponentially in Africa. Today we have the luxury of hyper-focused contact tracking and supervised quarantines in the United States, but these efforts take considerable resources and attention, and will fall apart if the disease count grows. Such is the terrifying power of exponential math.

It is not a good idea to have Ebola patients in conventional hospitals like Texas Presbyterian. Conventional hospitals are already a nexus point of the worst antibiotic-resistant contagions in the world. We need to enlist the help of groups like Doctors Without Borders that really know how to protect their staff, and we need to start thinking about containing and treating this infection outside the normal hospital box.

Build it, and hope they never come.

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Obama’s Foreign Policy Is Linked to a Healthy, Restrained Immune System

ObamaForeignPolicyWith 58% of Americans disapproving of Obama’s foreign policy, mounting Ebola virus deaths, and flu season around the corner, I think it is important to synthesize an overlapping theme between how our country fights perceived threats, and how our bodies successfully or unsuccessfully fight disease. In short, I think Obama’s continued restraint and use of soft power is evidence of a good prognosis for the country.

In this analogy, our bombs and military are the most caustic weapons of the country’s immune system, akin to a fever of 105 degrees and impending sepsis. Does “nuke them all” work?

Diplomacy, espionage, surveillance, economic sanctions, and other soft tools of foreign policy can be likened to low grade temperatures, coughing, mucous, and all the other less dramatic symptoms of immune system activation.

Considering medications is a stretch, but stay with me. Cholesterol-lowering medications called statins actually do more than lower our lipid levels – they mildly hamper the immune system and reduce inflammation. Intuitively this would seem to be a bad thing when fighting a war inside the body against an invader. But statins are increasingly suspected to be a beneficial kind of weakening force that paradoxically might save us from an immune system run amok.

Is Obama like Lipitor?

Consider influenza. Often young, healthy people with robust immune systems are at increased risk of dying from pandemic influenza simply because their immune systems launch such powerful attacks that the body cannot withstand the friendly fire.

One study found that patients hospitalized with influenza were 54% less likely to die if they were taking a statin medication. It is postulated that statins modulate and dampen the inflammation unleashed by the immune system, thereby limiting collateral damage.

Another study published in the journal Critical Care recently found “that early treatment of sepsis patients with a statin reduced the occurrence of organ failure (a complication that often kills Ebola patients) by 83 percent.” An opinion written by two medical doctor/professors appeared in the New York Times this week calling for a trial of statins in those dying of Ebola for this very reason.

ISIS is a cancer, surrounded by other diseased states. Putin is MRSA. The Middle East is the Middle East. I’m glad we don’t have Bush and McCain running in with their hands unwashed to try and save the day. I’m glad Hillary isn’t trying to do her best Clint Eastwood.

So far Obama seems to be managing these illnesses like a well-restrained immune system. Even though we disapprove of his foreign policy, a majority of Americans want to stay out of these foreign conflicts – putting Obama in no-man’s land in terms of chasing approval ratings.

Personally I’m much more worried about the planet’s fever, the looming environmental catastrophes, and being on the front end of the greatest mass extinction the Earth has ever known.

Push fluids with ISIS. Only send in bombers and troops to Ukraine prn, and start World War 3 if America is terminal in the ICU. But for now I salute the commander for swallowing his bitter pills, sneezing and hacking up mucous, and enduring the taunts of weakness from viral media on behalf of the country’s health.

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If You Don’t Look For It, You Will Miss It

Death leaves an invisible silence, a wrenching disappearance of love’s voice and presence.

Your father held you in your first moments, poured his love and life into your cup, and told stories that created a fabled purpose from the dull chaos.  And then he was no more.
photo

Are loved ones gone forever when they die?

They live a new, unselfish life within the murky, star-forming nebula of our memories.  We conjure them in moments of anxiety, sing along with them in the music they loved, and see how they once adored us as we tuck our children into bed.  And beyond our perceptions, they exist as nothing and everything.

And if we don’t keep a keen eye on the outside world, we may miss them there as well.  On a birthday I looked down and saw this dirty little puddle.  I paused, noting that it was heart-shaped.  And as great art can move mountains within us, so too can dirty puddles speak for the dead:

I love you.

it said.

