Dr. Jim Hill is a friend of mine and co-developer of the National Weight Control Registry – the nation’s largest database of individuals who have lost at least 30 pounds and kept off the weight for at least 1 year. Jim has been studying their commonalities – and has determined that there is in fact a recipe for long-term weight loss success. I shared the recipe with ABC news today. My interviewer (Natasha Barrett) was really funny, and had tendencies to blurt questions in the middle of our conversation (such as: “what do you think of granola bars?”)
But then I was greeted with a note lying on my desk.
Dr. Rob:
First, I want to tell you that for the majority of the many years my family has been patients of your practice, I believe we received excellent care and you always had our best interests in mind. Further, we appreciate all that you and your staff have done for us.
However, it is with great regret that I find myself in the position of writing to you with a problem I see as pervasive in your practice…
Ugh. This is not the way to start my day.
The letter went on to describe a problem with communication of a concern the patient had about a medical problem that was very worrisome to her. It didn’t point the finger of blame at my nurse, nor any one else in the office. It wasn’t at all angry in its tone to me. It simply expressed the disappointment of a patient who felt let-down by her physician.
The letter ended with:
I look forward to speaking with you about this issue early in the week of July 20.
Thank you in advance for your attention to this matter.
I put off calling her until the end of the day. I knew she would be reasonable overall, but beyond the fact that I hate calling people on the phone at all, I hate calling when I know I have to apologize. The problem in this case was not with my staff or with confusion in the office. The problem was with a physician who simply dropped the ball and did not follow-up as promised.
I finally called:
Hi.
First let me say thank you for the letter you sent. I mean that sincerely. I would much rather hear about problems in our office than to simply having people get angry and leave. This is something I needed to hear.
Second, let me say that the blame is 100% mine. I really wasn’t worried about the problem and so I honestly just let it slip my mind. I did tell you I’d contact you and would send you to a specialist if things weren’t clear after the tests I ordered. I’m sorry about that.
I went on to discuss the situation and that I didn’t think anything was serious at all. She still wanted to go ahead with the consultant because of some stuff she had heard about the condition. I told her that I have no problem with that, as I see my job as one of giving my advice and perspective; but not as making the final decisions. The most important thing is that her worries are addressed and that she feels comfortable that everything is OK. If it takes a consultant to do that, then I have absolutely no problem with that.
I also explained that communication in a medical office is very difficult – and has gotten much harder as we have gotten busier. It is our plan to eventually have communication by e-mail, but that is not ready for prime-time. This is not an excuse, I told her, but an explanation and a promise that I do see the problem and we are doing something about it.
As expected, she was gracious about the situation and was thankful for the apology. I didn’t do it to avoid lawsuit or to protect myself. I like this family and didn’t want to lose them as patients. Beyond that, though, I owed her an apology. I had let her down. I hadn’t done what I promised I would do. She had been kind enough to send me the letter and deserved a quick resolution to the situation.
I still hated picking up the phone, though. It isn’t easy to admit fault, no matter how accepting you know the other person will be.
As obvious as it seems that apologizing will prevent lawsuit, it is a hard thing to do.
Alternative medicine practitioners love to coin magic words, but really, how can you blame them? Real medicine has a Clarkeian quality to it*; it’s so successful, it seems like magic. But real doctors know that there is nothing magic about it. The “magic” is based on hard work, sound scientific principles, and years of study.
Magic words are great. Terms like mindfulness, functional medicine, or endocrine disruptors take a complicated problem and create a simple but false answer with no real data to back it up. More often than not, the magic word is the invention of a single person who had a really interesting idea, but lacked the intellectual capacity or honesty to flesh it out. Magic is, ultimately, a lie of sorts. As TAM 7 demonstrates, many magicians are skeptics, and vice versa. In interviews, magicians will often say that they came to skepticism when the learned just how easy it is to deceive people. Magic words in alternative medicine aren’t sleight-of-hand, but sleight-of-mind, playing on people’s hopes and fears.
A reader has turned me on to another magic word I hadn’t known about. It’s called the “Inflammation Factor”, and is the invention of a nutritionist named Monica Reinagel. Like most good lies, this one builds on a nidus of truth.
Inflammation is a medical term that refers to a host of complex physiologic processes mediated by the immune system. Inflammation gets its ancient name from the obvious physical signs of inflammation: rubor, calor, dolor, tumor, or redness, heat, pain, and swelling. As the vitalistic ancient medical beliefs bowed to modern science, inflammation was recognized to be far more complex than just these four external characteristics. In addition to being a response to injury and disease, the cellular and chemical responses of inflammation can cause disease. For example, in asthma and food allergies, a type of immune reaction called type I hypersensitivity elicits a harmful type of inflammation. Coronary heart disease, the biggest killer of Americans, is believed to have a significant inflammatory component.
But nothing in medicine is perfectly simple. For example, corticosteroids, which can be used effectively to treat the inflammation in asthma are not effective against the inflammation in cororary heart disease. It’s just not that simple.
But while inflammation may not be that simple, people can be. People want easy answers, and quacks are happy to step in to provide them.
So Ms Reinagel has invented a diet, available for sale in a book called The Inflammation Free Diet Plan. Her premise is that inflammation is at the root of all major diseases, and that your diet can affect inflammation, thereby improving your health.
While the hypothesis is intriguing, each step of the argument has problems, leading to an invalid conclusion.
Inflammation is the root of all disease
No, it’s not. “Inflammation”, which is actually refers to a lot of different processes, plays an important role in many diseases. But not all inflammation is the same.
