Judging from recent articles, surveys, and blog posts, the medical profession is remarkably demoralized. Typical complaints range from “feeling like a beaten dog” to “living in humiliating servitude,” to being forced to practice “treadmill medicine.” Interestingly, the public response to these complaints is largely indifferent. The prevailing attitude (if the “comments sections” of online articles and blog posts are representative) seems to be unsympathetic: “Poor doctors, making a little less income and not being treated like gods anymore? You have to do extra paperwork? You have to work long hours? Welcome to the real world, you whiners!”
But thank goodness that practicing medicine is more nuanced than the Facebook stream of hostility that we are subjected to on a daily basis. If patients spoke to me the way online comments read, I’d surely have quit medicine years ago. But my reality is that patients are generally grateful, attentive, and respectful. This could be because I work in inpatient rehabilitation medicine, a place where patients are screened for motivation to participate in their care, but I don’t think that’s the whole story. I have experience working in other settings across the country (including Emergency Departments), and I have found a significant number of good-natured, engaged patients there too.
I think that to some degree our attitudes shape our work environments. Patient and peer dispositions are in part a reflection of our own. Try approaching a frightened, sick patient with an arrogant, dismissive tone and see how your professional relationship with them (and their families) develops. There is a negative cascade that physicians can trigger (perhaps unwittingly) when they are rushed, curt, or inattentive. Beginning every new patient relationship with a caring, respectful, detailed history and physical exam lays a foundation of trust for future interactions. Once you have established that positive rapport, the daily grind (along with what my friend, Dr. Steve Simmons, has nicknamed ‘C.R.A.P.P.’ – Continuous Restrictive And Punitive Paperwork) is much more bearable.
As physicians we have the power to make our careers as meaningful or soul-sucking as we choose. Reducing the C.R.A.P.P. in our work lives can help (I’ve tried outpatient, “concierge style” practices and inpatient locum tenens assignments with good success), but that’s not the most important factor in enhancing work satisfaction. The relationships built by allying ourselves with patients, and shepherding them through this broken system, are where the rewards lie. They hold the keys to our professional fulfillment because nothing can beat the joy of helping those in need.
How do I know that patient appreciation is enough to make medicine worthwhile?
Because I still don’t hate being a doctor.
I recently treated a patient who was hospitalized with paraplegia. During some routine lab testing I noticed that his liver function tests were elevated, and so I began looking for a cause. I discussed the patient’s drinking habits (he rarely drank alcohol), risks for viral hepatitis (no IV drug use or exposure to those with known hepatitis), and general medical history (nothing relevant to liver disease). I reviewed his current medication list, and found little to explain a potential drug-induced hepatitis. He denied any history of acetaminophen use.
Next I ordered a hepatitis panel – all normal. And finally a liver ultrasound (which showed some non-descript “fatty liver” changes). My next best guess was that the patient was a heavy drinker who was simply not telling me the whole story about his history. I hated to have to press for more information, and worried that the patient would be annoyed that I didn’t seem to believe his vehement denials of regular alcohol use.
So I asked him again. “Are you SURE you don’t drink ANY alcohol? Nothing that could have alcohol in it that you might not realize?”
“Well, maybe there is alcohol in the cold medicine that I drink?” he said.
“Why are you drinking cold medicine? Do you have cold symptoms?” I asked.
“I use it to get to sleep at night.” He responded.
“How much do you use?”
“I use it every night. I just drink it out of the bottle.”
“So you don’t use the measuring cup?”
“No. I just drink it out of the bottle.”
Suddenly, I had my answer. There is a significant amount of acetaminophen in many different cold syrup formulations, which is why it is so important to use the dosing cup and not exceed the recommended daily amount.
“So is there alcohol in the cold medicine?” The patient asked.
I explained to him that it was very likely that he was over-dosing himself on cold medicine and that his liver was being harmed as a result of the acetaminophen (not alcohol) it contained. It was a good thing that we had caught the damage in the rehab unit – just an incidental finding on a blood test that could have saved him from eventual liver failure (and even death) if we hadn’t course-corrected.
This experience was a cautionary tale for us both – I realized how easy it was for patients taking liquid drug formulations to overdose themselves, and not be aware of the active ingredients that they contained. My patient didn’t believe he was taking any acetaminophen when I originally interviewed him, and it was my persistent nagging on the alcohol front that finally revealed the cause (again quite accidentally).
