Tag: Medical Practice

Truthfully, the Physician Shortage Doesn’t Exist!

Jul 21, 2023• 1

BY HANS DUVEFELT

Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. (Sinsky et al, 2016)

If we only had the tools and the administrative support that just about every one of us has been asking for, there wouldn’t be a doctor shortage.

The quote here is from 7 years ago and things have gotten even worse since then.

Major league baseball players don’t handle the scoring and the statistics of their games. They just play ball.

Somehow, when the practice of medicine became a corporate and government business, more data was needed in order to measure productivity and quality (or at least compliance with guidelines). And somehow, for reasons I don’t completely understand and most definitely don’t agree with, the doctors were asked not only to continue treating our patients, but also to more than double our workload by documenting more things than we ourselves actually needed in order to care for our patients. Even though we were therefore becoming data collectors for research, public health and public policy, we were not given either the tools or the time to make this possible – at least not without shortchanging our patients or burning ourselves out.

We didn’t sign up to do all this, we signed up to care for our patients. And we were given awkward tools to work with that in many ways have made it harder to document and share with our colleagues what our clinical impressions and thinking are.

Data Democracy! ‘Dr. Google’ (2023) Vs. ‘Every Man His Own Physician’ (1767)

Jul 7, 2023

BY MICHAEL MILLENSON

Every Man His Own Physician - Google Books — In the 18th-century, a pre-Google guide offered democratization of medical information

In 1767, as American colonists’ protestations against “taxation without representation” intensified, a Boston publisher reprinted a book by a British doctor seemingly tailor-made for the growing spirit of independence.

Talk about “democratization of health care information,” “participatory medicine” and “health citizens”! Every Man His Own Physician, by Dr. John Theobald, bore an impressive subtitle: Being a complete collection of efficacious and approved remedies for every disease incident to the human body. With plain instructions for their common use. Necessary to be had in all families, particularly those residing in the country.

Theobald’s fellow physicians no doubt winced at the quotation from the 2^nd-century Greek philosopher Celsus featured prominently on the book’s cover page.

“Diseases are cured, not by eloquence,” the quote read, “but by remedies, so that if a person without any learning be well acquainted with those remedies that have been discovered by practice, he will be a much greater physician than one who has cultivated his talent in speaking without experience.”

Translation: You’re better off reading my book than consulting inferior doctors.

To celebrate Americans’ independent spirit, I decided to compare a few of Dr. Theobald’s recommendations to those of his 21st-century equivalent, “Dr. Google.” Like Dr. Google, which receives a mind-boggling 70,000 health care search queries every minute, Dr. Theobald also provides citations for his advice which, he assures readers, is based on “the writings of the most eminent physicians.”

At times, the two advice-givers sync across the centuries. “Colds may be cured by lying much in bed, by drinking plentifully of warm sack whey, with a few drops of spirits of hartshorn in it,” writes Dr. Theobald, citing a “Dr. Cheyne.” Dr. Google’s expert, the Mayo Clinic Staff, proffers much the same prescription: Stay hydrated, perhaps using warm lemon water with honey in it, and try to rest. Personally, I think “sack whey” – sherry plus weak milk and sugar – sounds like more fun.

Moral Injury: A Physician’s Premature Retirement

Jun 28, 2023

BY HAYWARD ZWERLING

Synopsis:

After a 3 decade career in a solo private practice the healthcare environment shifted
As an employed physician, my institution’s policies hindered my ability to care for my patients
The consequent moral injury left me unwilling to re-engage with the healthcare industry

I retired early from the profession that I loved because the devolution of the healthcare system had made it impossible for me to provide care to my patients in a manner which met my own standards. The resultant “moral injury” left me leary of again becoming involved with our healthcare system in the near future.

My Early Career

Although I had originally planned a career as a physician-scientist, it became apparent toward the end of my training that this was not the best career path for me and I choose to pursue a career in private practice.

My first post-training job was as a physician working in a clinic owned by Blue Cross and Blue Shield (1989-1991.) After two years in this relatively low stress environment it became clear that taking care of young, healthy patients was not much fun nor interesting.

I then joined Dr. LP’s private medical practice where I learned how to run a private practice. It was in this setting that I began to create an electronic medical record program for my practice, ComChart EMR. ComChart evolved into a minor commercial endeavor, it was a hobby that earned me some money, and it connected me to many interesting physicians around the US, some of whom I continue to hear from to this day.

