Tuesday, July 15, 2014

What "I Wouldn't Worry About That" really means when it comes from your doctor

Nearly all the patients that come to one of our practices have done so after leaving another primary care physician with whom they were unsatisfied.  Among the many complaints fairly or unfairly directed at their former physician, one that I hear frequently after explaining some lab or result is: "My last doctor just told me not to worry about that.  They didn't care about me."

Not to worry... is there a more dismissive, potentially condescending way to explain something to a person who is in fear for their health?  What a terrible, uncaring and hurried physician.  But here is the kicker, contained within that phrase is the essence of what primary care, and all honest medicine is all about--balancing risk.

What their quite astute doctor thought, and meant to say was probably something like, "Based on what we know about the uncertainties of diagnostic testing, and the differential diagnosis of that particular abnormality, and the risk associated with further exploring and/or treating those possible abnormalities, the risks of harm, misery, cost, side effects and complications by proceeding on this issue far outweigh any potential benefit."

That is a much longer sentence, and worth breaking down a bit:

1.  Uncertainties of diagnostic testing: Every test is imperfect with possibilities for human, chemical or interpreter error anywhere along the way.  Even performed perfectly (which is the norm), there are still built in margins of error in every test (think presidential election results).  No test is perfect, and even though it looks like a beautiful, meaningful, significant number, it is not.  It is one of a range of numbers, some of which imply doom, some of which imply nothing.

2. Differential diagnosis:  Medical speak for all of the things this could be.  This is the essence of practicing medicine.  Patients come in with symptoms and want to know what they are.  It turns out that our bodies have a limited vocabulary and lots of things look similar.  It is why googling your cough on WebMD is so dangerous.  Colds cause cough, cancer causes cough--so which is it?  The differential diagnosis is a method we use to determine all of the likely diagnoses that explain your symptoms or lab results.  The more a physician creates but whittles that list down quickly by probability, the more blood (and parts) you get to keep.  Here is a hint-- some type of cancer is always on the differential, but its persistence & rarity only make it a major player in special circumstances.

3. Risks associated with further exploring and/or treating: Everything doctors do can be dangerous.  That is why we go to school.  If it isn't dangerous (or if not doing it isn't dangerous), you don't need doctors.  You need parents, friends, family, herbalists, physical trainers, coaches, yoga instructors, health coaches, smoothie makers, cooks, grocers, etc. etc.  It is why we are bad at recommending diet and exercise.  We are trained on judicious use on the dangerous stuff, and that is what you want us doing.  You don't want doctors rigorously evaluating what you should eat, because self experimentation is really useful and really safe--until you start to add in multiple medical conditions and medicines (which are dangerous) and then our input matters. Therein lies the key.  Our work is dangerous, and we work hard to minimize the danger and maximize the benefit.  It is why we don't want to give narcotics and antibiotics for everything, because it is dangerous.

And remember, our promise is to first do no harm.

So now you see why your doctor said not to worry-- it was an unfortunate attempt at time savings.  When I take patients through the above, I find that we are better connected, I can understand their values and preferences, and they see how (and that) I think.  To the docs out there, next time you tell someone not to worry, think about taking them through the above and see the magic that happens.

Wednesday, July 9, 2014

Maker's Schedule, Manager's Schedule: What does that mean for Physicians?

Before you read what I am about to write, go read the inspiration for this piece, Paul Graham's 2009 "Maker's Schedule, Manager's Schedule."  Then read everything else Paul Graham has written.  Then, please, come back.

Briefly summarized-- if you must do something that is hard, takes creativity, thought and solves uncertain problems by combining lots and lots of information, then you need uninterrupted time to do so.  You are making, and making is hard. If you must manage people, communicate, socialize, learn, obtain new information, present, etc. then by all means fill up your day with a series of 30 and 60 minute meetings with enough time to get to each.  You are managing, and managing is incredibly time consuming.

Reading Graham's piece was incredibly enlightening as it calls to some of my frustration about not being able to think, being "too busy to get anything done," having days full of meetings and then endless leftover work at night.  Long ago I saw Jason Fried's fantastic Ted Talk on a similar topic: Why Work Doesn't Happen at Work.  (I am writing this entry on a plane....).  If it were not for airlines with Internet I am unsure how I would ever keep up.

So what if your job is to meet with people, obtain new information, socialize ideas, present and teach AND THEN to synthesize large amounts of multi channel information to begin solve a poorly defined problem. Over, and over, and over again.  Are you a maker? Are you a manager?  No, you are a physician.

Such has become of the life of the modern physician, especially the primary care physician.  In our clinical work alone, we are forever switching back and forth between meetings and really big thoughts.  It is challenging, often impossible, and the work really matters.  Add to just our clinical work the numerous interruptions in the day from other team members, scheduled meetings, etc. and it is a wonder anything gets done at all.

