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Consumer Health Information: The New Third Party In The Exam Room

It was sometime in the mid-nineties that parents started showing up in my office with reams of paper. Inkjet printouts of independently unearthed information pulled from AltaVista and Excite. Google didn’t exist. In the earliest days of the Web, information was occasionally leveraged by families as a type of newfound control.

A young father and his inkjet printer

One case sticks clearly in my mind. It was that of a toddler with medically unresponsive acid reflux and chronic lung disease. After following the child for some time, the discussion with the family finally moved to the option of a fundoplication (anti-reflux surgery). On a follow-up visit the father had done his diligence and appeared in the office with a banker box brimming with printed information. He had done his homework and his volume of paper was a credible show of force.

At the time in Houston, the Nissen and Thal fundoplication were the accepted fundoplication procedures in children. Deep from the bottom of one of the boxes, the father produced a freshly-reported method of fundoplication from Germany. He had compared the potential complications with other types of fundoplication and this was the procedure he wanted.

What he didn’t understand was that an experimental technique used on a limited numbers of adults didn’t necessarily represent the best option for his toddler. I gave it everything I had but didn’t get very far. The tenor of his argument was slightly antagonistic. Ultimately there was nothing more I could do. I deferred the remainder of the discussion to one of our best “talking” surgeons, but knew the father wouldn’t get the time and consideration that I had offered.

I never saw the child again. As they say, the father voted with his feet. Read more »

*This blog post was originally published at 33 Charts*

The Physician Exodus: When Doctors Leave Hospitals Behind

My partners and I have long struggled with the lack of specialty back-up at our hospital. Semi-rural hospitals, out of the way facilities, just can’t always attract specialists. So, we’re happy to have cardiologists every night, but understand that we only have an ENT every third night. We’re thankful to have neurologists, even if they don’t admit anyone. We’re glad to have radiologists, even if they don’t read plain films after 5PM on weekdays.

Still, I continue to scratch my head about why only three of seven community pediatricians take call, such that family physicians have to admit their patients. I was bumfuzzled that our neurologists were previously going to require us to use telemedicine for stroke evaluation when their offices were close by the hospital. (In the same year they were called in roughly three times per neurologist for urgent stroke evaluation.) That problem was resolved, thank goodness.

Now, I find that the problem has returned and grown. We will, very soon, have no ophthalmologist on call, despite the fact that we have three in the community and that they are contacted with remarkable rarity to deal with on-call emergencies. Soon, we will have no neurologist on the weekend. And the pediatric problem remains.

Of course, I’m using my local experience to highlight something that isn’t a local problem at all. It’s a national problem. All over America, specialists are relinquishing their hospital priveleges and staying in the office. Proceduralists are opening surgery centers that are free from the burdens of indigent care. Primary care physicians are allowing hospitalists to do all of their admissions.

In the process, not only are patients losing out, but referral centers are being absolutely overwhelmed. The cities and counties that lie around teaching hospitals are sending steady streams of patients, since they have fewer and fewer specialists. Those referral and teaching centers want patients, but they can’t take all of the non-paying patients, all of the complicated, or even all of the mundane patients with no local coverage. Those facilities, for all their shiny billboards and “center of excellence” marketing, will collapse. Read more »

*This blog post was originally published at*

A Two-Biscotti Physician

[Recently] I ate at one of my favorite Italian restaurants. I had eaten there many times before, but the experience this time was different. After ordering, I received a vacuous bread basket with precisely two pieces of bread. At the end of my meal I was offered two biscotti — and no more. Only the manager could offer an explanation: As a means of containing costs, the decision had been made to capitate bread and biscotti distribution.

I was disappointed. I had been eating here for years. When Colic Solved was released, my publication party was held here. After all those anniversaries, New Year’s celebrations, and birthdays, I’m shortchanged on cookies? It’s remarkable how a great experience can be shadowed by something so small.

Then I got to thinking: Perhaps I’m a two-biscotti physician. Like this restaurant, there are times when I don’t finish well. I may do a phenomenal job with assessment and diagnosis, only to delay a callback on biopsies or X-ray results. Perhaps I get it all right, but fail to get the detail right on the home health orders. Are there small pieces missing in my encounter that represent everything a parent remembers? I know that there are, and I know there are things I have to work on.

There’s a lot we can learn from a restaurant. I don’t want to be a two-biscotti physician.

*This blog post was originally published at 33 Charts*

How To Energize And Engage The Doctor-Nurse Team

Some patients struggle to communicate effectively with their doctors and some doctors and nurses find it difficult to communicate and collaborate with each other.

Historically, the dynamic symbiotic relationship between doctors and nurses has been a little shaky, evidenced by the lack of engagement and respect for one another.

Hospitals are chaotic and stressful. Working in such an environment can lead to frustration and it can take a toll on the staff. Instead of a good working relationship (which may never have been fostered to its full potential from the start), doctors and nurses become a fractured team. As a result, the fractured team will not effectively communicate and patient care may suffer devastating consequences. Read more »

*This blog post was originally published at Health in 30*

Physician Burnout: Doctors And Patients Deserve Better

A new patient recently said he was referred to me after his last doctor had left medicine. His old doctor always looked unhappy and burned out, he noted.

Burnout affects more than half of doctors, according to researchers at the University of Rochester School of Medicine. Beyond mere job dissatisfaction, these doctors are emotionally exhausted to the point where they lose focus. They tend to be more depressed — perhaps one reason why doctors have a higher suicide rate than the general population.

While burnout can happen in any profession, the performance of stressed-out doctors can hurt someone else: Patients. Read more »

*This blog post was originally published at*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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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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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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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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