The most important factor in fighting inflammation is the food you eat every day.
Um, no. If you have a staph infection on your arm, your eating habits will not change the amount of heat, pain, swelling, or redness. The kernel of truth here is that diet can affect various measures of inflammation, such as C-reactive protein (here is one of many examples). There’s a long leap between this fact and the conclusion that diet can “stop inflammation”.
The benefits of reducing inflammation are immediate as well as long term. You’ll notice that your skin looks younger, your joints feel better, and your allergy symptoms improve. At the same time, when you reduce inflammation, you also reduce your risk of heart disease, Alzheimer’s disease, cancer, osteoporosis, diabetes, and other complications of aging.
It’s a very long walk from the claim that reducing inflammation is “a good thing” to proving that your particular diet reduces inflammation and thereby improves health . A hypothesis is not true simply because it sounds pretty.
Who wouldn’t love a magic book that would prevent and cure all illness? Perhaps you’ve noticed that these books come along every few months. None of them ever has the one true answer. Life is much more complicated and beautiful than any magic book. It may be a lot more difficult to commit science than to commit quackery, but in the end it’s a lot more satisfying and a lot more useful.
_________________________
*”Any sufficiently advanced technology is indistinguishable from magic.” –Arthur C. Clarke’s Third Law
When it comes to opiate drugs, like morphine, there is a bitter debate between patients who are in chronic pain, and the doctors who are vilified for under or over-prescribing these medications.
But there are some other subtle influences that push doctors to prescribe these drugs, in some cases inappropriately. An ER physician talks about the issue, saying, “when dealing with a patient who is in pain, or appears to be, it can be impossible to sort out when a patient needs opiates for legitimate reasons, and when it is merely feeding a long term addiction. We are trained to provide comfort and relief from suffering to our patients, and we generally will err on the side of treating pain, rather than withholding addictive medications.”
There is also the pressure to provide “patient satisfaction,” and indeed, low scores in this area can place a doctor’s job in jeopardy. Taking a stand against those who inappropriately request opiates will result in low patient satisfaction scores, and “will often times result in arguments, profanity, and calls and letters to administration.”
What’s the answer? Perhaps a little less reliance on these scores, since a good patient satisfaction score is not necessarily correlated with proper medicine.
*This blog post was originally published at KevinMD.com*
Few business models can top the inefficiencies, high costs, and overuse of manpower as primary health care. Every minor infection, cut, runny nose, goopy eye, hack, itch, rash, low back pain, stomach ache, urinary tract infection, tick bite, bee sting … ad infinitum must run the required gauntlet of the five-office-staff “touch points” in order to be treated. Let’s count them:
Once you’ve seen your doctor and interfaced with all of the “touch-point” staff, next comes the game of musical chairs between the patient, doctor, and insurance company to see who’s going to pay the bill. This game often lasts months and includes pitched battles before a resolution is reached, typically when someone gives up resentfully from sheer exhaustion. All this hassle might be understandable for a surgery, hospitalization or very expensive procedure, but instead we play this game for the simplest booboo. For day-to-day care, this translates into the American people playing this game at least 5 million times a day.
Every practicing family physician/internist’s office employs roughly 4.5 full-time people per provider who slog through the piles of paperwork needed in a third-party driven model. On the insurance side, it can be an even higher body count, with staff lined up to review the claims, police transactions, audit doctors’ notes, data mine patients’ data, review negotiated rates to be paid to each physician, and cut the checks. Instead of a model where the patient gets a direct service and pays an immediate and transparent price, we create the illusion that health care is “free” and then wonder why it costs so much money to see the doctor. Just look at the people we need to pay in order to receive our free care.
Automation has not reached health care as it has with nearly every other U.S. industry. Rather than streamlining healthcare through technology, we instead keep adding new layers bureaucracy, including administrators who find purpose by helping to improve the authorization process, or the reminder systems for patients not to miss their appointment, or the services which broker the whopping cost of care if the patient gets stuck with the bill, or act as navigators of “the system” for people who need to figure out who to see next in the process of care. To stay viable, twenty-first century medical care will have to address these inefficiencies because they create barriers to rapid and transparent care.
The ideal future family doctor’s office will be automated and render most office staff obsolete. Patients will schedule an appointment online without the hassle of a receptionist. Doctors and nurse practitioners will answer incoming phones and emails from their patients thereby immediately addressing medical questions, thus reducing delays and getting 50% of people what they need without an office visits when one isn’t needed. Patients will log-in and get copies of their personal health records that are linked to the doctors’ electronic medical record so that they can have a copy of their labs, vaccines, and update their own personal information whenever they need it. The bill for service will become transparent, immediate and mostly policed by the patient who has a personal stake in the price. No one cries “foul” faster than a person who sees a bill and wonders if he’s been ripped off.
By re-engineering the dynamics of the office visit, far fewer doctor’s office of the support staff are required. Instead of the 4.5 full-time staff per provider, a practice set up like what we’ve done at DocTalker Family Medicine requires only one employee per provider. The DocTalker model, which is a cash-only practice, uses computer, telecommunications and internet technology to enable the clinician to perform functions previously done by the front and back office staff, such as the receptionist, scheduler, in-window, out-window, billing specialist, and office assistant. Thus a person’s care is centralized through one person (the doctor) rather than many, leading to efficiency and reduction in overhead costs. If competition is encouraged, this process will only get better and less expensive.
Shouldn’t this be a consideration when overhauling cost efficiencies for healthcare reform?
Let us hope that it is.
Until next week, I remain yours in primary care,
Alan Dappen, MD
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