April 20th, 2007 by Dr. Val Jones in Medblogger Shout Outs
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“Be quick to listen, slow to speak.” That’s the old wisdom I was taught growing
up, though it sure is difficult to apply regularly and consistently, isn’t it? Nonetheless I can’t think of a better
principle for practicing good medicine.
I was reading Dr. Smith’s blog and was touched by his
observations:
Patients don’t know
how to put words on their pain, and there is no disease named for the pain that
the patient wants to tell you about. It’s about the inner anguish of this
particular person’s quest for life, their disappointment, the abuse they have
experienced, their feelings of failure and lack of significance, their rage at
the injustices they endure and they don’t have anyone else but you to talk
to. And, by having a relationship with a safe professional, some of their
pain is relieved and, in many cases, they get well or better! In some
cases, they don’t, but that begins to matter less than the fact that you begin
to understand that “getting better” is not the goal here. And,
if you keep trying to make the patient better with a prescription pad, they
will just keep bringing you new problems to chew on until you figure out what
they really need.
The truth is that at the root of many medical
misunderstandings is a listening problem. Sure we hear
lots of things, but in our rush to package complaints into a convenient
diagnosis we often miss the elephant in the room. An excellent example of a doctor practicing
good listening skills was described in Signout’s blog this week.
Some parents appeared a bit overly concerned
about their young child’s cold symptoms. The resident taking care of them
wisely recalled that the mom had mentioned that her aunt died of leukemia
as a child. The doctor made the
connection between that bit of history and their angst – and reassured the
parents that the child’s blood tests were normal, and did not suggest
leukemia (without them directly asking the question). The emotional relief that
ensued was the most therapeutic effect of the physician encounter that day.
The moral of the story is that listening really can be
a healing art. And it’s not just
reserved for psychologists and psychiatrists.
*another case of good listening here*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 18th, 2007 by Dr. Val Jones in Opinion
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Ask any American if they think
their current healthcare system is operating smoothly and efficiently, and
you’ll hear a resounding “NO!” Adjectives such as
“confusing, complicated, and disorganized” are often used to describe
our current state, and for good reason. The science of medicine has
advanced enormously over the past 50 years, but somehow this rapid growth in
knowledge has been plagued by chaos. With every new therapy, there’s a
new therapist – and the result is a fragmented assortment of tests, providers,
procedures, and administrative headaches. So what does a patient in this
system really need? She needs a coordinator of care – a compassionate
team leader who can help her navigate her way through the system.
She needs a central location for all her health information, and an easy way to
interact with her care coordinator so she can follow the path she has chosen
for optimum health. She needs a medical home.
Primary care physicians (especially family physicians, pediatricians, and
internal medicine specialists), are ideally suited for the role of medical team
leader in the lives of their patients. It is their job to follow the
health of their patients over time, and this enables them to make intelligent,
fully informed recommendations that are relevant to the individual. Their
aim is to provide compassionate guidance based on a full understanding of the
individual’s life context. The best patient care occurs when
evidence-based medicine is applied in a personalized, contextually relevant,
and sensitive manner by a physician who knows the patient well.
Revolution Health believes that establishing a medical home with a primary care
physician is the best way to reduce the difficulty of navigating the health
care system. We believe that our role is to empower both physician and
patient with the tools, information, and technology to strengthen and
facilitate their relationship. Revolution Health, in essence, provides
the virtual landscape for the real medical home that revolves around the
physician-patient relationship.
What’s the advantage of having a medical home? Jeff Gruen, MD, Chief
Medical Officer of Revolution Health:
1. Care is less
fragmented: how many times have you heard of friends with multiple medical
problems who are visiting several physicians, each of whom has little idea
of what the other is doing or prescribing, and none of which are focusing
on the big picture? When a single physician is also
helping to “quarterback” the care, there is less chance that
issues will fall between the cracks, and less chance that consumers will be
put through unnecessary and costly tests or procedures
2. Care is better:
studies have shown that excellent primary care can reduce unnecessary
hospitalizations and assure that preventive tests are performed on
time. One study for example showed that the more likely
it is that a person has a primary care family physician, the less likely
it is that they will have an avoidable trip to the hospital. This
makes intuitive sense: a physician who knows you is critical to have if
you were to get very sick and need alot of medical
attention.
3. Care is more holistic:
medical care is part art and part science and good care requires the
clinician to understand something about the whole person they are caring
for. Many complaints that are seen in primary care practices are
physical manifestations of underlying emotional, family or adjustment
issues. A good primary care clinician who knows the individual and
family is more likely to strike the right balance between appropriately investigating
physical causes for complaints, and addressing more subtle underlying
causes
So to physicians and patients alike, we say, “Welcome home to Revolution Health.”
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 16th, 2007 by Dr. Val Jones in Medblogger Shout Outs
5 Comments »
Richard Reece’s recent blog post echoes my sentiments – that it is important, in the midst of a broken healthcare system (and all the frustration that it creates), to stop and ponder the good things that yet exist. There are flowers popping up between the concrete slabs of our system…
Dr. Reece writes,
This is an anti-hero age. We no longer send bouquets or offer praise or optimism, beauty, life, or achievements.
Instead we doubt, dissect, disparage, analyze, impugn, question, and investigate.