~

In the moment my father died there was a beautiful, September-like sky, crisp and blue like the month he entered the world.  He shone in the sunlit footprints of his granddaughter as she ran down the sandy beach, brimming with her young life, a torch of his own.

My father jammed the electromagnetic waves of the police trying to call my cell phone to tell me of his demise.  Four times I answered the phone to static, which has neither happened before nor since.  Stay in this brilliant moment a little while longer, son. I’m with you and your family over this warm beach blanket as I join the sky, reveling in your daughter’s giggles.  Remember nothing in the universe has produced a greater sound.

We are of the world when we are born into it, why should we not remain of it when we die?

Look for your loved ones, hear them, sense them, and hold on in inexplicable ways.

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Is Thanksgiving Actually a Misguided Holiday?

auroraI used to think of Thanksgiving as the supremely humble, agenda-less holiday most deserving of our celebration. As an American adaptation of harvest festivals found in other cultures, it seems at once natural, secular, and modest.

Yet as I called a lovely woman a few days before the holiday to inform and counsel her that she has cancer, the notion of millions of others “giving thanks” rang hollow, selfish, self-referential, and arrogant.

The turkey on her table was unexpectedly as rotten as the necrotic mass in her pelvis, and her many arriving guests were suddenly interlopers in her nightmare. Perhaps there is a better way to frame the loaded notion of “giving thanks” that does not presuppose blessings, special entitlements, and personal good fortune.

The act of giving thanks necessarily involves a transaction between an actor and a receiver. Giving thanks is a reaction to something bestowed. This problem of agency is what makes Thanksgiving fundamentally flawed.

An unseen God known via faith can be thanked, but to do so takes a egotistical leap over the woman with cancer. What has she received from this same God? Instead, giving thanks seems most appropriate for the transparent exchange, such as that which occurs between human actors helping one another.

So what notions would be most honorable, most worthy of our sacred celebration? The best abstract ideas I could come up with would be reverence, humility, wonder and awe.

Reverence for humanism, the natural world on Earth, a newborn child’s silky head, the brilliance of the stars, and the capacity of love.

Humility that grasps our frailty, our inherent flaws, and the acceptance that every action we commit, even those considered altruistic, is ultimately self-serving.

Awe at the enormity of the universe from galaxy to gluon, the stubborn and heroic perseverance of life, comets from the Oort belt grazing the Sun, and the beauty of snow flurries falling as we exalt in the pleasures of sharing pumpkin pie.

If we were all equally blessed, or if there were some rational justice that determines who suffers, then we should say “thanks.” Otherwise I think a good prayer before the feast should focus on the ideas of reverence, humility, and awe… and to give thanks to those who journey along with us.

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Food Truck Examining Room, an Evolving Concept

Food Truck Examining Room
Given that our health care system has become a bloated carcass of once honorable intentions, I think a fundamental redesign of the examining room is in order.  For beyond the doctor and patient, the physical room which contains their ebullient repartee is the next logical target for improvement.  Here is one radical idea that may need only a few tweaks:

The foodtruckexaminingroom will roam from town to town across the United States, stopping in major cities and small towns with main streets in order to provide excellent medical consultations. The charge will be $25 per “visit”, with home made food gifts strongly encouraged. A medical “plan for your local doctor with malpractice coverage” will be generated from each visit, and will be thoroughly excellent.

The nerve center of the truck, and the heart and soul of this new concept, will be a very casual exam room inside the truck. There will be two chairs, a table, optional wine glasses, and a plush 1970’s style shag rug. A Norman Rockwell will be on the wall, a subtle and ironic nod to the midcentury demise of the “real” family doctor. Perhaps a bring-one-take-one-used-book-shelf will invite the free flow of subversive leftist literature.

A wine rack will be on the wall, highlighting the virtues of moderation and zinfandel.

Please rest assured there will be music gently streaming in the background, ranging from such therapeutic artists as Chopin, James Brown, and The Alabama Shakes. A nice, toothless, fluffy (and occasionally smelly dog) named Babaganoush will smile and purr gracefully at each patient, inviting intimacy and reducing anxiety from the start. For an additional 50 cents, “Baba” will roll around on your back, simulating a low cost sort of medical massage.