What we have developed as physicians is a honed sense of anxiety that something is not finished.  We remember using check lists, to do lists, fear, emotion, sticky notes, anything that we have to go back to where we were.  When given long blocks of time, I find that I work at a furious pace, assuming that some interruption is coming somewhere, so I better finish before it happens.

The toll it has taken on our profession (and therefore our patients, you know, everyone) is staggering.  Some physicians abdicate the "maker" portion of their job.  They simply meet with patients all day and do the bare minimum cognitive work necessary to bill.  If you have pain in your chest, you get sent to a cardiologist.  If you have pain in your back, you get a prescription for naproxen.  Patient and provider satisfaction is low, quality is abysmal, and patients end up ping-ponged around the medical system racking up risky tests, procedures, therapies and costs.

So what about the physicians who focus on minimizing interruptions and doing the cognitive work necessary to be successful and useful to their patients?  Enter the stereotype of the asshole physician.  The inverse response to interruptions is to block them out at all costs.  Don't answer calls, put up elaborate triage systems to keep people away.  Yell at people that interrupt you so they don't do it again.  Others do not have the temperament for this so they limit access and thereby interruptions in other ways.  Concierge physicians charge a lot to keep most people away.  Other arrangements see panel sizes get reduced (to arguably reasonable levels) so as to minimize the baseline interruption rate.

There has to be a better way.  We are physicians--we listen, examine, teach and interact.  We also think, deduce, reflect, review, synthesize disparate data and write all of this down to our future selves and colleagues.  There are two, related ways forward to preserve this vital role we provide to society.

First, we need to do less as physicians.  Not worse, but less.  Fewer forms, fewer check boxes.  We need to stop satisfying our vague managers, who generally do not recall their days in this role if they ever had them.  The mounting tide of regulation and billing related documentation is frankly terrifying.  It was made by managers and it will destroy us as makers.

Second, we need to find ways to minimize interruptions.  Perhaps it is time to recognize that a series of scheduled visits is not the optimal way to care for patients.  Rather, let us use time to our advantage to proactively manage our patients using data and evidence, and teams to carry out our plans.  We have been doing this for some time and watch as our in person visit rate declines as every metric we have improves-- patient willingness to recommend, clinical indicators, cost and utilization metrics, etc.

With fewer visits, we can use makers time to advantage and make something special for our patients.  It is time to get off the visit hamster wheel-- it benefits no one and is merely the status quo.  We need to organize our work to protect both the meeting and the thinking.  We need to organize ourselves and our teams to minimize the impact of the documentation insanity, and perhaps organize ourselves to fight it all together.

With every interruption we lose something we can regain-- our focus, our thoughts, our time.  We do not benefit, our patients do not benefit.  We must be mindful and fuse our inner manager with our inner maker.

Thursday, June 5, 2014

Thoughts on VIP Medicine

The concept of VIP medicine came up in a discussion today and someone liked how I phrased my thoughts, so I figured it was time to kick off the Schutzblog once again!

I like to think of VIP medicine as how a clinician would deviate from his or her usual style of care for a given patient who is of some special status-- wealthy, famous, connected, in some supervisory position over the patient, etc.  The general teaching is that VIP medicine is generally disastrous for the patient, and can even be lethal; but why?  Why would thinking of a patient more frequently, wishing to spare them discomfort, unpleasant examinations, embarrassing diagnoses, waiting, or the performance of clinical tasks by anyone but the physician be dangerous?

Fundamentally, our job as physicians is to balance risk and benefits for our patients.  All of our tests and therapies are potentially harmful, or at least uncomfortable and expensive and carry the risk of false or true positives and negatives of uncertain significance.  If this were not the case, we would not need physicians to make the decisions-- a reasonable safe therapy or test in all situations would not need to be protected.  

Now, we are able to balance risk and benefit for our patients because we train like crazy, read a ton, have seen good and bad outcomes from our own clinical work over time, and understand what our patients will value based on our relationship with them.  In short, we bring our experience to bear for someone we know well, think only of them, and guide them to a decision.  Whatever happens, they bear the consequences, good or bad, not us.  

Enter the VIP Patient.  VIPs are VIPs only because they can do one of two things:
  1. Help you in some significant way above and beyond a typical patient with financial reward, positive commendation, donations, recognition, etc.
  2. Hurt you in some way if the outcome of your guidance is not beneficial-- get you fired, sued, defamed, executed, etc.
So why is this a problem? Because the VIP Patient, usually through no fault of their own, has you thinking about YOU. Now all of your calculations are askew.  You need a good outcome for the patient so that YOU avoid pain or obtain reward.  

You risk choosing tests and therapies that are pleasant, flattering, and mild and avoid diagnoses that are embarrassing, tests that are painful or therapies that are hard to tolerate.  