Acetaminophen toxicity is the most common cause of acute liver failure in the United States. Better education is needed regarding over-the-counter medications and their potential harms if used incorrectly. I will certainly spend more time asking my patients about their OTC medication use, including sleep aids and liquid formulations. Perhaps I’ll be able to avoid ordering unnecessary liver ultrasounds with better history taking in the future!
For more information on safe use of acetaminophen, see my article at OTCSafety.com.
As a physician who openly despises many aspects of current EMRs (see “How An EMR Gave My Patient Syphilis” or “The Medical Chart: Ground Zero For The Deterioration Of Patient Care” ) I recognize that they are here to stay. And so, since we’re all stuck with these digital middlemen, I have some suggestions (based on popular social media platform functionality) for making them better.
1. Likes. Healthcare providers should be able to “vote up” an excellent note in the medical record. Let’s face it, not all doctors are equally good at documentation. Untold hours of our time are spent trying to cull through pages of auto-populated, drop-down-box checks to figure out what’s actually going on with a patient on a particular day. Once in a while you stumble upon some comprehensive free text that a physician took the time to type after a previous encounter, and suddenly everything becomes clear. If there were a way to flag or “like” such documents, it would help other readers orient themselves more quickly to a patient’s history. A “liking” system is desperately needed in EMRs and would be a valuable time saver, as well as encouragement to physicians who document notes well. Hospitals could reward their best note makers with public recognition or small monetary bonuses.
2. #Hashtags. Tagging systems are sorely lacking in medical records systems, which makes them very difficult to search. Patients make multiple visits for various complaints, often with numerous providers involved. If physicians had the ability to review notes/records unique to the complaint that they are addressing, it would save a lot of time. Notes could be tagged with keywords selected by the author and permanently recorded in the EMR. This would substantially improve future search efforts. Even if the EMR generated 10 search terms (based on the note) and then asked the physician to choose the 3 most relevant to the current encounter, that would be a step in the right direction.
3. Selfies. Medical records would benefit from patient-identifier photographs. In a busy day where 20-30 patients are treated and EMR notes are updated after the patients have gone home, a small patient photograph that appears on each documentation page will serve the physician well in keeping details straight. Patients should be able to upload their favorite portrait to the EMR if the standard one (perhaps taken during the intake process) is not acceptable to them. In my experience, nothing brings back physical exam and history details better than a photograph of the patient.
4. Contextual links. All EMRs should provide links to the latest medical literature (on subjects specifically related to the patient’s current diseases and conditions) in a module on the progress note page. UpToDate.com and other reference guides could easily supply the right content (perhaps based on diagnosis codes). This will help physicians practice evidence-based medicine and keep current with changes in recommended treatment practices.
5. Microblogging. Sometimes there are important “notes to self” that a physician would like to make but don’t need to be part of the official medical record. EMRs should provide a free-text module (like a digital sticky note) for such purposes. These sticky notes should not be admissible in court as part of the medical record, and should not be uploaded to the cloud. Content included in these notes could include social information (patient’s daughter just had a healthy baby girl), hunches (patient looks slightly pale today – will check H&H next time if no change), and preliminary information (remember to review radiology result before calling patient next Tues).
It is my hope that EMRs will slowly adopt some best practices from top social media platforms. After all, if millions of users are effectively using voting, tagging, linking, searching and imaging in their daily online lives, it only makes sense to capitalize on these behaviors within the constraints of the medical environment. Maintaining strict confidentiality and appropriate professional boundaries (often missing in the social media world at large) is certainly possible with EMRs. Let’s build a better information capture and retrieval process for the sake of our patients, and our sanity.
At least one EMR is already providing #3 and #5 as part of its software: see MDHQ.com Are you aware of any others already implementing these ideas?
Medical errors are estimated to be the third leading cause of death in America’s hospitals. Though some of these errors are beyond physician control, many are the direct result of physician action and inaction. I spend a lot of time thinking about how to reduce these errors and I (like many of my peers) lose sleep over the mistakes I witness.
When you ask patients what quality is most important in a physician, they often answer, “empathy.” I think that’s close, but not quite right. I know many “nice” and “supportive” doctors who have poor clinical judgment. When it comes to excellent care quality, one personality trait stands out to me – something that we don’t spend much time thinking about:
A physician with a curious mind doesn’t necessarily know all the answers. He may not be the “smartest” graduate of his medical school. But he is a great detective, and doesn’t rest until problems are solved. This particular quality isn’t nurtured in a system that rewards partial work ups, rapid patient turnover, and rushed documentation. But some doctors retain their intellectual curiosity about their patients – and to the extent that they do, I believe they can significantly reduce medical errors.