The truck will strive to park under shady trees in warm weather, and to maintain an alternate, open-air exam “area” with folding chairs. This area will have little to no privacy and so will be an optional, flagrant violation of HIPPA standards. A discretionary campfire, with a “Saturday Sausage Sizzle” (TM – trademark, all rights reserved) will mesh seamlessly with America’s entrenched tail-gating and RV culture.

On the top of the foodtruckexaminingroom will be perhaps the most important engineering feats – a mobile greenhouse growing organic kale, herbs, tomatoes, and mint for mojitos and tea. It will be fertilized periodically with excrement from the 500 pound, fully operational chicken coop. Free range chickens will be let out during the day to wander around eating local bugs, and will produce about a dozen organic eggs per day, which will be given to the first 12 patients of each session.

A beehive will be maintained on the roof as well, with honeybees diligently avoiding Bayer’s neonicotinoid pesticides, and Monsanto’s GMO crops, to bring us delicious honey, always on tap directly from the hive.

The rear of the truck will be retrofitted with a freezer for chocolate ice cream, the exclusive and happily restrictive diet that will be recommended for all willing nonagenarians.

The exercise zone will be fairly minimalistic, purposefully demonstrating that one really needs to just move around. The tai chi manual must be returned before sunset.

I am currently seeking investors and start up venture capital for this concept. I believe it to be scalable, yet inherently resistant to the mind-numbing, evil tendencies of big corporate paradigms and six sigma cannibalism. This concept will be “intuitive” and “quite natural” for patients willing to step inside the food truck and get some healing. Please allow me to clarify any questions you may have, and I would happily entertain suggestions for improvement.

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A Review of Chronic Resilience, a book by Danea Horn

book_cover_smallAuthor Danea Horn has written a book entitled Chronic Resilience in which she describes “10 sanity-saving strategies for women coping with the stress of illness.” I read a copy of the book and highly recommend it.

The stresses of being ill and suffering from chronic illness are manifold. Just today I listened to a woman in the examining room whose fear, anxiety, and sense of isolation with her medical problems were as distressing as the many unpleasant feelings of pain, dizziness, and dread. I did my best to listen to her, validate her concerns, and offer her constructive medical solutions – but I found myself also mentioning Ms. Horn’s book. Even in the first few pages of her disarming introduction, in which she describes her own congenital problems, you can sense her warmth and sincerity, and the toughness that she might lend to a besieged fellow patient and life traveler.

The ten guidelines within specifically address the many challenges of chronic disease, and give tangible means of coping with and overcoming the many adversities. Her approach is instrumental in moving past the initial feelings of ‘why me?” and on to an empowering sense of control recaptured. Ms. Horn effortlessly draws from her readings of other empowering authors, notions of spirituality, and the existential reckonings of her own lifetime to synthesize a holistic and wholly effective worldview of illness.

Instead of relying on broad strokes of clichéd and unspecific advice, Danea includes actual exercises in her approach. Similar in my opinion to the highly respected concept of cognitive behavioral therapy, these practical assignments function like homework to drive home and reinforce the positive methods that can promote resilience.

Ms. Horn shares her own experiences in a witty, candid way that fosters trust, establishes credibility, and engages the reader. But she is not content in any way to simply make this a book about her own life, but rather includes intimate portraits of nine other women whose struggles have been met with courage and grace. There is really nothing more powerful to convince and inspire the human mind than the sharing of human story. Through the lens of these women’s tales, we see ourselves as capable of facing our own trials, strengthening our own resolve, and ultimately transcending the cruel frailties of our shared human condition.

As we are all imperfect creatures, there is a lot to be gained from reading this book whether you have a major chronic illness or not. I found the book to be uplifting, inspiring, and compelling. I found ideas to improve my own approach to daily life, and ways to cultivate a healthy sense of wellbeing, even in times of sickness and despair. As a family doctor I found myself thinking of several patients that this book would be perfect for, and I intend upon recommending it to them.

Thanks for a noble guidebook through good mental health in the face of chronic disease, Ms. Horn. May your life’s work continue to make the world a better, more resilient place.

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