Once you have started thinking about yourself, you have terminally endangered your patient.  Perhaps not this one, but some future VIP will seek care from you and will lose.  And remember, VIPs are generally always VIPs, so they always run this risk?

So what to do?
  1. Be honest with yourself: Acknowledge, at least to yourself, that this person has you thinking about you and not them.
  2. Stop that: Focus on your patient, not their money/power/fame-- even if they flaunt it.  Presume they are delirious/demented and making wild unsubstantiated claims if it helps. 
  3. Get help: Talk the case over with colleagues leaving out the VIP part and see if they come to the same conclusions. 

Monday, November 26, 2012

NEJM: Bizarro Regulatory Suggestions

The two leading perspective articles in last week's New England Journal of Medicine are striking examples of the bizarre call for regulation when none is need.

The first, Kevin Outterson's Regulating Compounding Pharmacies after NECC is a lawyer's take on changes in the regulatory requirements after the New England Compounding Center fiasco in which hundreds of people were infected with rare fungal disease due to contaminated steroids.  Compounding pharmacies are an interesting entity in modern medicine.  In a time when drug companies and generic manufacturers are stamping out medicines left and right, it is the compounding pharmacy that is allowed to take existing medicines and combine them (or redose them) due to individual physician/patient needs.  Due to their unique role as the individual practice of pharmacy, they have avoided wide-scale regulation like their manufacturing counterparts.   Apparently Congress is already discussing new federal regulations.

However, as Outterson clearly points out, there are State AND FDA regulations in place (that were violated) leading up to these events.  In fact, Massachusetts and the FDA had begun investigating NECC as early as 2002.  He laments that the already overburdened FDA oversight leaves limited opportunity for proactive oversight due to elements of the current rules that were not passed.  Again, the FDA had knowledge of problems at the NECC 10 years prior to the events.  So it would seem that the problems are not a lack of regulations, but the enforcement of existing regulations.  How the passage of new regulations will do anything but punish those already in compliance with additional burdens without catching violators is beyond me.  I guess it is easy to write rules and hard to enforce them, so we might as well keep writing rules and hope that solves the problem.

In a second, Cerreta et al's Drug Policy for an Aging Population - The European Medicines Agency's Geriatric Medicine Strategy reports on the EU's Medicines Agency strategy for evaluating (and theoretically changing) its regulatory strategy in the "development, approval and use of medications."  This process, which started in 2006 produced a strategy 5 years later recognizing that:


  1. The elderly use most of the medicines
  2. Chronological Age alone is inadequate for characterizing frailty ("young old" vs. "older old")
  3. Investigators tend to cherry pick patients often making the results non generalizable
  4. Patients have different preferences and clinical scenarios leading to individual risk/benefit decisions
  5. Hard to open packages are hard to open
  6. Package inserts are hard to read
  7. Drug-Drug interactions are only likely to be picked up after the drug is in use
These are shocking conclusions, certainly worthy of such time and investment.  Furthermore, does this not all fit entirely within information that any producer of a product would like/need to know, and improve upon where possible?  In the backwards world of medicines, product innovation is best preceded by a "regulatory framework."  Because top down innovation has such a clear track record of success.  What could have been done if manufacturers (and new entrants!) had spent the last 5 years free to innovate based on the assumptions above, none of which are particularly ground breaking, nor dangerous enough to require evidence before action.  From the regulators seat, it must be preferable to spend years and untold amounts of money while preventing possible good for millions in order to prevent embarrassing and scandalous possible harm for a few.

And we wonder why our health care is bureaucratized, inefficient, inhuman and unable to innovate itself in over 50 years...

Time to get the Schutzblog going again

As cute as Max is, it has been 3 months since a serious post.  Time to debrand the Maxblog back to the Schutzblog (sorry everyone...)

Friday, August 24, 2012

Max's first photo collage

Thanks Aunt Leslie!


Max's Graduation Day!

Sorry for the delay on the exciting news!  On Tuesday 8/21 Max graduated from NIC University after 41 long days with a GPA of 6.08 (lbs & oz).  Like his over-educated parents he decided to stay long past his time, pretending to have trouble in spelling class to stick around longer.  He was enjoying too many late nights of popping bottles with nurses that he had met along the way to come home (especially Tracie & Yvonne!).  But finally he passed his Finals in Car Seats and Hearing-- he said it was a breeze and winged them (and now refuses to get out of the car seat).  His first night home was tough-- Max was looking for the late night entertainment to which he had become accustomed but only found darkness and snoring.  More to follow!
Latest photos at: https://www.dropbox.com/sh/zw5nrcxhmsfyrga/mSwpIa6zB_
Graduation Chic by Designs by Grandma, Socks sold separately