After a couple of years practicing alongside Dr. LP I decided it was time to strike out on my own. I built out a new office and soon thereafter added a nurse practitioner.

Two Patients With More Than One Diagnosis

Mar 16, 2023

BY HANS DUVEFELT

I have written many times about how I have made a better diagnosis than the doctor who saw my patient in the emergency room. That doesn’t mean I’m smarter or even that I have a better batting average. I don’t know how often it is the other way around, but I do know that sometimes I’m wrong about what causes my patient’s symptoms.

We all work under certain pressures, from overbooked clinic schedules to overfilled emergency room waiting areas, from “poor historians” (patients who can’t describe their symptoms or their timeline very well) to our own mental fatigue after many hours on the job.

My purpose in writing about these cases is to show how disease, the enemy in clinical practice if you will, can present and evolve in ways that can fool any one of us. We simply can’t evaluate every symptom to its absolute fullest. That would clog “the system” and leave many patients entirely without care. So we formulate the most reasonable diagnosis and treatment plan we can and tell the patient or their caregiver that they will need followup, especially if symptoms change or get worse.

Martha is a group home resident with intellectual disabilities, who once underwent a drastic change in her behavior and self care skills. She even seemed a bit lethargic. A big workup in the emergency room could only demonstrate one abnormality: Her head CT showed a massive sinus infection. She got antibiotics and perked up with a ten day course of antibiotics.

A month later, her condition deteriorated again. It was on the weekend. This time she had a mild cough. Her chest X-ray showed double sided pneumonia. She got antibiotics again and started to feel better.

Practicing at the Top of Your License is Not an Option for Primary Care Physicians

Mar 12, 2023

BY HANS DUVEFELT

You don’t really need a medical degree to know how to follow an immunization schedule, to recommend a colonoscopy, or order a screening mammogram (as long as, in this country, there is a standing order – in some places, mass screenings are done outside the primary care system).

You also don’t really need a medical degree to enter data into an EMR.

And when you decide to order a test, how many of the EMR “workflow” steps really require your expertise? I mean, borrowing from my iPhone, you could say “order a CBC” and facial recognition could document that you are the ordering physician. Really!

And you don’t really need a medical degree to, as I put it, open and sort the (electronic) mail; an eye doctor’s report comes in and if the patient is a diabetic, I have to forward it to my nurse for logging, and if not a diabetic, just sign off on it. And don’t imagine there is time in our day, evening or weekend to actually read the whole report. Patient A saw their eye doctor – check. Next…

Primary care in this country is pathetically arcane and inefficient. And we have a shortage of primary care physicians, they say. If we could all practice at the top of our license, perhaps not. It’s time to reimagine, reinvent, reinvigorate!

Hans Duvefelt is a physician, author, and writer of “A Country Doctor Writes.”

I Love Explaining Medical Things

Mar 2, 2023

BY HANS DUVEFELT

A lot of people don’t know much about how the body works. One of my jobs as a physician is to explain how things work in order to empower my patient to choose how to deal with it when the body isn’t working right.

On my blog I have written about this many times, for example in the 2010 post GUY TALK:

Guy Talk

One of the first challenges I faced as a foreign doctor from an urban background practicing in a small town in this country was finding the right way to explain medical issues to my male patients. They were farmers and fishermen without much experience with illness, medications or medical procedures. Most of them came to see me reluctantly at their wives’ insistence.

Gradually, I found my voice and a style that has served me well over the years. As a Boy Scout and grandson of a farmer with more than an average interest in automobiles, I have found enough analogies from my own experience to be able to cross the cultural barriers I have encountered in my new homeland.

I may explain risk aversion by talking about why some men wear both a belt and suspenders. Heart attacks and angina are, obviously, related to plugged fuel lines. Beta blocker therapy is similar to shifting your manual transmission into fifth gear. Sudden discontinuation of beta blocker therapy is like releasing an inadvertently engaged emergency brake while driving with your gas pedal fully depressed. Untreated hypertension is like driving down the highway in third gear, and orthostatic hypotension is a lot like getting poor water pressure in an attic apartment.

Practicing Medicine without a License: When Patients and Politicians Play Doctor

Feb 1, 2023• 1

BY MICHAEL KIRSCH

We’ve all heard the adage, leave it to the professionals. It’s typically used when an individual has wandered out of his lane. How many folks go beyond their knowledge and skills with home projects, for example, who must then hire a real professional to mop up the mistakes? Luckily for me, the only tools that I – a gastroenterologist – know how to use are a colonoscope and an endoscope, so there’s no chance that I will be tempted to perform any plumbing or electrical tasks at home.

