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Latest Posts

Finding Meaning In Illness: Lemons And The Demand for Lemonade

Jessie GrumanLife gives you lemons and you make lemonade…your response to all those cancer diagnoses is so positive, such a contribution!” “Your work demonstrates that illness is a great teacher.” ”Your illness has been a blessing in disguise.”

Well-meaning, thoughtful people have said things like this to me since I started writing about the experience of being seriously ill and describing what I had to do to make my health care work for me.  I generally hear in such comments polite appreciation of my efforts, which is nice because I know that people often struggle to know just what to say when confronted by others’ hardships.

But beneath that appreciation I detect a common belief about the nature of suffering from illness in particular, that in its inaccuracy can inadvertently hurt sick people and those who love them.

The belief is that sickness ennobles us; that there is good to be found in the experience of illness; while diseases are bad, they teach life lessons that are good. Read more »

*This blog post was originally published at CFAH PPF Blog*

Do-It-Yourself Health Care: A New Form Of Outsourcing?

Jessie GrumanThe outsourcing of work by businesses to the cheapest available workers has received a lot of attention in recent years.  It has largely escaped notice, however, that the new labor force isn’t necessarily located in Southeast Asia, but is often found here at home and is virtually free.  It is us, using our laptops and smart phones to perform more and more functions once carried out by knowledgeable salespeople and service reps.

This was particularly salient to me this week: I spent an hour online browsing, comparing prices, reading customer reviews and filling out the required billing and shipping information to get a great deal on a new lamp.  An airline would charge me 99 cents to talk to a person but provides information for free online.  Calls to Amtrak to make train reservations are routinely answered with a message that the wait to talk to an agent is 30 minutes, but that I can book travel myself – plus get better deals – if I do it online.  My bank has a small staff, limited hours and it charges extra for paper checks and mailed hard copy statements… but its Website is welcoming and useful, even at 3 a.m. Read more »

*This blog post was originally published at CFAH PPF Blog*

Does Your Doctor Trust You?

Jessie GrumanMembers of the  American public are frequently surveyed about their trust in various professionals.  Doctors and nurses usually wind up near the top of the list, especially when compared to lawyers, hairdressers and politicians.  Trust in professionals is important to us: they possess expertise we lack but need, to solve problems ranging from the serious (illness) to the relatively trivial (appearance).

How much professionals trust us seems irrelevant: our reciprocity is expressed in the form of payment for services rendered or promised, our recommendations to friends and families and repeat appearances.

So I was surprised to read an article in the Annals of Family Medicine describing a new scale to measure doctors’ trust in their patients.  This scale, based on input from focus groups and validation surveys of physicians, was developed for research purposes on the grounds that trust is a “feature of the clinician-patient relationship that resonates with both patients and clinicians.” Read more »

*This blog post was originally published at CFAH PPF Blog*

Survivorship Planning May Be The Key To Beating Cancer

Jessie GrumanI am a poster child for why everyone who has had cancer needs to work with their doctor(s) to develop and implement a survivorship plan.

Two of my four cancer-related diagnoses were found during routine screenings.  Two of my cancer-related diagnoses and one serious heart condition were almost certainly due to late effects of cancer treatment when I was young.

Each was a complete surprise to me, and while there is evidence that predicts most of these occurrences, not one of my doctors used this literature to shape a plan for my post-treatment care.

I was on my own.  My fear of yet another recurrence led me over time to cobble together a motley collection of oncologists (one for each body part) and other specialists (cardiologist, dermatologist, endocrinologist, and so forth) to watch over me.  I thought I was lucky that this has worked so far. Read more »

*This blog post was originally published at CFAH PPF Blog*

It’s Time To Tango: Impatient With Progress On Patient-Physician Partnership

The other day I came across this photo of a couple clasping each other in a dramatic tango on the cover of an old medical journal – a special issue from 1999 that was focused entirely on doctor-patient partnership. The tone and subjects of the articles, letters and editorials were identical to those written today on the topic: “It’s time for the paternalism of the relationship between doctors and patients to be transformed into a partnership;” “There are benefits to this change and dangers to maintaining the status quo;” “Some doctors and patients resist the change and some embrace it: Why?”

Two questions struck me as I impatiently scanned the articles from 12 years ago: First, why are these articles about doctor-patient partnership still so relevant? And second, why did the editor choose this cover image?

I’ve been mulling over these questions for a couple days, and I think an answer to the second question sheds light on the first. Here are some thoughts about the relationship between patients and doctors (and nurse practitioners and other clinicians) evoked by that image of the two elegant people dancing together:

It takes two to tangoEver seen one guy doing the tango? Nope. Whatever he’s doing out there on the dance floor, that’s not tango. Without both dancers, there is no tango. The reason my doctor and I come together is our shared purpose of curing my illness or easing my pain. We bring different skills, perspectives and needs to this interaction. When in a partnership, I describe my symptoms and recount my history. I talk about my values and priorities. I say what I am able and willing to do for myself and what I am not.  My doctor has knowledge about my disease and experience treating it in people like me; she explains risks and tradeoffs of different approaches and tailors her use of drugs, devices, and procedures to meet my needs and my preferences. Both of us recognize that without the active commitment of the other we can’t reach our shared goal: To help me live as well as I can for as long as I can.

Each dancer adjusts to his or her partnerIn tango, each partner has different moves; the lead shifts subtly and constantly between them throughout the dance. In a partnership, when I am really ill, I delegate more decisions to my physicians; when I am well we freely go back and forth, discussing treatment options and making plans. Read more »

*This blog post was originally published at CFAH PPF Blog*

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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