Many of the preventable adverse events I have witnessed (outside of procedure-based errors) began with warning signs that were ignored. Examples include abnormal lab tests that were not followed up in a timely manner, medication side effects that went unrecognized, copy errors in drug lists, and subtle changes in the physical exam that were presumed insignificant. All of these signs trigger the curious mind to seek out answers in time to head off problems before they evolve into real dangers.
Of course, there are other qualities that make a physician excellent – wisdom, experience, kindness, and a grounding in evidence-based practice come to mind. But without an engaged mind fueled by genuine curiosity, it’s hard to retain the vigilance required for continued good outcomes.
Curiosity may have killed a cat or two, but I’ve seen it save a large number of patients!
Health screening is part of good preventive care, though over-screening can lead to increased costs, and potential patient harm. Healthcare professional societies have recently developed excellent public service announcements describing the dangers of over-testing, and new research suggests that though additional medical interventions are associated with increased patient satisfaction, they also lead (ironically) to higher mortality rates.
And so, in a system attempting to shift to a “less is more” model of healthcare, why is resistance so strong? When the USPSTF recommended against the need for annual, screening mammograms in healthy women (without a family history of breast cancer) between the ages of 40-49, the outcry was deafening. Every professional society and patient advocacy group rallied against the recommendation, and generally not much has changed in the breast cancer screening world. I myself tried to follow the USPSTF guidelines – and opted out of a screening mammogram for two full years past 40. And then I met a charming radiologist at a women’s medical conference who nearly burst into tears when I told her that I hadn’t had a mammogram. Her lobbying for me to “just make sure I was ok” was so passionate that I simply could no longer resist the urge to get screened.
I knew going into the test that there was a reasonably high chance of a false positive result which could cause me unnecessary anxiety. That being said, I was still emotionally unprepared for the radiologists’ announcement that the mammogram was “abnormal” and that a follow up ultrasound needed to be scheduled. I must admit that I did squirm until I had more information. In the end, the “abnormality” proved to be simple “dense breast tissue” and I was pleased to have at least dodged an unnecessary biopsy or lumpectomy. Did my screening do me any good? No, and some psychological harm. A net/net negative but without long term sequelae.
My next personal wrestling match with screening tests was the colonoscopy. I was seeing a gastroenterologist for some GI complaints, and we weren’t 5 minutes into our conversation before he recommended a colonoscopy. I argued that I was too young for a screening colonoscopy (I was 42 and they are recommended starting at age 50), and therefore was doubtful that anything too helpful would be found with the test. My suggestion was that a careful history and some blood testing might be the first place to start. My gastroenterologist acquiesced reluctantly.
As it turns out the blood testing was non-diagnostic and my symptoms persisted so I agreed to the colonoscopy. In this case I felt it was reasonable to do it since it was for diagnostic (not screening) purposes. I was quite certain that it would reveal nothing – or perhaps a false positive followed by anxiety, like my mammogram.
What it did show was some polyps that had a 50% chance of becoming malignant colon cancer in the next 10 years. I was shocked. If I had waited until I was 50 to start screening, I could have missed my cure window. The uneasiness about screening guidelines began to sink in. As a physician I had done my best to apply screening guidelines to myself and resist the urge to over-test, even with a healthy dose of natural curiosity. Yet I failed to resist screening, and in fact, my life was possibly saved by a test that was not supposed to be on my preventive health radar for another 8 years.
Screening tests are recommended for those who are most likely to benefit, and physicians and patients alike are encouraged to avoid unnecessary testing. But there are always a few people outside the “most likely to benefit” pool whose lives could be saved with screening, and the urge to make sure that’s not you – or your patient – is incredibly strong. I’m not sure if that’s human nature, or American culture. But a quick review of Hollywood blockbuster plots (where tens of thousands of lives are regularly sacrificed to save one princess/protagonist/hero from the aliens/monsters/zombies) testifies to our desperately irrational tendencies.
I am now biased towards over-testing, because my emotional relief at dodging a bullet is stronger than my cerebral desire to adhere to population-based recommendations. Knowing this, I will still try to avoid the temptation to over-test and over-treat my patients. But if they so much as hint that they’d like an early colonoscopy – I will cave.
Does that make me a bad doctor?