Boy, do we investigate. We investigate Presidents, Vice-Presidents, Attorney Generals, Politicians, Army Generals, Priests, Physicians, and Establishment Institutions. The prevailing attitude is: if they or it have succeeded in our society, something must be wrong. Our most prominent heroes, even Mohammad Ali, have feet of Clay. So we send no flowers, only regrets that things are not perfect.
And physicians?
Well, they are the worst. Imagine. They err like other mortals. They occasionally misinterpret signs, symptoms, and results. They cannot guarantee perfect results under all circumstances. They cannot even repeal the Laws of Nature, or the inevitable Limits of Longevity. Physicians are not even omnipotent, omniscient, or omnipresent
…
Maybe we should praise our doctors and their institutions, considered many to be “the best in the world.” That may be why the U.S. introduces 80% of the world medical innovations and wins 80% of the world’s Nobel Laureates in Medicine even though we only have 5% of the world’s doctors. Maybe we should give our doctors flowers, instead of defoliating them. Maybe they should be our heroes, rather than our villains. American doctors are not miracle workers, but given limited resources and Nature’s limitations, they are damn good.
I encourage you to read Dr. Reece’s whole post. This excerpt doesn’t do it justice.
And if you’d like to give a shout out to a good doctor you know (in lieu of flowers) please comment here!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 12th, 2007 by Dr. Val Jones in Health Policy
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In my last post I described a form of short hand that we docs use to communicate. One of my readers sent me a personal note via email. I thought she made some excellent points, so I’m going to post them here (with the silent conversation going on in my head when I read it typed conveniently in ALL CAPS).
The modern day pace is so incredibly stepped-up nowadays that it makes me nervous about human error. YOU SHOULD BE AFRAID. When doctors don’t have time to write complete words on paper, do they have time to give your case enough thought? PROBABLY NOT. Will some important detail slip past them? SURE. Will they make a mistake because they misread one of those code letters? NO, I DON’T THINK SO, THERE ARE PLENTY OF BETTER WAYS TO MAKE MISTAKES, LIKE GRABBING THE WRONG CHART. I should think that would be easy to do when doctors have terrible handwriting due mainly to haste. DON’T KID YOURSELF, THEIR HANDWRITING LOOKS EXACTLY THE SAME WHEN THEY HAVE ALL THE TIME IN THE WORLD.
All jest aside, we are in a serious quandary here… the poor primary care physicians in this country are totally swamped, they are under extreme pressure to see more patients in a day than should be legal, and in the end the patients suffer. At a certain tipping point (let’s say 12 patients/day) speed really does become inversely proportional to quality.
Instead of developing complex pay for performance measures, why not find ways to incentivize docs to see fewer patients? Truly, quality would automatically improve, patients would learn more about how to manage their chronic diseases, and docs would be happier and more productive. The quality police fail to recognize that time is the key to improving care. Can we really afford to keep up this frantic pace?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 12th, 2007 by Dr. Val Jones in Opinion
5 Comments »
To you Internet savvy folks out there, LOL means “laugh out loud” but to us doctors, “LOL” usually means “little old lady.” We have shorthand for everything, and our notes can look like stock tickers to the uninitiated.
For example, “NAD” means “no acute distress” (which, when translated into consumer speech, basically means that the person looks well). We shorten common words with an “x” after the first letter. So “diagnosis” becomes Dx, “treatment” becomes Tx, and “past medical history” becomes “PMHx.” Of course, there are some exceptions – “significant for” becomes s/f and “chief complaint” (or the reason why the patient believes he or she is there to see you) becomes CC. The events leading up to the chief complaint are called the “history of present illness” or HPI.
We also abbreviate the most common diseases, so that hypertension becomes HTN, diabetes mellitus is DM, heart attack is MI, and coronary artery disease is CAD. We like to use “status post” to indicate “after” something happened. And many symptoms have shorthand: DOE means “dyspnea on exertion” which is basically that you get short of breath when you walk. Or chest pain, CP. We sometimes use “?” when the patient is a poor historian (this usually indicates psychosis, dementia or severe language barrier). The pain scale is always listed as a fraction of 10. We can summarize a person’s mental status with how alert and oriented (meaning they know their name, where they are, and what the date is – they get 1 point for each of 3) they are. Vital signs (VS), such as temperature, heart rate, blood pressure, and respiratory rate, are considered “stable” or VSS if the values are all normal. Now let’s see if you can decode these short medical notes on 2 theoretical patients in the ER:
Patient#1
CC: ?DOE
HPI: s/p long walk
PMHx no DM, CAD, HTN
PE: LOL in NAD, A&Ox2,VSS, 0/10
Dx: r/o MI
Patient #2
CC: CPx1 hr, 10/10
HPI: s/p walk
PMHx s/f DM, CAD, HTN
PE: LOL in AD
Dx: r/o MI
Now, both of these patients have the same diagnosis listed, but I can tell you that the first patient is going to wait around for many hours before she’s treated, but the second case is going to marshal the cavalry immediately.
Can you picture in your mind’s eye what patient #1 is like? A little old lady who appears physically well but is complaining of shortness of breath (we think – we’re not really sure what her main problem is as indicated by the question mark) and is a little bit disoriented. She has no major medical problems.
Now the second lady has severe chest pain that has been going on for an hour. She has all kinds of risk factors for a heart attack and appears unwell. This is worrisome, indeed.
So that’s your crash course in medical short hand. Do you think you can crack the code on your next chart review?
My next post will discuss one consumer’s fear of medical shorthand… So stay tuned!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