Although patients are not medical professionals, they routinely bring me results of their own medical research which suggest possible diagnoses and treatments. Often, these are patients whom I am meeting for the first time. I applaud patients who strive to be informed participants in their care. Indeed, there have been instances when a patient has brought me a valuable suggestion that I had not considered. But these are uncommon occurrences. A few computer clicks by a patient is not equivalent to the judgment and experience of a seasoned medical professional. It’s unlikely, for example, that I will agree that a patient’s elevated temperature is caused by malaria, despite this appearing on a patient’s internet search on the causes of fever.

However, even when I feel that a patient’s research results have no medical merit, the ensuing conversation is always valuable for both of us. I am in the room and can address the issue directly in real-time. I am the patient’s guardrail to protect him from careening off the road. I can explain right then the importance of being guided whenever possible by sound medical evidence. So, while I truly welcome the dialogue and recommendations from patients, I think that the maxim leave it to the professionals applies. Isn’t this why patients come to see us?

There’s a new player on the scene masquerading as medical professionals dispensing medical advice to the public. And in this case, there are no effective protective guardrails protecting patients as we doctors routinely do. I am not referring to middle of the night telemarketers or companies promising that probiotics are the panacea of our time.

As absurd as this sounds, politicians are now authorizing medical treatment for various diseases and conditions. Politicians? Could this be true?

The Dangers of EMR-Defaulted Prescription Stop Dates

Nov 10, 2022

By HANS DUVEFELT

It happens in eClinicalworks, I saw it in Intergy, and I now have to maneuver around it in Epic. Those EMRs, and I suspect many others, insert a stop date on what their programmers think (or have been told) are scary drugs.

In my current system all opioid drug prescriptions fall into this category. For a short term prescription that might perhaps be a good idea but for a longer-term or occasionally needed prescription it creates the risk of medical errors.

In Epic there is a box for duration, which is very practical for a ten day course of antibiotics. If I fill in the number 10 in the duration box, the medication falls off the list after 10 days. This saves me the trouble of periodically cleaning up the list.

Health Care Through the Back Door: The Dangers of Nurse Visits

May 12, 2022

By HANS DUVEFELT

In some practices, patients with seemingly simple problems are scheduled to be seen by a nurse or medical assistant. Sometimes they can even just drop off a urine sample in case of a suspected urinary tract infection.

This is a dangerous trap. What if the patient rarely gets urinary infections, has back pain and assumes it is a UTI instead of a kidney stone or shingles on their back just where one kidney is located; what if they have lower abdominal pain from an ovarian cyst or an ectopic pregnancy?

Another dangerous type of “nurse visit” is when patients focus on one symptom or parameter, thinking for example that as long as their blood pressure is okay, their vague chest pressure with sweating and shortness of breath isn’t anything serious. It’s one thing if I want a couple of blood pressure checks by my nurse, but a whole different thing when it is the patient’s idea, assumption or self diagnosis.

In many cases, a telephone call with the provider or a triage nurse can be safer and more diagnostic than starting with a nurse visit. Because the symptom history is usually more important when making a diagnosis. And nurse visits tend to be skimpy when it comes to the clinical history, even though the provider assumes responsibility for the diagnosis and treatment of a patient they didn’t talk to or examine.

The Healing Power of Even Virtual Human Connection

Dec 6, 2021

By HANS DUVEFELT

Almost two years into this new age of varying degrees of self quarantine, I am registering that my own social interactions through technology have been an important part of my life.

I text with my son, 175 miles away, morning and night and often in between. I talk and text with my daughter and watch the videos she and my grandchildren create.

I not only treat patients via Zoom; I also participate, as one of the facilitators, in a virtual support group for family members of patients in recovery.

I have reconnected with cousins in Sweden I used to go years without seeing; now I get likes and comments almost daily on things that I post. I have also video chatted with some of them and with my brother from my exchange student year in Massachusetts 50 years ago.

I have stayed in touch with people who moved away. And I have made new friends through the same powerful little eye on the world I use for all these things, my 2016 iPhone SE.

Members of my addiction recovery group stay in touch with each other via phone or text between clinics. They constantly point out the value of the social network they have formed, even though they only meet, many of them via Zoom, once a week. The literature has supported this notion for many years and is very robust: Social isolation is a driver of addiction.